Fatal errors more likely on 24-hour call

so what will it take for our "higher ups" to change the "tradition" of 30 hour shifts? a law suit? a really big one?

justwondering said:

so what will it take for our "higher ups" to change the "tradition" of 30 hour shifts? a law suit? a really big one?

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I would say some common sense.

justwondering said:

so what will it take for our "higher ups" to change the "tradition" of 30 hour shifts? a law suit? a really big one?

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Yeah great. Then we can all have 12-year surgical residencies . . .

In this study do they compare different interns in different fields? 80 hours with a 30 hour shift on medicine and surgery where you're making big time calls all the time is a lot different when you're comparing to a 63 hour derm, path, or optho etc etc residency. They have to explain the nature of the comparison better. Also that statement "fatal errors" is so loaded its ridiculus. I have yet to see someone die on a normal floor strictly from medical incompetance. People dying on SICU, CCU and other critical, call heavy floors may not be a reflection of the "mistake" the night resident made- it's because the people are so damn sick.

justwondering said:

so what will it take for our "higher ups" to change the "tradition" of 30 hour shifts? a law suit? a really big one?

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probably. and, now they have this study to reference.

Panda Bear said:

You know, I object to the line of arguement that we need to prove that long hours and call are only bad if patient care is compromised. There is nothing wrong with wanting to sleep every night (or day) and structuring any job to make this routinely impossible is idiotic.

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Ding! Ding! We have a winnah! No kidding. It's stupid to organize training like that. The question is why has it been done in said manner for so long, instead of being fixed?

Someday a few of us are going to be the "higher ups."

If something is going to improve, it's important that we understand why the system is the way that it is. I've heard many reasons:

1. Long hours give residents an opportunity to learn more (more patients, being there when a critical moment occurs, following a patient longer, etc.).

2. Residents and medical students can provide care that is less expensive (because they are cheap) and thus "extend" healthcare further.

3. (Rumor) I heard a rumor that in some cases cheap residents produce revenue for the medical school through a money trail that I have only heard rumors about (the hospitals "donate" money back to the school?).

When a few of us are eventually "up there" in the leadership of medical schools trying to figure out how to keep our bills paid and further the mission of our respective schools and programs, what will we do? Pure odds are probably that we'll do what our predecessors did: continue working residents for long hours. I would hope that we could come up with a better solution, but if there is, I suspect it will come at the cost of something else.

If you think you would eliminate long hours for residents ... do you think that there is no educational benefit to staying at the hospital long hours? Would there be a concern of graduating less capable and competent physicians? If this process does generate revenue, how would you replace this revenue? If this process does extend care to the indigent, etc., at a low cost, will you provide less care? I'm not sure what the exact questions are that med school deans and medical directors deal with, but I suspect that there are competing interests at play here.

(Oh, and I'm not in favor of long hours personally. I'm just suggesting that there may be some strong motivations keeping the grueling residency system the way that it is.)

Onco, I'm guessing you don't have a lot of work experience, nor training experience.

When you compare a person who's been going for 16 hours with someone who's been going 12, guess who's going to be more in the game.

Ditto for 20 and 16.

Ditto for 24 and 20.

Ditto for 30 and 24 (snuck in 2 extra hours there just for effect).


More time does not equal more quality time. After a certain point, you just have a corpse wandering the halls.

I agree that there may be some strong motives for keeping the status quo, I just think that they don't outweigh the harm done.

Church said:

Onco, I'm guessing you don't have a lot of work experience, nor training experience.

When you compare a person who's been going for 16 hours with someone who's been going 12, guess who's going to be more in the game.

Ditto for 20 and 16.

Ditto for 24 and 20.

Ditto for 30 and 24 (snuck in 2 extra hours there just for effect).


More time does not equal more quality time. After a certain point, you just have a corpse wandering the halls.

I agree that there may be some strong motives for keeping the status quo, I just think that they don't outweigh the harm done.

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Well, the most I have ever worked was a 120 hour work week, and 80 hours/week was pretty common for me in the past. I do remember that feeling of having worked 36 hours straight with no sleep (I think ~72 or so hours is the most I have ever worked without sleep). I did what I had to do. I'm not just talking hyptothetically. However, I'm not a resident (I'm not even in medical school yet) so you are right to dismiss my personal experience. I'm not sure if this is correct, but I read that ... "http://www.amusingfacts.com/facts/Detail/without-sleep.html : The world record for time without sleep is 264 hours (11 days) by Randy Gardner in 1965. or http://abc.net.au/science/sleep/facts.htm : The record for the longest period without sleep is 18 days, 21 hours, 40 minutes during a rocking chair marathon. The record holder reported hallucinations, paranoia, blurred vision, slurred speech and memory and concentration lapses." The second reference is that it can be hard to tell if someone is really awake or just dozing off with their eyes open . I like watching old war documentaries and they sometimes talk about soldiers going for days without sleep with their lives on the line if they doze off.

