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In 2003, in the face of errors and accidents caused by medical and surgical trainees, the American Council of Graduate Medical Education mandated a reduction in resident work hours to eighty per week. Over the course of two and a half years spent observing residents and staff surgeons trying to implement this new regulation, Katherine C. Kellogg discovered that resistance to it was both strong and successful—in fact, two of the three hospitals she studied failed to make the change. Challenging Operations takes up the apparent paradox of medical professionals resisting reforms designed to help them and their patients. Through vivid anecdotes, interviews, and incisive observation and analysis, Kellogg shows the complex ways that institutional reforms spark resistance when they challenge long-standing beliefs, roles, and systems of authority.
At a time when numerous policies have been enacted to address the nation’s soaring medical costs, uneven access to care, and shortage of primary-care physicians, Challenging Operations sheds new light on the difficulty of implementing reforms and offers concrete recommendations for effectively meeting that challenge.
3:50 A.M., WEDNESDAY
When Anne (a pseudonym) crept out the back door of her apartment building, a blast of cold, damp air hit her face. It was dark, 3:50 a.m. She closed the door quietly behind her and, shivering in her threadbare lab coat and scrub pants, found her way to her beat- up gray Honda. Anne pulled out of the parking lot and drove slowly down Springdale Avenue. At the traffic light, she yielded to the urge to let her head fall back on the headrest. Abruptly, she forced herself awake, leveling her head, straightening her arms against the steering wheel, and opening her mouth in a large yawn. It was only a five- minute drive from her apartment to the hospital, but she had fallen asleep waiting at traffic lights more times than she could remember. She was luckier than one of her fellow surgical residents: he had been in a car accident after drifting across a highway median line while driving to see his girlfriend on a rare weekend off.
In the United States, doctors like Anne who graduate from medical school receive the degree of medical doctor (MD) but are not permitted to practice medicine on their own. Those who hope to become surgeons must complete a five-year clinical training program (often with an additional two years in the laboratory) called surgical residency. During this time, under the tutelage of surgical "attendings" (staff surgeons), residents learn to diagnose patients, recommend potential surgeries, operate on patients, and provide post-surgical care. After the completion of their residency programs, they can enter into surgical practice.
Anne pulled into the low-ceilinged hospital garage and parked. She absent-mindedly buttoned up her white lab coat and pulled back her wiry red hair into a black scrunchie as she walked up the sidewalk to the hospital entrance.
I met Anne as she walked through the hospital's revolving doors at 4:00 a.m. Like her, I was dressed in surgical scrubs, a lab coat, and leather medical clogs. And I was bleary-eyed and tired like her, too. I marveled, as I had many times before, at Anne and the other residents' ability to arrive at work on time every morning while keeping up the punishing schedule of every third night on call.
To effectively study institutional change as it occurred on the ground, I needed to begin by establishing a baseline of how work had traditionally been done. That is why I was there on that damp June morning before any new compliance program had been introduced, observing Anne, an intern (first-year resident) assigned to the surgical oncology service that month.
A janitor pushed a mop across the gleaming marble floor of the dark, empty lobby and a stern-looking woman at the security desk glanced at our badges as Anne and I made our way toward the elevator bank. We took the elevator up to the eighth floor and I followed Anne to one of the call rooms. She entered a five-digit code on the metal keypad, and we went in. Light from the hallway fell across the body of a resident, asleep under a white cotton blanket. It was Ryan, the senior resident who was working on the oncology service with Anne.
At Anne's hospital, as in surgical residency programs at other hospitals across the country, teams of "chiefs" (fifth-year residents), "seniors" (second-, third-, and fourth-year residents), and "interns" (first-year residents) took care of ten to twenty patients on each general surgery service (e.g., surgical oncology, vascular, gastrointestinal [GI]). A team was typically composed of a chief, a senior, and an intern. Chiefs formulated daily plans for each patient on the service and assisted surgical attendings in difficult "cases" (operations) throughout the day. Seniors cared for the complex issues of general surgery patients and assisted attendings with moderately difficult cases. Interns implemented patient plans and assisted attendings with simple cases. Attendings worked on a particular service and operated with the team of residents assigned to that service for the month. Department directors (surgeons themselves) managed administrative issues associated with the attendings' activities and the surgical residency program (figure 1.1).
