One of my colleagues just forwarded me a NY Times article by Jerome Groopman. The article begins with the issue of inexperienced interns – how newly minted MDs begin clinical care for patients in July of each year, and how these rookies can make harmful mistakes.
He goes on to explain that doctors aren’t trained to think well about the diagnostic process (the thesis of his recent book) and that we’d all benefit from studying cognitive psychology.
Dr. Groopman makes some interesting points in this article, but I was most struck by his flippancy regarding the dangers of getting treatment in July. He simply says, “Today, most hospitals closely watch over interns.”
I personally think the issue is more sinister than that – there are many ways that an intern can make mistakes, without ordering a single test or procedure, and under the full scrutiny of red tape regulations and documentation practices.
When an intern fails to recognize a life threatening condition and chooses to do nothing, or to let the patient wait for an extended period of time before alerting his or her team to the issue, serious harm can befall that patient. And that harm is not caused by inexperienced procedural technique, or ordering the wrong medicine – it’s caused by doing nothing. This “doing nothing” is the most insidious of intern errors – and it is not remedied by any form of hospital quality improvement initiatives. It is the risk that a hospital takes by having inexperienced physicians in the position of first responders. Interns gather large amounts of information about patients and then create a summary report for their supervisors. The supervisors (more senior residents) don’t have time to fact check every single case, and must rely on the intern’s priority hierarchy for delivering care.
But many hours pass between the time an intern examines a patient and when a supervising physician checks back in with that patient. And within that period of time, many conditions can deteriorate substantially, resulting in the loss of precious intervention time.
Dr. Groopman describes an experience from his own life in which a surgical intern (in July) correctly diagnosed his son with an intussusception (twisted bowel) but then incorrectly determined that the baby could wait to go to the O.R. Of course, untreated intussusceptions are nearly always fatal, and each minute that passes without intervention can increase the risk of death.
And so, in my opinion, it is in fact more dangerous to be admitted to a teaching hospital in July, but not necessarily for the reasons that people assume (procedures performed by inexperienced physicians or drug errors – though those mistakes can be made as well). Rather, it is because interns don’t have the clinical experience to know how to prioritize their to-do lists or when to notify a superior about a patient’s health issue. Timing is critically important in quality care delivery – and that variable is not controlled by our current intern oversight system.
Now that I’ve completely terrified you – I will offer you a word of advice: designate a patient advocate for your loved one (or yourself) if you have to be in the hospital as an inpatient (especially in July). If you can, find someone who is knowledgeable about medicine – and who knows how to navigate the hospital system. A nurse, social worker, or physician are great choices. That person will help you ensure that concerns are prioritized appropriately when your intern doesn’t yet fully appreciate the dangers behind certain signs symptoms. If you have no advocate, then befriend staff members who are particularly caring and experienced. Be very nice to them – but don’t be afraid to insist on being examined by the intern’s supervisor if you really are concerned. Unfair as it may seem, sometimes the most vocal patients get the best care.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.