Complexity in Hospital Medicine

I attended a talk today by patient safety guru Dr. Wachter (whose book I reviewed previously) and it really got me thinking. The problem with modern day medicine is that it is awfully complicated. In the past, doctors only needed to know 40 or so drugs very well: heparin, morphine, digoxin, beta-blockers, and a few antibiotics. Today, the capable intern needs to know about 10 times more medications. Each area of the hospital - wards, emergency department, operating rooms, intensive care units, even psychiatric units - has become more specialized; equipment has become more esoteric; patients have become more "complex" meaning those with diseases which may have been fatal in the past are now surviving.

In the past, the well-trained, hard-working, well-meaning physician could be successful; by sheer diligence and integrity, he could take good care of his patients. Dr. Wachter argues that this is no longer the case; we must still have well-trained, hard-working, well-meaning doctors of course, but this is no longer sufficient. The complexities of medicine make it so that even a perfect doctor will make mistakes. This is a hard fact to swallow; we don't want to think that a person who does everything by the textbook will mess up, but he argues that human error is inevitable. Despite the years of school and postgraduate training to make a doctor, medicine has become so hard that we cannot always do everything perfectly. To err is human. As a result, we must set up systems and barriers that prevent inevitable human error from affecting patients. Whether it is computer prompts about medication interactions, nurses reading-back orders to confirm them, a culture where medical students can challenge an attending, or checklists to make sure anesthesiologists don't forget antibiotics, something more than "training good doctors" must be in place. Great doctors are necessary, but not sufficient for great care.