Since residents rotated through different surgical areas such as oncology, GI, vascular, and colorectal as well as working stints at community hospitals, they frequently changed work groups. As an intern, Anne spent four weeks on each rotation, and she had been on the oncology service since Monday. Ryan, who as a senior resident spent six to eight weeks on each rotation, had stayed overnight on call for the service last night.
"Morning. Anything happen last night?" Anne asked. Ryan flipped the lights on, blinking hard once. The call room had no windows and was so small that the one single bed almost filled it. There was just enough room for a bedside table and a walnut-colored wooden desk. A few graying lab coats hung on hooks next to the door. Ryan sat up in his scrubs, picked up his patient printout from the bedside table, and went through the list with Anne. "Anderson, nothing. Whelan, nothing. Cooper, I bolused him [gave him extra fluids]." He went through the rest of the patients. The exchange took about three minutes. Anne took the pile of dog-eared white index cards off the desk—one card for each patient on the service—and shut the door behind her. Ryan went back to sleep.
I had just witnessed the morning version of a long-standing daily work practice—the "sign out" between the intern and the on-call resident—a practice that, I had discovered, would have to change if residents were to reduce their work hours to eighty per week. As an intern, Anne was responsible for all the routine work associated with the pre-and post-operative care of patients on the surgical oncology service. Since she had not been on call this night, she had had to stay in the hospital the previous evening until about 10 p.m. to complete this routine work. She then had met with Ryan to "sign out" to him. During sign out, she had reviewed general information on the work she had done and alerted him to potential problems. After Anne left, Ryan, as the on-call resident, had taken care of any emergency patient care issues that arose for these patients overnight.
Anne, like other interns I observed before the initiation of the change effort, had not attempted to hand off any routine work tasks (such as completing paperwork required to admit a new patient) during her evening sign out. Interns took care of all of this "scutwork" themselves, even though doing so often required them to stay in the hospital until 9 or 10 p.m. and to arrive the next morning at 4 a.m. Historically, sign out encounters between interns and residents covering overnight had been characterized by the practice of "no handoffs."
This morning, like most mornings, Anne had returned at 4 a.m. to "pre-round" on all the patients—checking each of them, recording their "vitals" (vital signs), and writing progress notes—before beginning morning rounds with the other residents on the service at 6 a.m. In the morning sign out encounter I had just observed, Ryan had signed out to her by reporting on overnight emergencies. Since Ryan, as a senior resident, had not covered routine work tasks overnight, such as gathering vitals for morning rounds, he did not hand off any such tasks to her in the morning sign out encounter. Once Ryan had signed out to Anne, he was free to sleep until morning rounds began at 6 a.m.
Anne and I took an elevator up to the eighth floor, and Anne went to the computer on the tall, semicircular desk, "the pod," that wound around the middle of the patient floor. A nurse with a competent air was sitting down inside the desk circle, pencil to her lips, as she read progress notes in a red patient notebook. By 7 a.m., the floor would be full of technicians wheeling hospital carts, nurses talking with one another as they visited patient rooms, and teams of doctors briskly making their rounds. But now, at 4:10 a.m., all was quiet.
Anne stood at the computer on the outside of the desk and sorted the patients on the oncology service in descending order of hospital floors—seventeen patients. Not bad, but she'd be cutting it a bit close if she wanted to be done by 6 a.m. She went to the chipped metal rack outside the pod to find the blue notebook of the first patient on the list—blue notebooks were for recording patient vitals, red were for progress notes. Anne groaned, exasperated. She always had to hunt to find the notebooks, because the nurses never put them back where they should be in the alphabetized rack. One more thing to delay her when she was already pressed for time. Lack of sleep was making her irritable. In real life she wasn't like this. But real life was at least six years in her future at this point.