I'm not arguing that someone who works 30 hours is going to produce more quality work at hour 28 compared to someone who only works 8 hours per day. What I am curious about are the reasons that keep the system the way that it is. Obviously there are some or it would have changed by now. With the patient safety issue, some patients might argue that they don't want any intern or resident involved in their case (I know my mom was "subjected" to a nursing student who was learning, and she really did not like the abuse).

Here is an article from Dr. David C. Leach who is executive director of the Accreditation Council for Graduate Medical Education. My impression from that article is that ACGME has high expectations for what interns and residents are supposed to learn and that it apparently requires long hours. I'm not defending their beliefs. Here is an explanation from the man at the top.

http://www.usatoday.com/printedition/news/20061219/oppose19.art.htm

More hours, better doctors
Good patient care is complex; residents are students, not workers.
By David C. Leach

"To teach is to create a space in which obedience to truth is practiced," said Abba Felix, a desert preacher, a few thousand years ago. What is the truth about resident duty hours and how should it be obeyed?

Stories can reveal the truth: A thoracic surgeon meets with the family of a little boy whose life-threatening congenital heart lesion has just been corrected after a long and difficult operation. Though the lesion is corrected, the child remains critically ill, not yet out of the woods from the surgery.

The family members hover over the recovery room bed, somewhat relieved and yet still terrified and tearful as they query the doctor: "You're not going home now, are you?" One truth: A tired physician who has just spent several hours getting to know the particulars of separating a patient from his disease might offer more than an equally competent, well-rested stranger.

A recent study about duty hours and medical errors also reveals some aspects of the truth. After more than 24 hours on duty, interns (first-year residents) self-report that they are more prone to make errors. The study also provides some nice sound bites for socially constructed untruths and fails to tell the deep truths — the truth that good patient care is complex and is not achieved with simplistic approaches; the truth that residents are students, not workers.

Upon graduation from medical school, students have an M.D. but lack the practical skills needed to practice independently; they are not yet licensed to practice. They spend three to seven years in educational programs (residencies) in which they care for patients under the supervision of other more experienced physicians — senior residents and ultimately the patient's attending physician.

There is no steeper learning curve in medicine than residency. The dramatic difference in competence between interns and chief residents involves a journey in which learners discover both clinical wisdom and themselves. They learn to apply rules and values in particular cases; they learn how to deliver good patient care.

ACGME regulates resident duty hours. We have done much and have more to do. As we refine our requirements, we will be guided by rules but also by values. Fidelity to both is the key to good patient care. Our task is to discern and obey the truth, the deep truth.

Out of curiosity, aren't a lot of programs on "night float" protocols these days?

Maybe I'm just mistaken....but I thought the night float model where the resident works like 6PM to 8AM straight for a week were the new thing. Many of these programs cite resident happiness as a pro vs. continuity of care and case experience decrease as cons.

Just wondering.

Tired said:

Yeah great. Then we can all have 12-year surgical residencies . . .

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That would be better than causing patients to die because you're too tired to focus.

The system stays the way it is for a number of reasons.

Some of it is hazing--if we did it, you can do it philosophy to ensure that only the best and brightest enter medicine. This basically asks how much do you want to be a doctor.

There is also the very real issue of having enough docs staff hospitals round the clock. The system needs the bodies to handle the day in and day out cases that come in. Otherwise, consider why each surgical subspecialty can't have 1 year of general surgery (to teach the general techniques) followed by x number of years in that specific field. Some fields are going to this idea with students entering the field straight out and not by fellowship (e.g., some plastics slots). I am sure many would agree that 5 years of general surg and doing bread and butter surgeries like appendectomy or cholecystecomy will not make a neurosurgeon or a heart surgeon much better in his chosen profession than if he was working with that specific organ from the word go. Nonetheless, we need enough residents to help perform these surgeries when they arise (you often can't schedule to have your gallbladder or appendix removed in the same way you can schedule a cardiac bypass or plastic surgery).

I agree that it would be preferable to have longer residencies than 36 hours on call or 24 hours on call. Our patient's health and safety must take priority. The air traffic controllers can only work 4 hours each block and then must take a 15 minute break. Their shifts are 8 hours. Why? Because they have people's lives in their hands. Maybe the average doctor does not have 1000 passengers lives on his hands at one moment in time but we are still responsible for the lives of our patients however many there are on a shift. Being sleep deprived and not operating at optimal capacity is dangerous and in my opinion, unprofessional. I want the best from my doctors and hope to give the best to my patients. No matter how much we may want to do our best for our patients, when we are at that 28th hour, I don;t think it is possible. Maybe we can give adequate care but I doubt it will be outstanding care.

vtucci said:

The system stays the way it is for a number of reasons.

