There has been an explosion of interest in the etiology of and effect of medical errors on patient safety. The ACGME initiated work hour restrictions for residents with an intent to improve patient outcomes, and guidelines on these topics abound. Similarly, the growing interest in simulation centers has focused on their role in minimizing errors by learning in a “safe environment, away from patients”. However, there is another component of improved patient care that these interventions are ignoring – factors to increase physician productivity. These same simulation tools could potentially be leveraged to study the process of delivering care not to prevent mistakes, but to improve results in other more subtle ways.
The issues of complications and productivity seem like sides of the same coin, and I believe they are related. I also realize the practical utility of addressing errors first. Complications are readily identifiable, adverse events can be a focus for strategic interventions, and these variables are far easier to measure than productivity-related goals. However, I feel that they are only one side of the issue. And minimization of errors is not the only way we will improve the quality and consistency of patient care. In order for these safety-related interventions to work, they must go hand in hand with efforts to improve productivity, accuracy, and focus. I believe that those who study errors are aware of these needs, but I feel as though the public conversation has become so skewed to the negative end of the spectrum that we have lost some other components in the dialogue.
Productivity has certainly been mentioned when it comes to changes in the health care system. We, as physicians and health care providers, are being asked to transition to a system that will be based on outcomes, both good and bad. The focus is turning to bundled care, where each intervention or specialist is compensated for the overall outcome of the patient, not for their individual efforts. One could argue that this is shifting the discussion to productivity, however I would argue that these interventions are more focused on efficiency rather than productivity. While similar, these processes are not necessarily the same thing. Both efficiency and productivity are closely tied to cost and time variables, as well as negatively correlated with errors or complications. In the arguments for streamlined care, there is an assumption that productivity will increase as efficiency improves. This is the reason I am making this distinction – because the interventions needed to increased productivity may not be the same as those which maximize efficiency.
In the Oxford English Dictionary productivity is defined as: 1. the state or quality of being productive; or 2. the effectiveness of productive effort, especially in industry, as measured in terms of the rate of output per unit of input.
Efficiency is defined as: 1. the state or quality of being efficient: greater energy efficiency; or 2. an action designed to achieve efficiency; or 3. technical the ratio of the useful work performed by a machine or in a process to the total energy expended or heat taken in.
While there may be a relationship between productivity and efficiency when defined as a ratio of input to output, the difference lies in the approaches generally taken to achieve these goals. Historically, efficiency interventions have focused on minimizing unnecessary steps – i.e. maximizing useful work while maintaining the same baseline input or energy expenditures. Productivity on the other hand increases output through other means. These can be very complimentary processes, and the only reason to make this distinction is in order to guide interventions that focus on process improvement. In medicine, we are working to make ourselves more efficient – minimize unnecessary studies, limit needless interventions, streamline processes, eliminate superfluous steps. However, very little has focused on improving productivity. Everyone wants their trainees, employees, physicians to do more with less time, but there is a scarcity of data on how to improve the production of meaningful and quality work.
Anecdotally, I can describe to you my own experiences in work and productivity. As a surgical resident at a busy academic center and now a Surgical Oncology Fellow at a leading cancer hospital, I have spent almost the last decade of my life attempting to increase my own efficiency and productivity. Hand in hand with these goals has been a focus on minimizing the errors I make or identifying errors that are impacting my patients. This indoctrination begins during your time as a Surgical Intern when your mantra is “trust no one” and you triple check your orders and those placed by the overnight team to find errors that might have occured. You then graduate to the Surgical Senior Resident responsible for “running numbers”, which means reviewing vital statistics and lab values every day in order to make sure no small detail is overlooked, and finally you arrive when you become the Fellow responsible for preparing patients for the OR, responsible for understanding their clinical course leading to this day, the steps of the procedure to fix their problem, and the necessary details to manage them in the post-operative period. My life to date has been a struggle to safely manage patient data while having an increasing responsibility for patient care as well as an increasing patient load. It is an exercise in fastidiousness and detail, and it is a necessary one. I have been palpably aware of the role each data point plays in understanding the big picture of a patient’s clinical status. And I have followed these data points and learned to correlate them with the feeling I get when I examine and assess a real person. It is a subtle skill and one learned over time. Our entire training structure is focused on safety and minimization of errors, so I do not devalue these elements one bit.