Anne didn't find looking ahead to be that helpful. She had heard that the second year of surgical residency was also terrible. Third year might be a little better. The lab sounded good (most surgical residents spent two years in the lab learning to do research in the middle of their residency). She couldn't wait to spend time away from here. It made her anxious to look ahead to her fourth and fifth clinical years, because then she would be expected to have reached a certain level of skill.
Anne dug the white index cards out of her lab coat pocket and shuffled through them to find the card for Anderson, the first patient on her list. Her pockets were bulging with pens, patient lists from earlier days, stickers noting the names of the patients she had operated on, a pocket notebook of drugs, and a phone list with consult and department phone numbers. She searched for the red notebook on Anderson and turned to the back of the progress notes to make sure the nurse hadn't made any comments from last night. Nothing. Good. This guy could go home today, as soon as PT (physical therapy) saw him.
She needed to move the patients out so her list didn't get too long. Each patient meant about an hour of work a day. She began to resent people who stayed in the hospital longer than they needed to. When patients got nauseated, she wanted to tell them, "Suck it up." Sometimes she even pushed them out of the hospital sooner than she should have. She knew that was bad. From my observations of the other residents, I knew that this attitude was not unique to Anne. Because they worked such long hours, in order to get through each day residents cut corners on many things not absolutely critical to patient care. Pressing nauseated patients to leave the hospital fell into this category.
Anne went from patient to patient, floor by floor, using the staff-only staircase, finding the patients' blue and red notebooks and writing their vitals on her white cards. She used the list of patients she had printed out to track what she had done on each: L (checked labs), N (wrote progress notes), $ (discharged patient). When she had started her residency the previous July, she had been amazed at the huge amount of hours she had to spend copying numbers from one piece of paper to another. She and her fellow residents had been to medical school at places like Harvard, Stanford, and Johns Hopkins, and she had expected to spend her time during residency operating and engaging in hands-on patient care. If initially all of this paperwork had been useful to her education, it had stopped being so a long time ago. She spent hours each day doing routine administrative work. But she was too tired to worry about that now.
As it got closer to 6 a.m., Anne began to move more quickly, flipping through the notebooks rapidly and taking the stairs two at a time. Mornings were fast-paced because the residents needed to see all of the patients on this list first before showing up in the OR at 7:30 a.m. It was a ritual in surgery to see all the patients in the morning. The residents explained that physicians in other specialties just talked, talked, talked about the patients all day long. Surgeons, they said, always put their hands on their patients and actually took action instead of endlessly talking. That's why you became a surgeon, they explained: you liked the immediate gratification of fixing someone instead of waiting around watching them for ten years and never seeing any improvement.
At 5:57 a.m., Anne finished getting the numbers for the last patient. She took the elevator back up to 8 and went to the pod. Ryan was already there talking to the medical student on the service about Morris, a new patient. With the gallows humor common on surgical wards, they joked about his long list of problems—neutropenia, CNS (central nervous system) dysfunction, port-related infection, pain, nausea, and on and on. Neuro (the neurosurgery department) had turfed him to them (sent him to the surgical ward), and the general surgery residents weren't pleased about it. They hadn't even operated on this guy and now here he was, parked on their service, taking up their valuable time.
At 6 a.m. sharp, Bill, the chief resident, arrived. Anne handed Bill a list of patients. Mission accomplished. At least for now.
8:30 P.M., WEDNESDAY
Anne's day had been relatively uneventful, and because she was the one on call that night, there was no evening sign out to observe between her and Bill or Ryan. At 8:30 p.m. I watched her prepare for her night on call. The whole floor had quieted down. There was one nurse sitting at the pod, and the rest were walking around.
At the computer in one of the call rooms, Anne pulled up her list of patients. Only fifteen. That was light. When she had been working on thoracics (the thoracic surgery service), she said, she'd have two sheets single-spaced, and they'd all be complex patients with acute illnesses.
