One of the saddest aspects of healthcare is when the failings of a system are presented as the failings of an individual
It’s 2am and the emergency department is snowed under. Despite your best efforts to work through your meal break, the arrivals continue to mount, the wait times continue to climb. Ambulance trolleys now line any available corridors and the incessant alarming of bedside monitors rises above the background chatter to create a seemingly perpetual atmosphere of tension and anxiety. Steeling yourself before picking up the next case you glance left at a colleague, hoping to catch a sentiment of solidarity, some kind of acknowledgement to know you’re not alone in this moment but it never comes - they’re 15 minutes deep into a heated phone conversation with the medical registrar who is not having an ounce of Beryl’s abdominal pain admitted under them. On scrutinising the waiting list there is medical acuity at every level, and no smart way to sequence the languishing chaos of patients - a 90 year old gentleman with small bowel obstruction, 20 year old female with loss of her first pregnancy, 16 year old boy post attempted suicide awaiting medical review. Any system of triage or prioritisation seems heartless but idealism must play second fiddle to pragmatism, and now is not the time for philosophising. Even the indulgence of budget granulated instant coffee feels like an affront to the dozen nil-by-mouth patients anxiously waiting for CT scans and ultrasounds, and it would seem to require either transcendent zen mastery or sociopathic tendencies to take a meal break at a time like this. By nature, the emergency department represents the frontline and a kind of bottleneck for patient suffering, the weight of which is not one easily expunged from the forefront of the mind.
At a systems level, the interface of an ever-fluctuating patient load and fixed-staffed department without the inbuilt liquidity (if you will) to adapt, and meet increasing demand with increased throughput - and a ‘learned’ over-reliance of such strain being taken up by individuals working longer and harder. Such pressure on scarce healthcare resources, more specifically in an ED environment, seem manifested in protracted wait times and the very real human experiences of pain, anxiety, uncertainty, and additional time until definitive care - an omnipresent reality felt by all frontline healthcare staff. Equally concerning is the observed and expected workforce shortfalls both nationally (5) and internationally (6, 7, 8, 9) working synergistically with increasing hospital presentations (10) to create a perfect storm for medical error, clinician burnout, and poor patient outcomes; the emotional toll of which is not likely amenable to extra yoga sessions (11). Although as described much of this increased demand may well be taken up by staff working harder and faster, this is not without consequence, with a demonstrated association between increased time or production pressure poorer quality care, and rates of medical error (12, 13, 14, 15) especially true for emergency departments (16). It is therefore further regrettable that the fallout from adverse outcomes occurring in such a system, almost as a rule, rest with the unfortunate treating medic frequently without consideration of the situation in which she or he was operating (17). We can see many of these points highlighted in a recent British Medical Association report (18), which succinctly and unambiguously describes the signs, symptoms, and outcomes of a health system under pressure: burnout, longer ED wait times, poorer quality of care, and repercussions for patient safety (8, 18).
It is easy to feel helpless and disempowered when confronted with such a reality, and it is probable that without significant restructuring of resource redistribution and financial bolstering of the health system from a higher policy level that hospital access block, patient safety, and healthcare worker wellbeing will remain a regrettable reality (19). But several under-utilised and viable strategies exist for health networks and hospital administrators to address some of the immediate challenges that hospitals and emergency departments face. To begin, an immediate recommendation must be that more flexibility be built into the emergency department to better manage anticipated and unanticipated fluctuations in patient presentations; achievable from both a resource and staffing flexibility point of view (20) and through use of modern solutions such as statistical modelling and the practical application of queueing theory (21, 22, 23). Furthermore, the fundamental importance of adequate staffing, matching staff to accommodate peak patient periods, and having a critical mass of senior medical officers available in the department is mandatory to ensure high quality care can be provided (24). If we cannot first get the basics right and provide the current gold standard of medical care to every patient every time due to workforce and healthcare systems shortcomings, then we must collectively realise that in cutting edge frontier research and development into expensive and novel biomedical intricacies we are unlikely to find salvation.
I have always felt the existence of an especially hazy line between the issues attributable to shortcomings of a healthcare system and those I attribute to myself as personal inadequacies; rarely more so pronounced than whilst working in the emergency department. This is a dichotomy well elucidated by Reason (2000)(ref. 4), highlighting the conditions which make individual blame the dominant ideology in medicine when we think about medical errors. This is a mental dichotomy I propose exists also in the daily battles of healthcare, in procedural wait lists, in ED corridors, and in the race to always do more, and to do it faster.