Some of it is hazing--if we did it, you can do it philosophy to ensure that only the best and brightest enter medicine. This basically asks how much do you want to be a doctor.

...

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I have heard this hazing explanation more than once.

At the same time, I when I talked to a respected general surgeon about residency, he said that there is a lot to learn and you need to be willing to put in the time to learn it. He didn't see any other way to really master this.

I personally agree that sacrificing patient safety should be out of the question and take priority over any learning experience. I would be more open to doing stamina exercises on simulators for 30 hours straight. I suspect there is a way to accomplish the learning experience while protecting patients.

tacrum43 said:

That would be better than causing patients to die because you're too tired to focus.

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Fine, let's extend surgical residency to 12 years.

Of course, there are only so many surgical applicants every year. In fact, if you add in the prelim spots, there are more spots than applicants. So now you have the same number of residents, now working fewer hours. Who covers the wards? Who sees clinic? Who does the cases?

I know, let's start lowering the bar, letting in less qualified applicants. That should help reduce death rates, right?. Oh, and we can spend the money to start hiring more mid-levels to cover, thereby raising the already high cost of care. Or maybe we could accept fewer patients, do fewer cases? If we limit access to care, we could help prevent death (at least among those who can afford to get our care). We could expand home call, thereby seperating the caregivers from their patients, and forcing more residents to make life-and-death decisions without having the benefit of personally assessing their charges.

Seriously. I understand that being tired increases the risk of errors; everyone acknowledges that fact.

But if we're going to start dumping on the system, how about a few ideas on how to adjust the system so that we:

1) Do the same number of cases
2) See the same number of patients in clinic (already with ridiculous wait times)
3) Monitor the same number of patients on the wards

with the same number of residents working fewer hours?

Tired said:

Fine, let's extend surgical residency to 12 years.

Of course, there are only so many surgical applicants every year. In fact, if you add in the prelim spots, there are more spots than applicants. So now you have the same number of residents, now working fewer hours. Who covers the wards? Who sees clinic? Who does the cases?

...

But if we're going to start dumping on the system, how about a few ideas on how to adjust the system so that we:

1) Do the same number of cases
2) See the same number of patients in clinic (already with ridiculous wait times)
3) Monitor the same number of patients on the wards

with the same number of residents working fewer hours?

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Tired: Are the certain kinds of recognizable mistakes leading to injury/death just random missteps or are there certain kinds of mistakes that perhaps could be better controlled? Also, are there some teaching hospitals that have lower error rates (are they doing something that others could emulate)? Is it possible to prioritize the more rested residents for the risky procedures? Someone like you would probably have more ideas on what could be improved ....

OncoCaP said:

I have heard this hazing explanation more than once.

At the same time, I when I talked to a respected general surgeon about residency, he said that there is a lot to learn and you need to be willing to put in the time to learn it. He didn't see any other way to really master this.

I personally agree that sacrificing patient safety should be out of the question and take priority over any learning experience. I would be more open to doing stamina exercises on simulators for 30 hours straight. I suspect there is a way to accomplish the learning experience while protecting patients.

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I have spoken to a number of docs as well. Some will come out and say directly that they put their time in and now it is our turn. Others, as the surgeon you mentioned, do not see how we can learn all we need to without having those hours and being at the hospital all hours of the night and day to see those extra interesting cases. It is true that there is a lot more technology in today;s medical practice than there was 25 years ago.

Maybe we should revamp the med school curriculum too (have more clinical time and less basic science time-- I mean really, how important is it that we know which genetic mutation is most commonly responsible for ovarian cancer as opposed to the diagnosis and treatment of the condition. While interesting, I would rather have a doctor who is solid on the physical exam, history, ultrasound etc than know the biochemical/genetic background to every condition unless it has a direct impact on the treatment or diagnosis of a condition).

Tired- lets consider why there are not a huge number of surgical applicants. Surgery does have an appeal to many in terms of prestige and money and many of the subspecialties are still considered competitive or super competitive (like plastics). However, there are a number of students, myself included (some of whom are older), who are looking at the various specialties and want to have a life and family outside the hospital. These lifestyle considerations mean that we would prefer not to embark on a specialty that requires 80+ hours/week. I have heard numerous female surgeons state that they can be a good surgeon or a good wife/mother but not both. That is not acceptable to me or to many of my colleagues of both genders. In case you are wondering, I have done my 120 hour work weeks as a lawyer and it is not a stamina issue for me. If I love my job, I can do the long hours. However, our lives do not have to be solely comprised of our jobs. Perhaps if a system was devised where the work hours could be 50/week for 8 years instead of 80/week for 5 years (in a general surgery program), more people would consider it.

Simulators are becoming more en vogue. Many other professions are already using them (think fighter pilots). It might be a way to simulate crisis situations and give advanced training with multiple scenarios.

humuhumu said:

The article below is from the latest issue of American Medical News. Just thinking about the future....

