Unlike most elective students, I'm doing a good number of my electives at my home school.
Part of this was by design - as a student applying primarily to Family Medicine, I don't need to do nearly as many electives in one field, so I've got some extra elective time to spend on learning opportunities, on rotations I haven't experienced yet first-hand. Those can be done anywhere, so might as well do them in a familiar setting where I don't have to pay for travel or accommodations. Plus, I can spend more time with my partner and dog at home!
Part of this was definitely not by design - I had some electives at other schools fall through last-minute after months of waiting. Just a reminder that despite the new electives portal in Canada that is supposed make electives more accessible and to eliminate the need for elective-hoarding, there's still a major incentive to gather up as many electives as possible, dropping any excess ones as you go.
One unexpected advantage of this arrangement, however, is getting to see some patients I saw previously on my third year rotations. Seeing a familiar name, or stumbling across a prior dictation with your own name on it is pretty exciting! (Side note - dictation services do a pretty good job. Recently read a note I dictating very early in clerkship and superficially, it looks amazing! When I actually read the content, it's fairly disorganized and rambling. It does its job, but I feel I can do so much better at this stage and it only looks half-decent because the dictating service my hospital uses made it look that good).
This is not necessarily a common experience in medical school. We get shifted from service to service regularly enough that any continuity within these services is pretty short-term. Seeing a patient after 2 months isn't quite the same as checking in on them over a year later, but this longitudinal care is a core part of being a physician. Even as just a reminder of the growth we go through as medical students, I'm appreciating the experience. I know some schools, particularly satellite campuses, have been working with clerkship models that build these sorts of longitudinal experiences into their structure, and US schools having been piloting studies on longitudinal clerkship for years. From speaking to some people in longitudinal medical education programs, I've been given the sense that these set-ups are better in theory than in action, but there is some interesting research on the subject. Given my recent experiences, I would love to see effective longitudinal care fit more cleanly and reliably into undergraduate medical education.
Showing posts with label continuity of care. Show all posts
Showing posts with label continuity of care. Show all posts
Tuesday, 18 October 2016
Saturday, 20 February 2016
Work Hours and Handovers
A major argument against restriction of work hours for residents (or staff, though that gets less attention) is the notion of increased handovers. The basic story goes that when you have residents work fewer hours, or at least fewer hours in a row, they have to handover the care of their patients to other residents more often and since handovers are well-established as leading to error, more handovers mean more errors. It is thus hypothesized that any gains made on resident fatigue by restricting hours will be eliminated by increased problems associated with handovers.
When work hour restrictions were put in place in the US, studies on healthcare quality came back pretty equivocal, so the hypothesis appeared valid and has been seized upon by many with an interest in medical education, particularly those opposed to work hour restrictions. I accepted this theory as well, since it seemed to fit the evidence and was plausible in theory.
Now, acceptance of this theory didn't change my views on reducing work hours in medicine, since handovers are not an inherent problem, but rather one that could be addressed and improved. Moreover, since our current system necessarily involves a lot of handovers, fixing them should be a top priority anyway. As a result, any losses in care due to increased handovers associated with shorter working hours should, if anything, get better as time goes on, allowing any gains from those shorter hours to be realized.
However, the more I look at the problem, the less I'm convinced this theory holds much water in the first place, at least not in many cases.
For example, shorter shifts don't necessarily lead to more handovers for the majority of patients. Individuals on call for 24 hour shifts don't typically just take care of their own patients, they take care of patients on their "team", many of which are cared for by other team members. When I'm on call during my current rotation, I am responsible for up to 30 patients, yet most days I only care for 4-6 patients. Residents often take on a bit more work, but even then, they're unlikely to be familiar with more than 10 patients. They need to be updated - or receive handover - from the other members of the team. If we had two distinct shifts taking care of a set of patients, one day shift and one night shift, the total number of handovers would be virtually unchanged for the majority of patients.
Likewise, not all handovers are created equal - handing over a patient that both parties are reasonably familiar with is a much different situation than handing over a patient that the receiving party has never cared for before. This gets back to a more fluid concept of continuity of care which I've written about before, where continuity of care doesn't mean one physician caring for one patient, but rather one physician maintaining the same role in caring for that one patient.