In one hand an individual narrative - I can always envisage myself as working harder, better, faster, stronger; and taking lengthening wait-times as a personal failing, indicative of the very real human pain and anxiety ongoing prior to definitive care. If only I didn’t take the coffee break, if only I had read up on this presentation last night, if only I wasn’t so slow at taking blood, if only I could touchtype better. This mentally destructive thoughtline runs like a common thread through healthcare, peddled and perpetuated by the training atmosphere and culture of medicine so historically ingrained as to seem inextricable the profession, and an almost universal to those working in health - with stories such as Yumiko Kadota’s a fairly saddening indictment of the current climate (1).
In the other hand a health systems narrative - a statistically unpredictable and fluctuating patient load intersecting with a fixed-staffed department, interwoven with bottlenecks of imaging and diagnostic services, coupled with the exponentially increasing documentation requirements (2) and medicolegal ramifications that pervade the modern healthcare climate mean that the system itself is fundamentally incapable of accommodating the idealistic throughput so avidly sought by administration. Such turnover not possible without due counterbalance of briefer and riskier consultations, run with the kind of heuristic, seat-of-your-pants, system 1 thinking required for high turnover - this risk becoming entirely inherited by the individual practitioner, as evidenced in the Bawa Garba saga (3).
And there seems no way to truly reconcile these two competing storylines, not least any satisfactory armistice with which I am familiar. For myself, and I am sure for many others, this cognitive tug-of-war will continue without reprieve, each day and each shift, undulating between a sense of guilt from personal shortcomings, and helplessness as a cog in the wheel. I don’t know that there is ever going to be any clearer of a line between the two, and I don’t know that a happy middle ground or goldilocks zone truly exists somewhere between crippling self-doubt or jaded cynicism at each extreme. What I do know is that I am unconditionally grateful to all who can compose themselves to work and thrive each day in such an environment - let such steadfast dedication not be undervalued.
NB: All situations and patient cases described above are for illustrative purposes only and do not relate to any specific persons. The health situation detailed above is fictional and does not reflect any scenario occurring in any specific hospital, health network, or district, at any time. All patient case details are fictional and for illustrative purposes only, and as such, any association to real cases, health networks, hospitals, or situational similarities are therefore entirely coincidental and unintentional.
T Michniewicz, August 2019
Reference
1. Kadota, Y (2019) ‘Physically alive but spiritually broken: why I had to resign as a junior doctor’. The Guardian [online]. Available from: <https://www.theguardian.com/commentisfree/2019/feb/08/physically-alive-but-spiritually-broken-why-i-had-to-resign-as-a-junior-doctor> [Accessed 02/08/2019].
2. Xu, R (2018) ‘A major medical crisis: doctor burnout’. The Atlantic [online]. Available from: <https://www.theatlantic.com/health/archive/2018/05/the-burnout-crisis-in-health-care/559880/> [Accessed 07/08/2019].
3. Ketchell, M (2018) ‘What happened in the Bawa-Garba case and why was reinstating her the right decision?’. The Conversation [online]. Available from: <http://theconversation.com/what-happened-in-the-bawa-garba-case-and-why-was-reinstating-her-the-right-decision-101606> [Accessed 02/08/2019].
4. Reason, J (2000) ‘Human error: models and management’. BMJ. 320(7237): 768-770. Available from: <https://www.jstor.org/stable/25187420> [Accessed: 09/08/2019].
5. Calderwood, K and Miskelly, G (2018) ‘NSW needs nurses as ‘catastrophic’ shortage predicted to affect patient care’. ABC News. Available from: <https://www.abc.net.au/news/2018-01-12/nsw-set-for-major-shortage-of-nurses-and-midwives/9321464> [Accessed: 09/08/2019].
6. Campbell, D (2018) ‘NHS ‘could be short of 350,000 staff by 2030’. The Guardian. Available from: <https://www.theguardian.com/society/2018/nov/15/nhs-could-be-short-of-350000-staff-by-2030> [Accessed: 08/08/2019].
7. The Economist (2019) ‘A shortage of staff is the biggest problem facing the NHS’. Available from: <https://www.economist.com/britain/2019/03/23/a-shortage-of-staff-is-the-biggest-problem-facing-the-nhs> [Accessed: 08/08/2019].
8. Johnson, S (2018) ‘Patient safety hit by lack of staff, warn 80% of NHS hospital workers’. The Guardian. Available from: <https://www.theguardian.com/society/2018/mar/18/hospitals-staff-shortage-nursing-nhs-rcn-patient-care-sarah-johnson-survey> [Accessed: 08/08/2019].
9. World Health Organization (2013) ‘Global health workforce shortage to reach 12.9 million in coming decades’ [online]. Available from: <https://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/> [Accessed: 08/08/2019].