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Fatal errors more likely on 24-hour call

Harvard sleep scientists say residents' hours still put patients at risk.

By Myrle Croasdale, AMNews staff. Jan. 22, 2007.

Patients are dying at the hands of tired medical residents, according to Harvard sleep scientists, because the work-hour limits imposed in 2003 are not preventing sleep deprivation.

Their research reveals that first-year medical school graduates who worked five shifts of 24 hours or more during a month were three times more likely to make an error that contributed to a patient's death.

"Academic medicine is failing these doctors and their patients by requiring exhausted doctors to work 30-hour marathon shifts," said Charles Czeisler, MD, PhD, co-author of the study and director of sleep medicine at Harvard Medical School and Brigham and Women's Hospital in Boston. "The human brain doesn't function correctly when working 30 hours straight."

David C. Leach, MD, executive director of the Accreditation Council for Graduate Medical Education, the organization that regulates resident hours, said trimming call hours further would not necessarily improve patient safety.

"[Dr.] Czeisler's study has given us a little truth," Dr. Leach said. "Residents who work 24 hours self-report they are prone to more errors. He has not given us a deeper truth. The problem is more complex than 16- vs. 24-hour shifts."

The study builds on previous research from Harvard that compared interns who worked an average of 80 hours a week with call periods of 24 hours and longer, to interns working 63 hours a week, with call limited to 16 hours. The interns working the longer schedule made 36% more serious medical errors.

The study, in the December 2006 issue of the online journal PloS Medicine, looked specifically at fatigue-related errors that harmed patients. It found that interns who had worked one to four overnight call shifts in a month were three times more likely to report at least one fatigue-related event that hurt a patient.

If they worked five or more shifts in a month, they were seven times more likely to report at least one adverse event. Under ACGME rules, interns can work up to nine 30-hour call periods a month.

"Extended-duration work shifts are hazardous to patients," Dr. Czeisler said. "We need to be concerned about safety and think creatively about alternatives. It's time to rethink [resident hours.]"

Over the course of a year, one out of 20 interns made a serious error that injured a patient. One out of 100 made a mistake that was serious enough to result in a patient's death, Dr. Czeisler said.

"The data suggest tens of thousands of patients are being injured each year, and thousands are dying in relation to fatigue mistakes," he said.

Dr. Leach questioned such reasoning. The data were collected in July 2002 through May 2003, before duty-hour reforms were instituted. Dr. Czeisler said the data were applicable because residents still work call shifts of 24 hours or more. But Dr. Leach said the accumulated sleep debt from longer work weeks may have produced higher error rates than would be found under the current system.

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Just to play devils advocate, what if the residents were just f*cked up and would of made the medical mistakes regardless of the number of hours they slept. I mean this research is taking in consideration the residents are 100% competent and do things 100% perfect all the time, hell you can get crap loads of sleep, have a bad day and still screw up. So I am sure being sleep deprived doesnt help, but their is also other variables that should be taking into consideration.

Panda Bear said:

You know, I object to the line of arguement that we need to prove that long hours and call are only bad if patient care is compromised. There is nothing wrong with wanting to sleep every night (or day) and structuring any job to make this routinely impossible is idiotic.

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I read part of your blog Panda, I admire you for going back to study medicine later in life. Curious, what were your stats, like where did you go to undergrad, how long did you spend in the military, other jobs before the military. Your road to success is inspirational.

OncoCaP said:

Tired: Are the certain kinds of recognizable mistakes leading to injury/death just random missteps or are there certain kinds of mistakes that perhaps could be better controlled? Also, are there some teaching hospitals that have lower error rates (are they doing something that others could emulate)? Is it possible to prioritize the more rested residents for the risky procedures? Someone like you would probably have more ideas on what could be improved ....

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Since I'm only an MSIV, my clinical experience with what's involved in being a resident is necessarily limited. Someone like Panda is better suited to answer these questions (assuming EM and FP spent significant time on the wards, which I actually don't know since I haven't spent much time with those guys). And I don't know if the problem is in the OR, stuff missed on the wards, stuff missed in clinic, I'm honestly not sure.

My point is more one of logistics: how to do more with less? As it stands, I get the impression that the 80-hour work week has resulted in significantly more call for the uppers. When I rotate through the surgical services, everyone up to the chief is maxing out their hours (and of course, they are lying through their teeths, since they all go way over anyway). So how do we cut out 24-hour days and still run the service? Expand the programs? Convince the attendings to take in-house overnight call?

