A few days ago, I was speaking to an assembled group of residents . It was late in the afternoon and I could tell that the residents’ eyes were becoming heavy. The topic was Quality Improvement and Patient Safety, (QIPS), one of my favorites, because it can make such a difference in the lives of our patients, but not an easy topic for tired residents. I described the history of QIPS and how anesthesiologists had been the early leaders , focusing on problems due to preventable operative deaths, but that now all specialties were engaged in the area. Residents had become a focus of concern later, when fatigued and unsupervised residents were implicated in a patient’s death in New York leading to the development of duty hours limitations for residents. These statistics did not seem to awaken much interest in my topic, so finally I mentioned that some institutions were offering monetary rewards for quality improvement activities.
“How much?” asked one of the sleepy residents.
“Let’s say $800 in one year. I think that was the average bonus at an institution that rewarded residents for achieving QIPS goals.”
Now the residents’ eyes were wide open. “Really? Could we do that here?”
“I don’t know. “ I went on to tell them about the program at UCSF that is featured in our March issue of Academic Medicine. In that program residents have identified goals in patient satisfaction, QIPS and operational utilization and achieved significant improvements in the areas identified by the institution. The authors mentioned that initially there were debates about whether providing incentives might send the wrong message to resident physicians who should be working on improving care as part of their professional obligations. But ultimately the institution agreed to try it, and the results thus far had been encouraging. The residents were all enthusiastic about our starting the same type of program at our institution. “I’m not sure I could talk the administration into coming up with that kind of money,” I said.
“But won’t we lose even more money if we don’t reduce our re-admissions and hospital acquired infections?” said another resident.
“Good point. Well, I will ask about it,” I said, “but in the mean time I would like you all to think about projects you could initiate right now. What areas would you select?”
The residents identified problems with communications between the nurses and doctors, the electronic medical record, clinic wait times, and unnecessary pages in the middle of the night that disrupted their sleep. They were particularly irritated at the calls in the middle of the night that could have waited until the morning. In this month’s Academic Medicine there is an article on protected nap periods for residents that improved the amount of sleep residents got on night duty. Such a system might improve resident alertness and reduce the burnout that affects many residents during training, and diffuse the frustration about calls that could wait until the morning. Another article from our March issue by Dyrbye et al investigated burnout and depression among residents during training. Not surprisingly the burnout and depression scores of residents exceeded that of similarly aged individuals who had graduated from college . As we consider engaging our residents in QIPS, whether we provide financial incentives or not, we should commit ourselves to identifying and addressing those issues that contribute most to resident fatigue, burnout and depression and to improve their quality of life so that they have the enthusiasm and energy to improve the quality of care of our patients. A recent book of stories by leaders in medical education edited by Headrick and Litzelman describes how passionate, dedicated and visionary education leaders can create a supportive, dynamic and healthy learning environment that will facilitate the education of faculty and students. When we wonder how we can bring about the changes in thinking that will lead to effective action to improve our health care system, this book of stories should encourage us to make that effort, as it demonstrates numerous examples of success in changing medical education. It reminds us how much each of us can do through inspiring others and how important educators can be as agents of change for our health care system.