10. Australian Institute of Health and Welfare (2018) ‘Emergency department care 2017–18: Australian hospital statistics’. Health services series no. 89. Cat. no. HSE 216. Canberra: AIHW. Available from: <https://www.aihw.gov.au/getmedia/9ca4c770-3c3b-42fe-b071-3d758711c23a/aihw-hse-216.pdf.aspx?inline=true> [Accessed: 09/08/2019].
11. Girgis, L (2018) ‘Meditation, yoga, and mindfulness aren’t going to solve physician burnout’. Kevin MD [website]. Available from: <https://www.kevinmd.com/blog/2018/10/meditation-yoga-and-mindfulness-arent-going-to-solve-physician-burnout.html> [Accessed: 10/08/2019].
12. Zavala, A, Day, G, Plummer, D, Bamford-Wade, A (2018) ‘Decision-making under pressure: medical errors in uncertain and dynamic environments’. Australian Health Review. 42(4):395-402. doi:10.1071/AH16088. Available from: <https://www.ncbi.nlm.nih.gov/pubmed/28578757> [Accessed: 10/08/2019].
13. AlQahtani, D, Rotgans, J, Mamede, S, Mahzari, M, AlGhamdi, G, Schmidt, H (2018) ‘Factors underlying suboptimal diagnostic performance in physicians under time pressure’. Medical Education. 52(1): 1288–1298. doi:10.1111/medu.13686. Available from: <https://onlinelibrary.wiley.com/doi/pdf/10.1111/medu.13686> [Accessed: 10/08/2019].
14. Tsiga, E, Panagopoulou, E, Sevdalis, N, Montgomery, A, Benos, A (2013) ‘The influence of time pressure on adherence to guidelines in primary care: an experimental study’. BMJ Open. 3(4): e002700. doi:10.1136/bmjopen-2013-002700. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641486/> [Accessed: 10/09/2019].
15. Carayon, P (2007) ‘Production pressures’. Patient Safety Network [website]. Available from: <https://psnet.ahrq.gov/webmm/case/150/> [Accessed: 10/09/2019].
16. Adams, J and Bohan, S (2000) ‘System contributions to error’. Academic Emergency Medicine. 7(11):1189-1193. Available from: <https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1553-2712.2000.tb00463.x> [Accessed: 10/09/2019].
17. Ketchell, M (2016) ‘Blaming individual doctors for medical errors doesn’t help anyone’. The Conversation [website]. Available from: <https://theconversation.com/blaming-individual-doctors-for-medical-errors-doesnt-help-anyone-28212> [Accessed:10/09/2019].
18. British Medical Association (2018) ‘Working in a system that is under pressure’. Available from: <https://www.bma.org.uk/collective-voice/influence/key-negotiations/nhs-pressures/working-in-a-system-under-pressure> [Accessed: 09/08/2019].
19. Cameron, P (2006) ‘Hospital overcrowding: a threat to patient safety?’. MJA. 184(5):203-204. Available from: <https://www.mja.com.au/system/files/issues/184_05_060306/cam11160_fm.pdf> [Accessed: 10/08/2019].
20. Ward, M, Ferrand, Y, Laker, L, Froehle, C, Vogus, T, Dittus, R, Kripalani, S and Pines, J (2015) ‘The Nature and necessity of operational flexibility in the emergency department’. Annals of Emergency Medicine. 65(2):156-161. doi:10.1016/j.annemergmed.2014.08.014. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302065/> [Accessed: 10/08/2019].
21. Alavi-Moghaddam, M, Forouzanfar, R, Alamdari, S, Shahrami, A, Kariman, H, Amini, A, Pourbabaee, S and Shirvani, A (2012) ‘Application of queuing analytic theory to decrease waiting times in emergency department: does it make sense?’. Archives of Trauma Research. doi:10.5812/atr.7177. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876544/> [Accessed: 10/08/2019].
22. Chowdhury, N, Riddles, L, Mackenzie, R (2018) ‘Using queuing theory to reduce wait, stay in emergency department’. American Association for Physician Leadership [website]. Available from: <https://www.physicianleaders.org/news/queuing-theory-reducing-wait-stay> [Accessed: 10/08/2019].
23. Vass, H and Szabo, Z (2015) ‘Application of queuing model to patient flow in emergency department. case study’. Procedia Economics and Finance. 32(1):479-487. Available from: <https://www.sciencedirect.com/science/article/pii/S2212567115014215> [Accessed: 10/08/2019].
24. Northern Rivers University Department of Rural Health (2009) ‘Literature review of emergency department staffing redesign frameworks’. The University of Sydney and Southern Cross University, Australia. Available from: <https://www.health.nsw.gov.au/workforce/Documents/literature-review-emergency-department-staffing.pdf> [Accessed: 10/08/2019].