Monday, December 28, 2009

The Days of Christmas - Number 12 - Christmas Reflections

Well the first thing to do is to apologise that this is so late...but I've got a fair excuse. I've spent the whole Christmas period in increasing pain, culminating in a trip to the Emergency Department today. I hope, after 7 hours there, that I'm finally on the improve, though it's not really clear at the moment.
Seven hours, mainly waiting, gives you some time to reflect. The thing that always comes to me is that EDs are amazingly inefficient. It's interesting to speculate on why this is. What is clear though is that the process is not very streamlined, not designed for speed and effectiveness. What it appears to be designed for is to deliver on the antiquated notions about how a doctor should do their job.
Before I go further I need to say two things: Firstly, every time I've been to an Australian ED the care has been exemplary for whoever the patient was. Protracted, a feat of endurance, but great care. The second thing is that on a number of occasions I've been to an ED and have been startled by the speed with which they have assessed and treated the patient. Royal Hobart Hospital holds the record: 15 minutes to clerk the patient in, assess them, suture the wound and kick them out onto the street. The suture line was very pretty and the result was great. It is therefore possible to be efficient.
Go to a busy ED on a busy day however and you see the system failing. Each and every staff member, individually works hard to do a great job, to look after the patients and to get a good outcome. Collectively however the system creaks and groans. Staff are often tired and overworked, the "doctor system" just doesn't work. It is patently inefficient, repetitive and slow.
The difficulty is that doctors, by and large, believe that doctors and only doctors are the people who are capable of understanding the system. Therefore it is only doctors who are capable of proposing change. Take the matter of overwork. Which other profession would not only tolerate fatigue from excessive working hours, but actively propose that it was necessary to achieve good training outcomes? The airlines, the maritime industry, train and truck drivers are all subject to mandatory maximum working hours and prescribed rest periods. We know from detailed research that fatigue has a similar effect on human performance to excessive alcohol intake. The medical profession continues to argue that in order to get the necessary amount of patient contact during a period of training, doctors must work excessive hours - sometimes shifts of 24 hours or more. Sorry that's simply wrong, negligent and unacceptable. Quality not quantity is what we should be aiming for and please don't let me hear "I did it so why shouldn't this generation". Yes steps have been taken, but we are still a long way off.
I think there is also plenty of evidence from a wide range of fields that often really effective change is generated by a set of outside eyes. A new perspective leads to challenge and change that never would have occurred if those who "own" the system are left to their own devices. I suggest that this is never more true than in Emergency Departments. These are intensive environments, resource hungry and highly inefficient. The nurses, doctors, radiographers, porters, cleaners, ambos and all the other staff deserve a better working environment. The patient, oh so patient, population deserve a better deal. Ultimately as a society we can't afford the continued inefficiency.
Someone I know, a medico, once tried to reform the system at a major ED. He described the "assassination" process that ultimately led to his demise. It wasn't pretty and it points to the inordinate power that the medical establishment wields. It was ultimately the worst sort of industrial thuggery.
The irony is that perhaps the biggest beneficiaries of real reform at the coal face - the EDs - would be the staff. Reform can't come soon enough for them - or for me!

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