The Maynard Doctrine: Killing patients is wrong!

Health economist Professor Alan Maynard outlines recent research into  changeovers of the new staff – the July effect – and suggests that killing patients is wrong.

The mortality and morbidity effects of being admitted to hospital as a patient out of usual working hours in the week and over the weekend have been well chronicled for decades, At those times, you have a higher risk of dying and having serious morbidity effects if you survive. This is a product of staffing, delays in diagnostics and delays in treatment.

Another significant threat to patient well being is junior doctor change over dates e.g. this coming August in the NHS. This is when callow, newly graduated doctors (F1s) and those progressing in training (F2s) change posts and confront the realities of clinical care outside the protected walls of their medical school.

In a recent edition of Annals of Internal Medicine, there is a systematic review of international evidence of what they call the “July effect”, when juniors who are training, interns and residents in US parlance, change jobs to develop their learning.

The authors (Young, Ranji, Wachter, Lee, Niehaus and Auerbach) identify some very bad effects. Of the 39 studies, they found of the changeover 69 percent reported increased mortality, 46 percent reported declines in efficiency (e.g. longer lengths of stay and duration of procedures), 59 reported increased morbidity and 15 percent reported medical errors.

The most robust of these studies showed increased mortality and decreased efficiency.

Not a new problem; not being fixed either
In an accompanying editorial, Branach and Philibert argue that junior change over is a suitable subject for “systems improvement”. They note that despite a decade of patient safety initiatives in the USA, preventable errors continue to rise.

The problem of poor care at changeover is a product of “clinical inexperience, inadequate supervision of trainees functioning in new clinical roles and loss of “system’s knowledge” due to team changeover and the departure of “systems literate clinicians”.

They note that these problems have been evident and written about for 20 years with little response to improve systems of care.

Shall we tell patients?
Clearly, it is best to avoid admission to inpatient facilities at times of changeover of junior staff. But how many patients know about this and can make a choice to avoid these risks?

Elective patients might decide August is not a time for treatment. But emergency patients - the majority of patients entering care - do not have the ability to choose. Is enough being doing to protect them? These papers clearly demonstrate that there are major failings.

Are we looking at this? Um, no
So how can we get better practice? Does the Care Quality Commission collect such data and hold hospitals to account? I fear not!

Does the tax-financed General Medical Council and the publically subsidised Royal Colleges who are in charge of medical training monitor these problems and invest in proven interventions to protect the patient?

I look for some evidence; but as is usual with the GMC, they seem laggardly and more concerned with protecting practitioners - which is a breach of their statutory duty, which requires a primary focus on patient protection.

As in the US, so it is in the NHS. Poor systems of training and managing bright but callow trainees at change-over ensure  that hospitals kill patients and waste resources due to increased lengths of stay.

Physicians, heal thyselves! Killing patients is wrong!