I mean hell, someone has to be there. Someone has to answer the pages. Someone has to call in the chief/attending. So who's going to do it if we're going to send people home early? It feels easy to bash a system where residents are exhausted and broken for years and years, but who will be there instead? (I'm actually asking an honest question; I really don't know)

Tired said:

Since I'm only an MSIV, my clinical experience with what's involved in being a resident is necessarily limited. Someone like Panda is better suited to answer these questions (assuming EM and FP spent significant time on the wards, which I actually don't know since I haven't spent much time with those guys). And I don't know if the problem is in the OR, stuff missed on the wards, stuff missed in clinic, I'm honestly not sure.

My point is more one of logistics: how to do more with less? As it stands, I get the impression that the 80-hour work week has resulted in significantly more call for the uppers. When I rotate through the surgical services, everyone up to the chief is maxing out their hours (and of course, they are lying through their teeths, since they all go way over anyway). So how do we cut out 24-hour days and still run the service? Expand the programs? Convince the attendings to take in-house overnight call?

I mean hell, someone has to be there. Someone has to answer the pages. Someone has to call in the chief/attending. So who's going to do it if we're going to send people home early? It feels easy to bash a system where residents are exhausted and broken for years and years, but who will be there instead? (I'm actually asking an honest question; I really don't know)

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The problem is that people are dying due to a correctable problem. I have $50 that says when the first multi-million dollar lawsuit hits a hospital and they loose, the issue will be resolved as quick as lightning.

I don't think it is impossible to find a way to squeeze in 5-6hours mandatory sleep time in a 30hr shift, they just need to spend money on some extra staff(and this is what they dont want to do). The fact is residents provide cheap labor and hospitals will like to maximize the use of their labor, but it is now clear that it is affecting pts, so we can only hope they fix the problem before blood thirsty lawyers cash in.

sirus_virus said:

The problem is that people are dying due to a correctable problem. I have $50 that says when the first multi-million dollar lawsuit hits a hospital and they loose, the issue will be resolved as quick as lightning.

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They have been hit by bad publicity and multiple lawsuits. Read the history of why the 80hr week was instituted (and why in New York it is actually mandated by state law). See a lot of big changes since 1989 when this issue hit the public consciousness? Not much . . .

sirus_virus said:

I don't think it is impossible to find a way to squeeze in 5-6hours mandatory sleep time in a 30hr shift, they just need to spend money on some extra staff(and this is what they dont want to do). The fact is residents provide cheap labor and hospitals will like to maximize the use of their labor, but it is now clear that it is affecting pts, so we can only hope they fix the problem before blood thirsty lawyers cash in.

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Really, and what "staff" are you talking about? Attendings? Locums? Mid-levels? Can you imagine the cost of hiring an extra physician for every service in the hospital, just so the residents can sleep a few hours?

Are you going to prevent surgical residents from operating at night? Will the same rules apply to attendings who were up all day? Who will be the first assist in those cases?

When the patient has a fever, who will the nurse call to come assess the patient? How about codes, who will run those, the nurses? How about ER consults? Will you demand the specialty attendings come in to the ER at all hours of the night to assess those patients? Do you have idea how much that will cost?

If you have solutions, let's hear them. But you're treating costs like they are of no consequence, and that simply is not realistic. Our system is already collapsing under the weight of its own costs. Your blithe response that we should just hire more staff would result in dozens of extra doctors being added to the payroll (and of course "payroll" is a deceptive term, the cost would be directly passed on to patients and public welfare systems). Assuming there are even that many docs available (which I sincerely doubt), the money would be staggering.

Tired said:

They have been hit by bad publicity and multiple lawsuits. Read the history of why the 80hr week was instituted (and why in New York it is actually mandated by state law). See a lot of big changes since 1989 when this issue hit the public consciousness? Not much . . .

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Agree. There have been many lawsuits. The Libby Zion case was what got things cut back to 80 hrs per week in the first place, and that was very ground breaking and atypical, and the resultant change certainly hasn't been embraced whole-heartedly by all of the industry - the surgeons are still grumbling and quite a few hospitals still have noncompliance issues. Many cases of injury allegedly caused by sleep deprivation make it to court, many have been multi-million dollar suits, and it is telling that there has been no real movement or further push for change in over a decade now. So no, don't expect any near-term changes from lawsuits. The profession had its big change. Staffing needs prohibit further modification. A lot of us will be happy to take sirus' $50.

OncoCaP said:

Someday a few of us are going to be the "higher ups."

If something is going to improve, it's important that we understand why the system is the way that it is. I've heard many reasons:

1. Long hours give residents an opportunity to learn more (more patients, being there when a critical moment occurs, following a patient longer, etc.).

2. Residents and medical students can provide care that is less expensive (because they are cheap) and thus "extend" healthcare further.

3. (Rumor) I heard a rumor that in some cases cheap residents produce revenue for the medical school through a money trail that I have only heard rumors about (the hospitals "donate" money back to the school?).