Yet, it was not until I took time out of my fellowship for research that the concept of productivity finally occurred to me. Until now, I have been frantically plowing my way through the tasks of each day – data review, patient assessment, orders, paperwork, operative cases, more orders, more paperwork, then patient-reassessment and data review, then preparation for the next day, and on….. It is often hard to keep ahead of your days and I always felt that I was just treading water or that my grip on certain services was tenuous. And now, since taking some time for research I find my return to clinical duties far less frantic. Much of that has to do with the fact that although I am taking call or managing patients, I still am not back on a full operative schedule. I also worry less about pleasing people and more about the task at hand – a luxury afforded to me with some distance. I do have time to prepare, to read up on all the patients, to reference my analysis of their issues with a search of the literature on their disease and subtleties of management. I would like to believe that we all finally graduate from our programs and reach this place of calm as attendings, but I am somehow doubtful that this magical moment occurs. I am not implying that we all need to work less, operate less, or lighten our clinical loads. But what I have found is that in slowing down my pace somewhat, I have become more productive in what I am doing. I regained focus when the background noise was turned down. I was no longer rushed. It was not that I did not have the same amount of work to do in the same amount of time, but the stressors contributing to the need to hurry had been removed.
This brought to mind the famous study of Darley and Batson in 1973, which examined altruism by setting up an experiment with seminary students enrolled in a religious course. They completed questionnaires about their religion and then were asked to move from one building to another for the lecture to continue. On their way from building to building, they encountered a person slumped in an alley in need of assistance and examined what would happen. The one variable in this experiment was the amount of urgency the person felt in getting from one building to the other. They were then judged on a scale of helpfulness to the victim from 0 = failed to notice to 5 = refused to leave or insisted on taking him somewhere. Interestingly the major distinction between helping and non-helping behavior was in the hurriedness of the subject. In all, 40% of seminarians helped the victim, but in a low hurry situation 63% helped as compared to a high hurry situation where only 10% stopped to help. They did note that many subjects who did not stop appeared distressed or anxious upon arrival at their destination, to me speaking to their internal conflict. They weighed more heavily the tasks in the forefront of their mind over what they felt in a more subtle way was the right thing to do. I think we are all susceptible to this dilemma. I have found myself rushing by situations in which I would normally help when I have been pressed for time or under psychological stress to do other tasks. I am not proud of this fact, but believe it is one we should be aware of. If your resident/physician/care team member is pushed for time, their ability to process and receive messages from the current situation may be impaired. This is of far greater import to address than to add strategic napping to their day.
I do not claim that the solution to all our safety and productivity problems is to just slow down or to offer yoga and meditation to your surgical team, but when I reflect on my residency and fellowship I realize that over time the tempo is not sustainable and we all become tired. This is not the fatigue you hear about in the work-hour conversations, readily corrected by a brief nap. It is the chronic exhaustion of too many tasks in too short a timeframe in situations of conflicting responsibilities. I think this creates a similar situation to the altruism experiment with discordant signals being received and processed. In these types of environments, whether in the hospital or in the classroom, it becomes easy to relieve yourself of “unnecessary” tasks such as patient interaction or teaching or altruism and focus solely on doing more cases or meeting required benchmarks of your program – those things monitored by the ACGME or emphasized by your residency. Instead, increased productivity and improved quality needs to arise from patient-centered care, and that is a focus we should not lose.
I certainly do not think that the work hour restrictions are the solution that we are looking for. I think they have caused a host of other problems with pass-offs, lack of continuity, and a higher burden on attending surgeons for patient care. I agree with the intentions of improving patient care, but I wonder if there is a way of training and educating ourselves that may be more efficient, more productive, and more humane as well. I must admit that currently I am not only more productive during my clinical days, I am also a nicer person. I have a few seconds to spend time with patients, to get a better history, to acknowledge their fears, to pay attention, and to not resent them for making me do my job. That is the part that I found insidious and sad – I started down this path to help people, but became tired and distant along the way. Each day our patients are at their most vulnerable – they are sick, weak, and often facing their own death and mortality. The responsibility is on us to guide them through this process, but to do that requires clarity of vision that we may not always have.
I believe it is not only rushing that is a problem. There are several states of being associated with errors – rushing, frustration, fatigue, and complacency. Each of these states are readily identified in surgical residents, and yet we have chosen to only focus on one – fatigue. I propose that we institute a process-oriented approach using errors as the final readout but addressing factors contributing to these other states as well. There is something to be said for having the time and encouragement to read, plan, prepare, and execute. Not in your spare time, but as an emphasized goal of training. My personal goal is now to pursue this slower, more focused path – one that co-exists with empathy. I think we should train high performers who are whole people too. It would be a shame to strive for excellence as a surgeon, only to lose our skills as doctors and healers.