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    It’s the 'law'

    Why unintended consequences can have bad results

    Hubert Horatio Humphrey, former U.S. Senator from Minnesota, Vice President, and unsuccessful candidate for the presidency, is famous for his observation that “the Senate is a place filled with goodwill and good intentions, and if the road to hell is paved with them, then it’s a pretty good detour.”

    This saying about good intentions is thought to have originated with Saint Bernard of Clairvaux who wrote, “L’enfer est plein de bonnes volontés et désirs” (Hell is full of good wishes and desires).

    The concept that apparently rational people, in an effort to make the world a better place, make decisions or rules that inadvertently screw things up even more is fairly evident. This common but troublesome little scenario, the law of unintended consequences, rears its ugly head in many situations, both within and outside of medicine.

    Yellow lights, red lights

    This month, I read about a study of the effect of red light cameras placed at intersections according to a law passed in the (laudable) effort to decrease the number of crashes caused by motorists running red lights. After considerable time had passed, some wise guy performed a retrospective analysis of the number of accidents at these intersections. The number of accidents, rather than decreasing, had actually increased (because of rear-end collisions from drivers hitting the breaks in response to yellow lights so they don’t get tickets).

    On a medical note, legislators and regulatory bodies became concerned some years ago about the problem of house officers being on duty for extended periods, getting tired and making a mistake that harms a patient. Anecdotes of patients dying in hospitals and emergency rooms under the care of reportedly exhausted young doctors appeared in the media and lawyers pursued damages in courts.

    In response to this (legitimate, in my opinion) concern, new laws were passed by state legislators and new rules were promulgated by regulatory bodies limiting the number of hours that house officers could work (consecutively and over the course of a week). So strongly was this considered the right thing to do, that training institutions that failed to comply were threatened with being shut down (the death penalty).

    Who could be against the idea of happier, better-rested, and healthier residents who, more alert, would be better learners and providing better care to sick people? Teaching hospitals scrambled to obey—hiring workforces of technicians, nurse practitioners, and physician assistants to get the work done.

    A decade later, what have been the consequences of these new rules? According to two recently published studies, the interns training under this new regime “make more mistakes and learn less” (emphasis added). The trainees did not sleep more, did not report being less depressed and did not report a better sense of well being. They did, however, report that they were more concerned that they had made a serious medical error (with the percentage increasing from 19.9% to 23.3%).

    “Our results suggest that the negative unintended consequences of the reforms may outweigh any positives,” says an author of one of the studies.

    How do we explain this bad result?

    One theory is that the increased transfer of care for patients from one house officer to the next, the logical outcome of shorter workdays, increases the risk that a newly arriving doctor will know the details of his/her patient less well and something is more likely to fall through the cracks.

    It seems to me that the careful scientific rigor with which new medical drugs and devices are evaluated is the model that we should follow whenever a significant change is being contemplated in how we train our young doctors. With all of the training programs in our country and the many faculty who are steeped in the scientific method of clinical trials, it would not be difficult to beta test proposed new rules for 1 year or 2 to determine whether they actually help our trainees become better and healthier doctors and make our patients safer.

    References

    Ammer C. The American Heritage dictionary of idioms. 1997. ISBN 9780395727744.

    Morin M. Limiting hospital intern shifts may not cut errors, studies find. Los Angeles Times, March 25, 2013. http://articles.latimes.com/2013/mar/25/science/la-sci-medical-interns-hours-20130326. Accessed April 16, 2013.

     

     

    Peter J. McDonnell, MD
    He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of ...

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