So how do I explain the rather equivocal results from studies on resident work hour restrictions? My current belief is that work hour restrictions failed to achieve their process goal, which was improving resident fatigue. Through a combination of increased work intensity, scheduling loopholes, and well, simply ignoring the restrictions, residency programs simply found creative ways to continue to work their residents far, far too hard. We didn't see a change in patient outcomes, because we never really saw a change in resident working conditions, simply trading one inadequate resident work system for another.
I can't dismiss handovers as a factor entirely, since I've seen first-hand how poor handovers can cause substantial problems for patients. Yet, when it comes to work hour restrictions, I'm coming around to the conclusion that they're used a bit as a red herring, part of a rhetoric thrown out to justify maintaining the status quo on work hours, without much conclusive evidence to demonstrate that the status quo should be maintained.
When work hour restrictions were put in place in the US, studies on healthcare quality came back pretty equivocal, so the hypothesis appeared valid and has been seized upon by many with an interest in medical education, particularly those opposed to work hour restrictions. I accepted this theory as well, since it seemed to fit the evidence and was plausible in theory.
Now, acceptance of this theory didn't change my views on reducing work hours in medicine, since handovers are not an inherent problem, but rather one that could be addressed and improved. Moreover, since our current system necessarily involves a lot of handovers, fixing them should be a top priority anyway. As a result, any losses in care due to increased handovers associated with shorter working hours should, if anything, get better as time goes on, allowing any gains from those shorter hours to be realized.
However, the more I look at the problem, the less I'm convinced this theory holds much water in the first place, at least not in many cases.
For example, shorter shifts don't necessarily lead to more handovers for the majority of patients. Individuals on call for 24 hour shifts don't typically just take care of their own patients, they take care of patients on their "team", many of which are cared for by other team members. When I'm on call during my current rotation, I am responsible for up to 30 patients, yet most days I only care for 4-6 patients. Residents often take on a bit more work, but even then, they're unlikely to be familiar with more than 10 patients. They need to be updated - or receive handover - from the other members of the team. If we had two distinct shifts taking care of a set of patients, one day shift and one night shift, the total number of handovers would be virtually unchanged for the majority of patients.
Likewise, not all handovers are created equal - handing over a patient that both parties are reasonably familiar with is a much different situation than handing over a patient that the receiving party has never cared for before. This gets back to a more fluid concept of continuity of care which I've written about before, where continuity of care doesn't mean one physician caring for one patient, but rather one physician maintaining the same role in caring for that one patient.
So how do I explain the rather equivocal results from studies on resident work hour restrictions? My current belief is that work hour restrictions failed to achieve their process goal, which was improving resident fatigue. Through a combination of increased work intensity, scheduling loopholes, and well, simply ignoring the restrictions, residency programs simply found creative ways to continue to work their residents far, far too hard. We didn't see a change in patient outcomes, because we never really saw a change in resident working conditions, simply trading one inadequate resident work system for another.
I can't dismiss handovers as a factor entirely, since I've seen first-hand how poor handovers can cause substantial problems for patients. Yet, when it comes to work hour restrictions, I'm coming around to the conclusion that they're used a bit as a red herring, part of a rhetoric thrown out to justify maintaining the status quo on work hours, without much conclusive evidence to demonstrate that the status quo should be maintained.
Sunday, 7 February 2016
Continuity of Care
Continuity of care, as ideally envisioned, involves a patient being cared for by a single provider each and every time they interact with the healthcare system, or at least every time they come for care for a specific condition.
That situation is, of course, impossible. No medical professional has enough knowledge and skills to care for a person once their medical condition becomes the least bit complicated. There's a reason we have a progressive increase in specialization and sub-specialization, one person just can't know enough. More importantly, one person can't be there 24/7. Anything that requires urgent or continual attention means bringing someone new into the care of the patient.
Despite being relatively well-accepted that we can't have a single person care for a patient, and that continuity of care has to involve more than one provider, efforts to improve continuity of care are still largely centered around minimizing the number of providers. That's not enough.
