Learning from Our Errors
Karen S. Sibert, MD, the Associate Editor of the CSA Bulletin wonders in the Spring, 2010 issue about “When is the best time for mistakes?”

Back in the 1990s, my husband and I spent a year working at one of the largest hospitals in West Virginia. The patients were the nicest people in the world, and the hospital staff was terrific — kind, generous, and hard working. Some of the surgeons were excellent, but others definitely were not. My husband (a cardiac anesthesiologist) and I had to cope with surgical complications the likes of which we had never seen before. Patients walked into the hospital for elective aortic aneurysm repair and left in a hearse because the surgeon could not get the aorta back into one piece. I particularly remember watching the geyser of blood that erupted one day when a surgeon sliced open the right ventricle during what was supposed to be a simple mediastinal debridement. Steve and I thought we were capable anesthesiologists when we arrived in West Virginia, but we were better by the time we left.

Maybe the best place to train anesthesia residents isn’t the one with the top surgeons or the most dedicated teaching anesthesiologists. If surgeons are skillful and supervise their residents closely, the anesthesiologist won’t face surgical disaster often and may be unaccustomed to dealing with it. Likewise, if attending anesthesiologists guide their residents’ hands at every opportunity, anesthetic missteps will be rare. That may not be a blessing for the anesthesia resident who should learn how to manage both surgical and anesthetic mayhem.

If you’re in private practice and don’t work with residents, you may not realize just how much pressure there is today to watch the resident’s every move during a case. We’re compelled to chart our presence at the preoperative assessment, induction, line placement, emergence, and any “critical event.” Many of us whip out the fiberoptic bronchoscope at the first whiff of a problem airway rather than let the resident have another try. Attending surgeons rarely leave their residents alone in the operating room except to close skin. To do otherwise could be interpreted as poor quality care.

Certainly I don’t want a resident to make every mistake I’ve made; it’s better to learn some things by hearing tales of horror than by living them. That is the point of a good “morbidity and mortality” conference. But we had far less supervision as residents years ago, and nothing focuses the mind better than the need to fix a mess of one’s own making…

Today’s arbitrary restriction of “duty hours” worries me too. In case you haven’t heard, there is a limit of 80 hours a week for the residents of any specialty to be in the hospital, and that may soon drop to 60 hours. This includes night call hours when they may be asleep. Surgical residents now break scrub abruptly in the middle of a case, like Cinderella when the clock strikes twelve, lest they overstay their legal time limit. If they work up a patient at night in the ER, they can’t scrub in on that patient’s surgery the next day. Anesthesia residents rarely interview their inpatients the night before surgery. The concept of continuity of care, or taking ownership of one’s patients, apparently has gone for good…

For the first time, we’re starting to see residents graduate, go into practice, and then come back to do fellowships because they realize how much they didn’t know. One private anesthesia practice near Los Angeles no longer hires anyone directly out of residency because they have found new graduates unable to function independently. The question I have for the talking heads who make the residency rules is this: Is it better to make decisions and face the consequences when you’re a resident, or to make all your mistakes later when there may be no one around to help you?

The entire article can be read online at www.csahq.org/pdf/bulletin/sibert_59_2.pdf.

Politics and Medicine
Philip R. Alper, MD, discusses “The Obama Health Act and the Further Politicization of Medicine” in the April issue of the Bulletin of the San Mateo County Medical Association.

Ever since the enactment of Medicare in 1965, government and politics have become major forces in reshaping American medicine. Only a handful of physicians have been able to avoid the rules, regulations, blandishments and threats of the Medicare program. These are now administered by CMS, the Center for Medicare and Medicaid Services.

Some 25 years after the debut of Medicare, physicians discovered that while Hilary Clinton’s health initiative went down to defeat, its section on physician fraud and abuse lived on. It was adopted in its entirety by Medicare as administrative law, which is just as binding as legislative law. Many of the provisions are so Draconian that they appear not to have been enforced. Which is, more or less, how the interaction of law and politics works as usual. If this leaves physicians unsure where they stand, everyone seems to have learned to live with it.

Next we come to President Obama’s 2010 Patient Protection and Affordable Health Care Act. Like Hilary Clinton’s bill, it contains some measures that physicians generally support, but the overall structure is similarly legalistic, complicated and unwieldy. (It is 1,000 pages longer than Hilary’s bill.) The new law offers many job opportunities in the more than 120 health care agencies that it creates. It also invites the Internal Revenue Service to participate. One would have to ignore all past experience to believe that such an expanded corps of regulators will have a benign impact on physicians…

Clearly, the new law attempts to be supportive of primary care. The devil, however, remains in the details. For example, a bonus of 10% is awarded to primary physicians. But it is only for five years and it only applies if 60% of services to Medicare patients are “primary care services.” How will these ultimately be defined? Who can predict or depend upon a bonus that is statistical and opaque in the course of practice? Will this and similar measures entice young physicians into careers in primary care? My guess is that the horse-trading and outright bribery that were so prominent in Congress during the creation of the legislation will not work in enhancing primary care.

Nor are new primary physicians likely to be very popular with their specialist colleagues who will be squeezed by the promise of $500 billion dollars in savings from the Medicare program and who will then see primary physicians as not sharing their pain. Whatever shred of collegiality that is left after nearly three decades of managed care will further unravel.

The new law also promotes large group practice with cash incentives that small group or individual physicians cannot hope to obtain because of their limited ability to comply with the complex regulations governing statistical assessments of their practice activities. Furthermore, only a minority of practicing physicians are in large group practices and since government seems to favor this mode, the majority of physicians may be disadvantaged in future payment schemes.

All physicians will be affected in one way or another and it is impossible to predict all the ramifications of the Obama health bill. Nevertheless, the thrust remains an increase in documentation and greater standardization of care in the service of “best practices.”…

Read the entire article by Dr. Alper at www.smcma.org/bulletin/issues/April2010.pdf.