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Perverse incentives in residency training

Posted by Ishani Ganguli  October 21, 2011 08:00 AM

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It was an hour into my overnight shift and three new patients had already hit the floor. One of the nurses on our medical unit pulled me aside and asked me to see another patient who had been with us for days: a 20-something man who’d come in for treatment of his blood disorder. 

The patient had just developed a cough and she asked if I wanted him to be tested for the flu. If we did test him, then we’d be obliged per hospital policy to put him in a private room, even before the results were in, to avoid infecting his roommate. And because our floor only has 24 beds in single and double rooms that are divvied out based on gender and the risk or presence of certain infections, this would mean one fewer patient for me to admit that night - four instead of five in a span of 12 hours. It was a very tempting proposition.

But there was only one way to make the call. I went to see my friend with the cough. It was mild, and he had no fever or chills, no body aches. The chances that he’d developed the flu, days into his hospitalization, were slim. He stayed where he was. 

As ethical dilemmas go, this one was pretty straightforward. But it would have been so easy to rationalize a flu test “just to be safe.” This sort of “working the system,” whether conscious or not, happens all the time in residency. I’m not immune to it, and it’s certainly not unique to our program. 

Another example: In an effort to ease overcrowding in the Emergency Department, MGH administrators have been pushing for pre-noon discharges (ie. getting paperwork done early to let inpatients leave before noon and free up hospital beds). The reward for the floor with the highest percentage of pre-noon discharges is an ice cream party. Predictably, the floors that have done a better job of this are paying a price: when there are more open beds before noon, they get a deluge of new patients in the afternoon, putting the intern who admits those patients in a tough spot. 

So how do you ensure that the resident who handles discharge paperwork doesn’t drag her feet in order to protect the admitting intern? (Hint: the answer probably isn’t an ice cream party.) High turnover is good for hospitals but can be bad for residents at the front line - how do we sort out what is truly better for patients? 

For residents with fixed salaries, I can safely say that our motivations are not strictly financial - we are trying to do our jobs well and to emerge in one piece at the end of our training. Still, the idea that physicians are at all sensitive to incentives seems to demean our cherished rhetoric of a higher calling in medicine. 

We can’t avoid it: As doctors (well, as human beings), our behaviors are driven by complicated and competing forces. And as I’m reminded every day, it’s critical for us to think through the downstream effects of these forces when making policy decisions, and to align them more effectively with better patient care.
This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

Ishani Ganguli, MD, is a journalist and a second-year resident physician in internal medicine/primary care at Massachusetts General Hospital. She studied biochemistry and Spanish at Harvard College and received her More »

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