Guess What. Tired People Make More Mistakes. (Surprised?)

It comes as no revelation to us that we make more mistakes when we are tired. Drive late at night, and you will undoubtedly notice that you’ve got a slower reaction time and that your mind wanders more. Think of the silly errors you make when it is late at night and you are dead tired. Ever find yourself squeezing out more shampoo right after you already washed your hair? Despite what the brilliant marketing label says (Lather. Rinse. Repeat.), most people only wash once. The point is that there is no surprise that we slip up in a direct relationship with the elapsed time since our heads last hit a pillow.

So, it is with no great surprise that I recently read an article about the risk of infection and its relationship to the workload of a nurse. The statistics quoted in the article are somewhat strange.

A 2002 study found that adding a single patient to a nurse’s caseload increased the risk of dying within a week by 7 percent. Boosting the load from six patients to eight increased the risk by 31 percent over a nurse caring for four patients.

Hard to precisely follow what the author was trying to say, but it is clear that more work = worse results once a certain threshold was reached. No surprise there.

Of course, medical residents still routinely work ungodly numbers of hours in the name of education. The theory is that the more they are exposed to, the more they learn. I suspect that their mistake stats mirror those of the nurses, and perhaps even exceed the magnitude. Residents are, after all, still learning their craft.

Add in the demand due to new healthcare legislation, and the system is ripe for an epidemic of errors. There could be a shortage of 90,000 doctors in the US by 2020 as a result of adding 32 million people to the rolls of the insured. Since it takes 10 years or so to make a doctor, there should have been a big uptick in admissions a decade ago to prepare for the sudden additions to patient demand.

This comes at the same time the insurance companies are increasingly reducing payments to physicians. Furthermore, malpractice premiums are rising, and lawsuits for malpractice are increasing in both frequency and the size of the awards. The American Medical Association estimates that 75% of all physicians in “low-risk” specialties will face a malpractice claim by age 65. The high-risk specialties? A whopping 99%! And the costs associated with a lawsuit rose 13.9% from 2000 to $324,969 in 2009.

So, what is in store? Unless those in charge do something drastically different, here’s what I take away from the combination of the facts listed above.

1. In the short term, flooding the current healthcare system with tens of millions of new patients will dramatically increase waiting time in walk-in clinics, and grossly extend the time it takes to see a specialist. This will increase the acuity of medical conditions left to fester, requiring more treatment, further straining the system.
2. Already stressed doctors and nurses will face a much larger workload. That means more mistakes. Fixing those mistakes will also increase demand on the system.
3. Lean healthcare efforts will take a hit, as they may not be able to overcome the external pressures. Despite best efforts, costs, quality, and waiting times may all drift in the wrong direction. Lean may slow the drift, but some will still say that the lack of improvement will be an indicator of Lean’s ineffectiveness in healthcare. If Lean efforts slow down, the impact of the rest of this list will be larger.
4. Admissions standards for medical training programs will be lowered. A dramatic increase in the number of doctors will mean that medical schools and residency programs can’t be as selective. While it is politically correct to talk about how people are all equal and how mistakes are process problems and not people problems, the truth is that not all people are cut out for all jobs. The big question here is where the line is between potential to be a doctor and incorrect job placement. The hope is that the admissions line will not cross it. But, as an old boss of mine liked to say, hope is not a method.
5. Medical education standards will drop. There will simply be too much strain on the systems too quickly. It could come from things like cadaver shortages which will lead to more sharing, or dilution of the student to teacher ratio. But with a looming crisis in the form of a doctor shortage, there may be little choice in the short term before the institutions can adjust.
6. Medical trainers will be less qualified. One of the problems Toyota faces is preventing the dilution of its production system as it grows. Spread the cadre of exceptional mentors too thin, and they can’t share the knowledge fast enough. Medical schools will need more instructors, so, like students, the bar will be lower. Less qualified trainers teaching less qualified students is a scary thought.
7. Experienced doctors will retire earlier, compounding the problem. Major changes in healthcare tend to bump people’s satisfaction contraption out of whack. In effect, the bad stuff increases enough to offset the good stuff. Some doctors who no longer need to work, but do it because they love it will change their minds. Those are the worst kinds of doctors to lose.
8. Patient satisfaction scores will plummet. Nobody likes to wait for an appointment. But they will be further angered when told, inevitably, that the problem could have been treated more easily if they had only come in earlier. Sitting in waiting rooms also does little to strengthen the patient-provider relationship. And the pressure that doctors will feel to keep on time with a crushing workload will make patients feel rushed along like cattle.
9. Doctors will talk youngsters out of being a physician. Insurance companies are putting the squeeze on doctors, forcing them to accept ever lower payments for services rendered. If the doctor wants to be part of the network, they have to accept. Add in a dramatically increased workload, and chronically irritated patients, and fewer doctors will groom their children to follow in their footsteps. The pool of candidates will drop.
10. Malpractice suits will rise. The facts about nurses and fatigue likely applies to doctors as well. Overworked doctors mean more mistakes. Ironically, the time spent fighting lawsuits makes doctors, as a group, have less time to provide actual medical care, further increasing the risk of lawsuits.
11. The best doctors will stop taking insurance. Some wealthy patients pay out of pocket to get premium care. As doctors face pressure from insurance companies to accept lower payments, the best ones with the strongest reputations can attract the clientele that will pay in cash. This demand will increase as the wealthiest patients face longer lines behind all the newly insured and think that their time and health is worth more than the money saved by using insurance for preventative care and minor treatments.
12. Some medical supplies will be in short supply. Most vendors will see rising demand and will adjust production. But some will be pushed beyond what they can provide. Whether the limiting factor is custom production machinery, special materials, or unique skills, there will be some industries that will not be able to meet increased demands.

Obviously, more access to healthcare is a good thing. I am not intending this list to be a political statement one way or the other. I think that there is a moral obligation of any culture to protect those among it that cannot take care of themselves. I’ll stay out of the argument about whether the recent healthcare reforms are the right way to go or not.

My point in this article is really just to highlight some of the hidden costs of stressing a system beyond what was designed to do, and the effect that stress has on people. I suspect that some of the things on this list will be addressed before they come to pass. But I also suspect that my list, as an outsider to the inner workings of the healthcare world, will be incomplete.

Many of the points on this list will also apply to your own operation. Customer service faces the same increase in workload when lines get longer. Customers call in more to check on their account. And they are more irritable when they do call. That means more service reps are needed. In economic downturns, that is not often a problem. But in good times, HR teams can have trouble attracting top candidates.

So, the key takeaway is that if you push your system and people too hard, they will push back in unexpected ways.