Death by a Thousand Papercuts: How We Unburden Medical Providers
By: Lucas Neff, MD, FACS, Chief Business Development Officer
Medical workforce shortages are here to stay.
The Association of American Medical Colleges estimates that in just over ten years, there will be a physician shortage of as many as 139,000 doctors, caused by an increase in aging patient populations, as well as the number of retiring physicians. This report does not account for future shortages of other medical provider roles like nurse practitioners, physicians assistants, etc.
It’s widely acknowledged that medical professionals on the whole are under too much stress and pressure–with bigger workloads, increasing administrative hurdles, longer hours, and data overload—and that was the case before the COVID pandemic hit. These conditions are leading many to leave medical professions, further compounding the workforce strain.
As the burden increases, issues like burnout and cognitive overload are thrust to the forefront, to the point that the Office of the Surgeon General has issued a warning about physician burnout. According to the American Medical Association, cognitive overload comprises almost 90% of individual medical errors, stemming from issues with attention to task and processing information, among others.
Due to the immense toll of medical errors both on the patient and the healthcare system, it is clear that something must be done. However, generating consensus on the best solutions is far from easy.
The Anatomy of Cognitive Overload
Cognitive overload can happen to providers in a wide range of circumstances, but it is especially apparent in critical care. It happens to the nurse simultaneously caring for three critically ill patients in an ICU, the physician working a night shift and monitoring a computer bank’s worth of patients in multiple ICUs, the combat medical team trying to save four severely injured personnel in a hostile environment, and the EMT providing care in the back of a moving ambulance.
When providers delivering life-saving care experience cognitive overload, mistakes can cause a snowball effect on a patient’s condition. One error can lead to another, and the smallest changes in a patient’s condition can result in large downstream problems, which lead to increased suffering and death.
For patients in intensive care, the downward spiral of one complication after another is actually a “death by a thousand papercuts.” Each one of those papercuts could potentially be averted by catching the smallest of changes in physiology at the perfect time. When those subtleties are missed, those cuts can increase things like length-of-stay and time on the mechanical ventilator, as well as increasing the likelihood of other complications.
Patients are not the only ones who suffer the death by a thousand cuts. Rarely is cognitive overload the result of one clinical scenario facing a physician or EMT; instead medical providers are filled to capacity and worn down by the litany of little things that sap attention and energy. Cognitive overload occurs when medical providers experience either task saturation or data saturation, or both simultaneously.
Task Saturation: Critical care is incredibly complex and time-sensitive, particularly during transport and diagnosis. As a patient’s condition fluctuates moment-by-moment, the list of tasks providers must complete also changes. Multiply that continually-changing list by the number of additional patients requiring attention, and it’s no wonder that providers run out of capacity to keep up with the to-do list. That saturation can result in tasks being left undone or done incorrectly.
Data Saturation: As medical technology advances, more data is available to health care providers, but rarely is there any accompanying analysis or interpretation of the information. Medical providers must sort out what pieces of information or trends are relevant to caring for their patients, and, to add to their challenge, the data continually increases and changes. Hidden in that data are micro- or macro-trends that need to be deciphered to understand how a patient’s condition might change. The subtlety of those trends makes them difficult to see, and missing the trends can mean the difference between life and death.
When cognitive overload hits, clearly patients suffer. In addition to causing negative outcomes for patients, the medical errors that result from cognitive overload also strain health systems, sapping their resources and capacities. Every additional day a patient occupies a bed in the intensive care unit becomes a very expensive proposition for a health system, and the longer a patient requires critical care, the greater the reduction in a health system's ability to care for other sick and injured patients.
Unburdening Medical Providers
There’s a great deal that medical providers do that is irreplaceable–diagnosis, treatment plans, interacting with patients’ families, and more. There are also many things we currently rely on providers to do that computers could do—and do better.
“Technology can handle rote, mundane tasks that take a lot of bandwidth, and I believe medical technology companies have a responsibility to leverage innovative technology to build the future. ”
Consider how many aspects of our daily lives are already augmented by computers–virtually all of them. These technologies don’t replace our activities; they increase our capabilities. The smart watch on your wrist doesn’t get you to your appointment on time, but it reminds you when it’s time to leave. Your new refrigerator doesn’t shop for you, but its algorithms tell you when you should and what you need.
With all the advances in technology we’ve experienced, why haven’t we translated those advances into technologies that increase the capacities of health care providers, instead of draining them?
As a trauma surgeon, I see some of the worst cases that come into my hospital. I know firsthand the crucial moment when there are too many inputs to process, but you have to make immediate decisions to sustain a life. In those moments, all the technology in the world is worthless if it doesn’t help me intervene faster and smarter.
This crisis in medical treatment is one of the core reasons I helped found Certus Critical Care, an early-stage medical device company, with other emergency and critical care physicians. At Certus, we believe that technology should unburden medical providers, instead of adding to their load, and we’re doing it by leveraging advances in technology–sensors, robotics–to develop first-in-class devices that increase the capabilities of providers.
Take our flagship product, the Endovascular Aortic Control (EVAC) system, an aortic balloon catheter that can be used to treat severe hemorrhage, cardiac arrest, and stroke. The EVAC uses solid-state sensors to gather data on absolute blood pressure and, through advanced algorithms, translates that data for the provider, who can use the device to maintain specific blood pressures both upstream and downstream with an automated balloon. It has the potential to help medical providers be more effective at repairing hemorrhages, treating cardiac arrest, and stabilizing stroke by monitoring and sustaining blood pressures autonomously.
Since medical staffing shortages are likely here to stay, health systems everywhere need to work smarter, not harder. To stay relevant, health systems must optimize the personnel they do have, and the current suite of technologies available in the ER, OR, interventional labs, and ambulances are not enough. Technology can handle rote, mundane tasks that take a lot of bandwidth, and I believe medical technology companies have a responsibility to leverage innovative technology to build the future.
At Certus, we believe that medical providers should have the best tools possible to save lives and that those devices should make their jobs easier, not harder. Our medical providers and patients deserve only our best.
About the Author
Lucas Neff, MD, FACS, is co-founder and chief business development officer of Certus Critical Care, an early stage medical device company that creates adaptive, intelligent medical devices that increase survival and quality-of-life in the aftermath of critical illness and injury. Dr. Neff is an Associate Professor of Pediatric Surgery at Atrium Health Wake Forest Baptist and Brenner Children’s in Winston-Salem, NC. His interest in developing new critical care technologies stems from his time in the Air Force, when he treated military and civilian casualties during deployment in Afghanistan, and has grown over his many years of treating children with traumatic injury or illness.