Anne started to prepare some of her discharge orders. As she was doing so, a nurse paged her about a patient who had been operated on that day. Anne went down to the PACU (post anesthesia care unit) on the basement floor to check the patient's wound. She needed to make sure there was no hematoma (subcutaneous bleeding that can occur after surgery). As soon as she returned to the eighth floor, she was paged by a different post-op nurse. She called back curtly, "I was literally just down there." She hung up the phone and turned to me: "Welcome to my world."
She told me that being on call every third night had made her depressed and bitter. Winter was especially bad because she never saw daylight—it was dark in the morning when she came in at 4 a.m. and dark again when she left at 9 or 10 p.m. Anne said she saw her friends about once every three months. She had expected to see them more. It was really hard to be around them. Their table conversation, their perspective, their lives were so very different. Part of her felt irritated listening to it, and part of her asked why she couldn't have it too. She tried not to think about marriage and kids, but she thought about both daily, hourly. "I think it's bullshit. I think about it all the time. I care about my personal life. I don't want to be a woman surgeon, old and alone. I turn a deaf ear, though. You know what it is, so be it."
A patient paged Anne from his home. He had recurrent metastatic colon cancer—a forty-eight-year-old guy with kids. His recurrence was localized, so they had thought they might get the growth out and treat him with chemo. He was young and otherwise quite healthy, a nice person with a family. It was a horrible disease, and right after the operation he had the complication that his bowels didn't start working right away. Now he was leaking gas into his belly. When Anne had seen the leak yesterday, she had hoped that it would go away.
She pursed her lips, upset. I asked her how she handled bad news like this. She said that she tried to be academic about it, that it was to be expected, that this was the way it was. She tried to remember that this was a high-profile tertiary care center—they got the hardest cases, the ones with the most complications, the ones the community hospitals had turned down. But it was tough caring for patients who were so critically ill, she said, especially when she was so tired.
As the night progressed, Anne continued to answer pages. The interns referred to their pagers as "devil machines." Anne's pager beeped, and she took it from her pocket to read the text message. "Can the patient shower?" "No," she texted back. A few minutes later it beeped again. "Does the patient still need telemetry [connection to a machine that measures data such as blood-oxygen level and sends it to computer screens for nurses to monitor]?" She texted back, "Yes, per order 1 hr ago." She turned to me: "Telemetry is something that is hard for the nurses to do, so they are always trying to get us to stop it."
One problem with the long hours, Anne said, was that she spent a lot of time hating the patients. Sometimes, if they considered her their doctor or if she had made a small difference in their day or their life, it was great. But it was gratifying only briefly, and anyway, it didn't happen a lot. It was hard to build any kind of relationship with them, because she was too busy. She said that she took longer to round in the afternoon than most because she had a sense of guilt. She believed that she needed to give them at least five minutes of her time and not be rushing in, ripping off their dressings, and leaving.
At around 11:30 p.m., Anne went to the call room to sleep. There was one call room for the oncology service; everyone on the team shared it because only one of them was on each night. There were silverfish bugs all over, and no matter how much the hospital cleaners sprayed, they couldn't get rid of them. But Anne was so tired that bugs were the last thing on her mind. She fell asleep right away, praying for no Tylenol calls (routine requests from nurses, preferably handled during the day).
Excerpted from CHALLENGING OPERATIONS by Katherine C. Kellogg Copyright © 2011 by The University of Chicago. Excerpted by permission of UNIVERSITY OF CHICAGO PRESS. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Part I: The World at 120 Hours a Week
1 A Day in the Life of an Intern
2 Similar Hospitals, Similar Programs
3 Meet the Iron Men
4 Potential Reformers
Part II: Collective Combat
5 Defending Stability
6 Relationally Mobilizing for Change
7 Countermobilizing for Resistance
8 Collectively Disrupting
Conclusions and Implications