When a few of us are eventually "up there" in the leadership of medical schools trying to figure out how to keep our bills paid and further the mission of our respective schools and programs, what will we do? Pure odds are probably that we'll do what our predecessors did: continue working residents for long hours. I would hope that we could come up with a better solution, but if there is, I suspect it will come at the cost of something else.

If you think you would eliminate long hours for residents ... do you think that there is no educational benefit to staying at the hospital long hours? Would there be a concern of graduating less capable and competent physicians? If this process does generate revenue, how would you replace this revenue? If this process does extend care to the indigent, etc., at a low cost, will you provide less care? I'm not sure what the exact questions are that med school deans and medical directors deal with, but I suspect that there are competing interests at play here.

(Oh, and I'm not in favor of long hours personally. I'm just suggesting that there may be some strong motivations keeping the grueling residency system the way that it is.)

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Slavery also generated revenue, but that didn't make it right.

dutchman said:

Slavery also generated revenue, but that didn't make it right.

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No, but it took a civil war to change this. I don't think the plight of young physicians is going to similarly divide the nation.

I agree Panda- the system needs to change or the best and brightest might very well go elsewhere.

I did not choose medicine because I want the easy path. I could have made way more money as a lawyer (for those of you who might think otherwise, a partner in a NYC law firm can make in excess of 3 million/year). I really do want to make a difference in people's lives. However, like Panda, I also don't think it is unreasonable to have a full night of sleep, each and every night. I am much more concerned about my patients than myself in the 100+ workhour week. I have been there and done that. But when I was a lawyer, no one's life depending on my state of mind (maybe their bank account or livelihood and a mistake while tragic would not be life-threatening). I don't know about anyone else but I know that we are all going to make a mistake one day that is going to harm a patient (or worse, cost them their life) even under the best of circumstances because we are human and medicine is as much an art as science. Being sleep-deprived is hardly the best of circumstances.

We need to get the safeguards in place ASAP. What will we do then once the baby boomers crash headlong into our healthcare system-- the devastation from such an affront will be like an intercontinental ballistic missile hitting into downtown LA.

Maybe I'll see you on the wards someday Panda. I too am EM bound. I can't imagine a better specialty for me.

I dont even know why this is an issue for debate. One life lost is one too many. I dont know why people should be begging for sleep(normal body function) either. This is the type of nonsense that makes people question the very intelligence doctors claim to have.

Panda Bear said:

Ah. But that's not my problem. I want to sleep every night and this is not an unreasonable request. In fact, in any other job they'd laugh at you if you asked them to go without sleep every four days for three years.

The solution is to streamline the hospital, reduce the paperwork burden, and stop practicing wasteful and defensive medicine. Easier said than done, of course, but as long as you swallow that "patient care comes first" mantra nothing will ever change.

Now, I believe that patient care does come first. The hospital, JHACO, and lawyers don't believe it or they wouldn't keep throwing obstacles in the way of patient care, and by this I mean anything that serves the bureaucracy and not the patient.

As you know, a huge bolus of self-indulgent baby-boomers is about to hit the system. If you think residents are swamped now wait a few years. It's going to be utter chaos.

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Look, I'm not one of those ******s who's trying to argue that "exhaustion builds character" or anything stupid like that. I do think there's something to be said for the educational value of spending more time vs less in the hospital. But I don't think that the current system as it stands is particularly pleasant, and certainly it is sometimes dangerous and results in harm to patients.

But what I'm not getting is what we could do about it. "Streamlining" and "paperwork reduction" are laudable goals. Reducing bureaucracy is also a good thing. But I don't see how that settles the problems I outlined earlier, except possibly giving residents who are on for 24hrs more time to sleep that would have otherwise been spent filling out forms. But it still doesn't answer the question of who takes the calls, who sees the patients, and who writes the orders.

And really, this is your problem (and mine, and everyone else's who enters this world). There has to be bodies present to manage the problems. Private docs may get away with not staying in house, but that's because their personal services don't encompass 20+ patients. They play the law of averages that neither of their two inpatients will code that night, or have abdominal pain, or lose the pulse in their foot. Teaching services just don't get away with that. If they want enough cases to actually train residents, they have to accept a large volume of patients, simple as that.

dutchman said:

I dont even know why this is an issue for debate. One life lost is one too many. I dont know why people should be begging for sleep(normal body function) either. This is the type of nonsense that makes people question the very intelligence doctors claim to have.

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There you go dropping bombs again without offering alternatives.

So again I will ask, who should manage the patients if the residents are all going to bed?

Tired

You say "going to bed" like we are suggesting a routine slumber party. All we are saying is have some sleep time(maybe as little as 5 hours) worked into any 18+ hour shift, so people don't get killed. Nothing wrong with employing some PAs to help with coverage. It does not make sense to knowingly endanger lives when you are supposed to be saving it. Thank god the argument is not going in the direction of "we need them to work that long so they can learn", because we all know how much learning you can do on your 25th hour without sleep.

