Switch - Chip Heath [100]
The story of Libby Zion became the centerpiece of a campaign to limit the workweeks of medical residents. Almost two decades later, in 2003, Congress finally seemed ready to move. Then the American Council for Graduate Medical Education—which accredits medical schools—made an effort to preempt congressional legislation by requiring 80-hour workweeks for residents starting in July 2003. That might seem to be the end of the story. A switch happened in medical schools because someone with fiat power mandated the change.
In this case, though, fiat power failed. A subsequent study by the Journal of the American Medical Association found that only a third of general surgery residency programs complied with the new workweek limits. Why would hospitals fail to change their ways in spite of the fact they were putting patients at risk (as well as their own accreditation)?
Katherine Kellogg, an ethnographer at MIT’s Sloan School of Management, wanted to understand why some organizations complied with such regulations and others didn’t. She decided to study two northeastern teaching hospitals, nicknamed Alpha and Beta, that were well matched in size, sector, structure, and other factors. She was given full access to the staffers of the two hospitals, and she observed the two hospitals for an average of twenty hours a week, each, for fifteen months. Kellogg was the perfect eyewitness to a real-world cultural change effort.
6.
In the quest to reform, the fiercest battle would be fought over a surprisingly mundane practice called the “daily signout.” The daily signout is the point, usually about 9 or 10 p.m., when surgical interns hand off their patients to the on-call night resident. During the signout, the intern briefs the resident on each patient’s status, so that the resident is prepared to take care of any emergencies that happen overnight.
But interns weren’t really handing off their work, and that’s one reason why they were working 120 hours a week. On every third night, there was no handoff at all—the interns were on duty all through the night. And on the other nights, they stayed late to finish the paperwork they should have handed off. Worse, night residents usually refused to do any paperwork overnight, so the interns had to show up early the next morning—at, say, 4 a.m.—to complete it before beginning their normally scheduled rounds at 6 a.m.
To enforce an 80-hour workweek, the hospitals needed to start taking the daily signouts seriously, but that wasn’t quite as easy as it sounds. Emotional resistance to reform was entrenched in both Alpha and Beta and, indeed, in most hospitals across the country. Signing out conflicted with long-standing cultural practices. For instance, one opponent said, “You learn by being here. There is a huge amount of information passed on in an ad hoc fashion at 2 o’clock in the morning when the senior resident and you are trying to get a patient’s blood pressure up or an IV in. You need to be the one managing it, doing it, in order to learn.” (In other words, interns would be putting their medical education at risk by, er, sleeping.)
Other opponents stressed the importance of “continuity of care”—minimizing the number of times that patients were passed among doctors. As one resident said, “The problem with handoffs is that things fall through the cracks and things get missed.” A final objection, in essence, was that if the interns didn’t pay their dues, it would be unfair to everyone who’d already put in time as the paperwork lackeys: “These guys have been there and done that…. You can see how it would be tough as a fourth-year resident