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Author's Reply: Chronicle of a PLoS Medicine Publication

Posted by plosmedicine on 31 Mar 2009 at 00:15 GMT

Author: Kenneth R. Fernández Taylor
Position: Physician in training; Editor of Signos Vitales, a medical journal
Institution: Universidad Dr. José Matías Delgado, La Libertad, El Salvador
Submitted Date: October 04, 2007
Published Date: October 8, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

The journey of publishing my essay Excessive Work Hours of Physicians in Training: Putting Patients at Risk (1) has been one the most academically rewarding experiences in my life. It took quite some time and effort, but the effect has been something I never could have for seen. I started to write it last year while I was immersed in internship at Hospital Nacional San Rafael, but publishing in an international journal of the quality of PLoS Medicine isn’t easy, especially while you are struggling through a 120 hour work week, so I finished it well into this year.

I was sure the piece would attract considerable attention, but couldn’t even imagine the cascade of events that would come as a result of a story well told. I received congratulations from doctors from all over the world through PLoS Medicine’ reader’s response system at its website (2), many e-mails also came from prestigious institutions from Central, South America, the United States, Europe and Asia (3). I would like to thank everyone who has participated in this forum for their vital support. In addition, I sent my essay to key researchers and policy makers at Universities and institutions such as Harvard University, the Pan American Health Organization (PAHO) and the World Health Organization (WHO).

Various physicians in training from my own University, Universidad “Dr. José Matías Delgado”, expressed their thoughts. Two of them are working internationally as residents at prominent hospitals; they both tell two different stories. Huang, at the Miami Children’s Hospital, is happy to work under the regulated US regime, where “the hospital has laws that penalize doctors who go over their hours of duty”; Martín-Menjivar, at the Mexican Red Cross Trauma Center, on the other hand, says he is “still a victim of such a system”, this time in Mexico. Hoyos, an instructor of Family Medicine at the mentioned University, recalls the time when he had a car accident while post shift, and underlines the fact that physicians in training become “accomplices of acts of medical negligence and irresponsibility due to the lack of supervision from staff (because most of the time there are no attending physicians at the hospital)”. This indeed is serious business. “The focus on PATIENT SAFETY is the guarantee of a system of quality”, he expounds.

Other physicians in training from Europe who lived the exploitation here in El Salvador as IFMSA (International Federation of Medical Students Associations) exchange students also commented the article. It’s saddening to hear Christine Berndt from Germany saying, “before coming to El Salvador I actually planned on going to a central or south American country to spend my Intern year there (or parts of it). I really loved my time in El Salvador and enjoyed so many things, but because of those inhuman working conditions I decided to go somewhere else”. Schou Holm’s account of what takes place because of sleepiness at the delivery room is particularly shocking. Is this what El Salvador wants to sell to the world?

The essay has also been posted in different websites of institutions in charge of health care quality and patient safety, such as the Agency for Healthcare Research and Quality (AHRQ) (4), the WHO’s Patient Safety website (5), the Institute for Epidemiological Research of the National Academy of Medicine of Argentina (6), etc, and it has brought me the possibility to continue working for the work hour reforms to take place in El Salvador.

In the two and a half months that have passed since the essay was published I have had the opportunity to travel abroad twice. I received a scholarship to attend the Sixth Annual Quality Colloquium at Harvard University (7), where I met Dr. Odet Sarabia González, from the Mexican Ministry of Health, who invited me to go to Mexico to the Second International Forum on Healthcare Quality, which took place on the 20th and 21st of September. On September 21st, a historical event took place at the Mexican Museum of Anthropology, where the Ministers of Health of Mexico, Central America and the Caribbean signed an agreement to work for the first global challenge of the World Alliance for Patient Safety (8) which has to do with hand washing and hospital infections. This should get some attention to the topic of patient safety in a country where little is spoken about it. I was very pleased to hear at Harvard Dr. Carolyn M. Clancy, Director of the AHRQ, say: “If it works in Coral Gabbles, it will work in El Salvador”. It sure will! We just need to start working in this latitude of the world. Currently I am studying to receive a Patient Safety Officer (PSO) Certificate from the Quality Colloquium at Harvard University.

After the Quality Colloquium I had breakfast with a group of researchers from the Harvard Work Hours, Health and Safety Group who will give me their support to conduct research on the work hours, working conditions and patient safety in some of the hospitals in San Salvador. Lest hope this brings policy change in the future.


1. Fernández Taylor KR (2007) Excessive work hours of physicians in training in El Salvador: Putting patients at risk. PLoS Med 4: e205. doi:10.1371/journal.pmed.0040205. http://medicine.plosjourn...
2. http://medicine.plosjourn...
3. Kasi PM, Kassi M, Khawar T. Excessive Work Hours of Physicians in Training: Maladaptive Coping Strategies. PLoS Medicine Vol. 4, No. 9, e279 doi:10.1371/journal.pmed.0040279
6. http://www.errorenmedicin...
7. http://www.qualitycolloqu...

Competing interests declared: The author worked as an intern in El Salvador last year.