I'm kind of wired weird so take this for what it's worth...

I don't claim to own the world record, but I've had some pretty long stints without sleep related to high work hours (120+) in a high stress environment (EMS) which brought about a severe case of insomnia. (Seriously, at one point I quit even trying to sleep/rest and it didn't make a difference). I've noticed that after I've been awake for 36 hours I don't ever seem to get any more tired/drowsy/debilitated after that. For me, it's like somewhere in between 18-24 hours I'd start to get tired and then from 24 to 36 my sympathetics kick in and give some extra push, so I'd almost feel rested again. But then, somewhere around hour 36 the adrenaline rush has faded and I'd assume some form of slightly altered consciousness: I think slower, my vision gets a bit blurry, my gait gets a bit lax, etc (things you'd typically see in a patient with a BAC of .08 or so). Anyway, from hour 36 to whenever I finally caught some Z's, I never really noticed much further degradation of function.

Still, I honestly don't feel like it was a good idea to let myself (or anyone in that state) handle patients at that point, but somehow (as far as I know) no one ever was hurt because of it. But, frankly, I would have asked for someone else if someone was trying to treat me medically who was in my state at 36+ and probably even 18+ hours without sleep.

However, I'd much rather do crazy work hours for a few years than see an increase in the number of years in residency...That's just me though

I don't have time to read the entire thread right now, but I just thought I'd throw something in. Sorry if this has already been brought up.

One of the general surgeon attendings here recently informed me that because of the 80-hour rules, she now is working many more hours than before, and also now has to take in-house call for the first time in years. She didn't say exactly how many more hours she's working now, but she did say that when the resident has to go home at noon (or whatever time it is) post-call, she has to continue to work a full day post call. So even if the residents aren't working more than 30, someone else is.

Essentially, I think it all comes down to the hospital wanting to save money.

I don't buy the argument that residents have to loose sleep so that attendings can rest. Like panda said, we are only talking about 5 hours of sleep.

BTW the attending can always find another job. Not the case for a resident.

Hey, I'm not saying it's right. Just throwing it out there.

Tired said:

Oh, and we can spend the money to start hiring more mid-levels to cover, thereby raising the already high cost of care

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i at least think we could hire more mid level workers. They could take a lot of the wasted time out of the typical residents day. Cut out a few discharge notes, write down a few orders while you're in the OR etc and you can cut at least an hour or two out of each day. How to pay for it? Thats the rub. i can recite the tired rhetoric of cutting the hospital CEOs salary by about 100k ditto a lot of other administrators but that will never happen.

I found this article:

http://www.acgme.org/acWebsite/dutyHours/dh_dhSummary.pdf

"The Standards
"The ACGME's common duty hour standards acknowledge scientific evidence that long hours and sleep loss have a negative effect on resident performance, learning and well-being.4,5,6,7 They cap hours for physicians in training at 80 per week; limit continuous duty time to 24 hours, with added time for transfer of care and didactic activities; require rest periods between duty shifts and one day in seven to be free of program responsibilities. They also require in-house call to be scheduled no more frequently than every third night, and time on home-call spent in the hospital to be counted toward the weekly duty hour limit.8 An 80-hour limit was chosen as the upper limit
to safeguard against the negative effects of chronic sleep loss, and a limit of 24 hours plus up to six hours was chosen to address the effects of acute sleep loss, and to allow for adequate time for patient hand-off and didactic learning.9 It was also chosen to avoid sending individuals home at the time of their circadian nadir, which has been associated with increased risk for motor vehicle accidents.10,11 To provide for added time beyond 80 hours to allow residents to participate in educationally valuable activities, the standards provide for an increase of up to 10 percent beyond the 80-hour weekly limit. Individual programs may apply for this exception with the endorsement
of their sponsoring institution's Graduate Medical Education Committee.

*****
What concerns me about the above explanation is that there is no mention of patient safety anywhere. It gives the (hopefully mistaken) impression that patient safety was not as seriously considered when setting hours and standards for residency programs as, for example, the safety of residents when driving home. Also, while patient safety is clearly emphasized and is one of the criteria that is used to assess programs, it is not mentioned anywhere in the brief statement of the mission and values of ACGME:
http://www.acgme.org/acWebsite/about/ab_mission.asp . When you drill down into the program evaluation criteria, patient safety is indeed prominently featured (it is in the top ten of http://www.acgme.org/acWebsite/Resident_survey/res_sampleResSurvey.pdf). However, I would be curious as to whether the public would find that enough emphasis is placed on patient safety if they took a closer look at it. While education of physicians is very important, I fail to see it as more important the safety of the patients. The end does not justify the means, in my opinion: "first, do no harm."

Since when has health care in the US ever really cared primarily about patient safety anyway?