For one, it means we are still terrible at maintaining good continuity of care between providers. Handovers, whether in person or by written communication, are fraught with errors and omissions. As a medical student, I do a fair number of dictations that serve as the definitive record of a patient's stay in hospital or visit to a clinic. I have received zero formal training on how to do this appropriately or efficiently. Not yet being a true medical expert, I don't always appreciate what details are pertinent and which ones aren't, which means I alternative miss important information, or include unimportant minutiae. More than a few times, I've had to dictate discharge summaries for patients I've never met, or only met once briefly. All my dictations have to be signed off by my supervising physician, but they're busy and are often relying on me or other trainees to know the details of the patient's visit, so these reports often get submitted with no or minimal changes.
Even how we try to maintain a single provider in the care of a patient could use a good dose of extra scrutiny. Call schedules for residents are a major problem in my mind. In inpatient medicine in academic centers, teams are often comprised on a single consultant physician and multiple learners. Each learner takes a set of patients to manage during the day. To cover nights, individuals from the team take turns on 24 hour shifts. That sounds like good continuity of care, but for two giant holes. First, the learner on the team doesn't know all the patients on their team, at least not well. They cover a subset during the day, so everyone else is a stranger. Not good. Secondly, since the learner gets a post-call day, the patients they typically cover during the day have to be covered by other learners who likely haven't met their patients before.
Some programs are playing around with night float - where a person repeatedly cover a team overnight for multiple nights - which I think makes a lot more sense. The care needed at night and the care needed during the day are often very different. Having continuity from one night to the next, as well as one day to the next, is generally more valuable than continuity from day to night. However, few programs have tried this out yet, and the approach of those who have isn't always that great for the health of those on the night shifts - some have tried 16 hours on, 8 hours off, which is a recipe for inadequate sleep and through-the-roof stress. There are ways to ameliorate this (might write more on that later), but it shows where the debate currently stands when it comes to actual practice. The medical community does talk a lot about improving continuity of care, but when it comes to practical solutions, we're barely putting our toe in the water.
That situation is, of course, impossible. No medical professional has enough knowledge and skills to care for a person once their medical condition becomes the least bit complicated. There's a reason we have a progressive increase in specialization and sub-specialization, one person just can't know enough. More importantly, one person can't be there 24/7. Anything that requires urgent or continual attention means bringing someone new into the care of the patient.
Despite being relatively well-accepted that we can't have a single person care for a patient, and that continuity of care has to involve more than one provider, efforts to improve continuity of care are still largely centered around minimizing the number of providers. That's not enough.
For one, it means we are still terrible at maintaining good continuity of care between providers. Handovers, whether in person or by written communication, are fraught with errors and omissions. As a medical student, I do a fair number of dictations that serve as the definitive record of a patient's stay in hospital or visit to a clinic. I have received zero formal training on how to do this appropriately or efficiently. Not yet being a true medical expert, I don't always appreciate what details are pertinent and which ones aren't, which means I alternative miss important information, or include unimportant minutiae. More than a few times, I've had to dictate discharge summaries for patients I've never met, or only met once briefly. All my dictations have to be signed off by my supervising physician, but they're busy and are often relying on me or other trainees to know the details of the patient's visit, so these reports often get submitted with no or minimal changes.
Even how we try to maintain a single provider in the care of a patient could use a good dose of extra scrutiny. Call schedules for residents are a major problem in my mind. In inpatient medicine in academic centers, teams are often comprised on a single consultant physician and multiple learners. Each learner takes a set of patients to manage during the day. To cover nights, individuals from the team take turns on 24 hour shifts. That sounds like good continuity of care, but for two giant holes. First, the learner on the team doesn't know all the patients on their team, at least not well. They cover a subset during the day, so everyone else is a stranger. Not good. Secondly, since the learner gets a post-call day, the patients they typically cover during the day have to be covered by other learners who likely haven't met their patients before.
Some programs are playing around with night float - where a person repeatedly cover a team overnight for multiple nights - which I think makes a lot more sense. The care needed at night and the care needed during the day are often very different. Having continuity from one night to the next, as well as one day to the next, is generally more valuable than continuity from day to night. However, few programs have tried this out yet, and the approach of those who have isn't always that great for the health of those on the night shifts - some have tried 16 hours on, 8 hours off, which is a recipe for inadequate sleep and through-the-roof stress. There are ways to ameliorate this (might write more on that later), but it shows where the debate currently stands when it comes to actual practice. The medical community does talk a lot about improving continuity of care, but when it comes to practical solutions, we're barely putting our toe in the water.
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