It's probably better than at any point in the past, but it still isn't too good. Consider a scenario in which a certain drug may be dangerous to 1/1k people. Ideally, you'd want to use the less dangerous one, but then consider the possibility that the less dangerous drug costs the hospital as little as $150 more per patient than the more expensive one. In this case the hospital would need to spend $150k more, just to prevent one adverse event. Which drug do you think the hospital chooses? I'd just about guarantee it chooses to save money. The same goes for medicare/medicaid/insurance/HMO's/etc.

First, do no harm nothin'...

Tired said:

They have been hit by bad publicity and multiple lawsuits. Read the history of why the 80hr week was instituted (and why in New York it is actually mandated by state law). See a lot of big changes since 1989 when this issue hit the public consciousness? Not much . . .




Really, and what "staff" are you talking about? Attendings? Locums? Mid-levels? Can you imagine the cost of hiring an extra physician for every service in the hospital, just so the residents can sleep a few hours?

Are you going to prevent surgical residents from operating at night? Will the same rules apply to attendings who were up all day? Who will be the first assist in those cases?

When the patient has a fever, who will the nurse call to come assess the patient? How about codes, who will run those, the nurses? How about ER consults? Will you demand the specialty attendings come in to the ER at all hours of the night to assess those patients? Do you have idea how much that will cost?

If you have solutions, let's hear them. But you're treating costs like they are of no consequence, and that simply is not realistic. Our system is already collapsing under the weight of its own costs. Your blithe response that we should just hire more staff would result in dozens of extra doctors being added to the payroll (and of course "payroll" is a deceptive term, the cost would be directly passed on to patients and public welfare systems). Assuming there are even that many docs available (which I sincerely doubt), the money would be staggering.

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You know, I usually don't agree with you on many points, but this one is definitely true. Medicine, like all things, is subject to scarcity. Money doesn't grow on trees.

That being said, the simple solution to chronic night call has already been instituted in many places in the form of night float, where residents are actually taking call q14 or so. As a solution even to that, take those rare call nights with two residents, and have them split sleep shifts. For example, resident A sleeps from 2200-0300 and resident B sleeps from 0300 to 0800. This would only be on weekends anyway, due to night float. In the event of a true disaster, both residents would be in the hospital. However, I'm not sure this would really be necessary without a cholera epidemic or nuclear bomb.

Another solution might be to give each ward team a small and specific number of patients that they as a team could figure out how to follow. Like in the real world, the team would have patients that they were responsible for, and they could split call. If the service is too busy to allow teams comprised of all of its housestaff doctors to cover all of the patients effectively, than the hospital is too busy. The only GOOD arguments for long call have to do with continuity of care. This solves that, as all of the patients will be repeatedly seen by the same team. Making a bleary eyed resident on his 28th hour awake answer pages for six different services makes no sense at all, and he obviously provides no continuity of care benefit for all five of the services that aren't his.

NEATOMD said:

Since when has health care in the US ever really cared primarily about patient safety anyway?

It's probably better than at any point in the past, but it still isn't too good. Consider a scenario in which a certain drug may be dangerous to 1/1k people. Ideally, you'd want to use the less dangerous one, but then consider the possibility that the less dangerous drug costs the hospital as little as $150 more per patient than the more expensive one. In this case the hospital would need to spend $150k more, just to prevent one adverse event. Which drug do you think the hospital chooses? I'd just about guarantee it chooses to save money. The same goes for medicare/medicaid/insurance/HMO's/etc.

First, do no harm nothin'...

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Certainly there is a limit to how much can be spent to safely treat patients. If that figure is $1000/patient for a certain procedure, then that's what it is. I'm comfortable with that because I realize that there are financial limits to everything in life. All I'm suggesting is that safety be assessed; I'm not suggesting that it is always right to spend more. In other words, patient safety should be prominent part of the decision on how many hours residents can work, what kind of drug to use, and how to perform a procedure.

For example, maybe instead of using the more expensive drug for every patient, there might be a way of identifying those patients who are at the greatest risk (elderly, certain allergies, etc.) and providing the more expensive drug to them (and hopefully billing for it). Sometimes a safety improvement is more expensive, but not always. It may just be less convenient and otherwise cost neutral. Unfortunately, with the current system, if the residents work less, someone else needs to work more (attendings, etc.). Eliminating some of the SCUT work ("make work") would be a start toward improving patient safety. Some of the ideas above with changing up schedules for specialties and letting teams have more say in their on-call schedules could also be looked into, I'm sure.

I know that achieving improvements in residency working conditions and the associated quality and safety of patient care might seem hopeless or impossible. However, residency working can improve, particularly if the people pushing for change understand the tradeoffs and can propose practical solutions that consider those tradeoffs in cost, patient care, training quality, staff availability, etc. If nothing else, maybe when our generation of physicians gets into leadership, we can change it.