Sleep deprivation and medical errors

[sirus_virus]

Okay so I had a wierd experience yesterday. Some doctor(I think a resident) wrote me a prescription totally different from what he had in mind(supposedly), basically made a medical error.
By some stroke of luck the pharmacist picked out this error, but the worst part was that someone from the hospital called me to apologize and shamelessly blamed the error on "lack of sleep". Since I am not in the business of lawsuits I simply registered my displeasure and hung up. If we know lack of sleep actually impairs judgement, why the hell do we have sleepless doctors handling peoples' lives?
I however wonder how many medical errors could be attributed to lack of sleep? Do you guys find a lot of your colleagues making errors due to lack of sleep?

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[Faebinder]

I however wonder how many medical errors could be attributed to lack of sleep? Do you guys find a lot of your colleagues making errors due to lack of sleep?

YES!!!

Hence the first surgeon to make a surgery residency was a big time cocaine addict.

But to counter your note, you have to also understand that there is an expectation of ZERO errors in the medical field and that is just unrealistic.

 

[sirus_virus]

I also found this



Bertrand M. Bell, MD, in a letter to the editor, "Journal of the American Medical Association", Vol. 274:6, August 9, 1995, writes, "The occurrence of errors among health officers is attributable to sleep deprivation, chronic fatigue and inadequate supervision. The culture of the medical practice experienced by residents and interns encourages them to hide what they do not know and makes extremes of sleep deprivation and chronic fatigue be accepted norms of behavior among physicians."

At some point the AMA is going to have to grow some balls and deal with this problem.

 

[Faebinder]

I also found this



Bertrand M. Bell, MD, in a letter to the editor, "Journal of the American Medical Association", Vol. 274:6, August 9, 1995, writes, "The occurrence of errors among health officers is attributable to sleep deprivation, chronic fatigue and inadequate supervision. The culture of the medical practice experienced by residents and interns encourages them to hide what they do not know and makes extremes of sleep deprivation and chronic fatigue be accepted norms of behavior among physicians."

At some point the AMA is going to have to grow some balls and deal with this problem.

Only if they get sued for it....

 

[dutchman]

Only if they get sued for it....

Yes I believe the solution to this problem is going to come from lawyers. At some point they will discover this goldmine and start sueing hospitals for putting the equivalent of drunk doctors in charge of peoples' lives.

 

[Shah_Patel_PT]

Okay so I had a wierd experience yesterday. Some doctor(I think a resident) wrote me a prescription totally different from what he had in mind(supposedly), basically made a medical error.
By some stroke of luck the pharmacist picked out this error, but the worst part was that someone from the hospital called me to apologize and shamelessly blamed the error on "lack of sleep". Since I am not in the business of lawsuits I simply registered my displeasure and hung up. If we know lack of sleep actually impairs judgement, why the hell do we have sleepless doctors handling peoples' lives?
I however wonder how many medical errors could be attributed to lack of sleep? Do you guys find a lot of your colleagues making errors due to lack of sleep?

It all about money.....medical residents (3-7 years) are the cheapest form of labor in the medical profession. Impairing their sleep.....leads to better sleep for the senior physicians (aka attendings). This has been how it is for years...and it is not going to change either...

 

[Misterioso]

the sleep deprivation angle is mostly a gimmick used by the lazy among us to not work as hard as their predecessors did.

there's a reason why the "lifestyle" specialties have become so popular...laziness.

 

[8744]

the sleep deprivation angle is mostly a gimmick used by the lazy among us to not work as hard as their predecessors did.

there's a reason why the "lifestyle" specialties have become so popular...laziness.

Har har. I was about to get all indignant and lecture you about "not talking out of your ass until you actually start residency" or denigrate all that cool shadowing experience that forms the basis of your opinions but then I realized you were just pulling our legs.

Har har. Stop it. You're killing me!

 

[8744]

It all about money.....medical residents (3-7 years) are the cheapest form of labor in the medical profession. Impairing their sleep.....leads to better sleep for the senior physicians (aka attendings). This has been how it is for years...and it is not going to change either...

Amen. We do a medicine rotation where we basiclly admit patients all night for a medical service that is more of patient mill than anything else. And we do all the scut that they don't even do at most hospitals because you can't get it done for the $7.83 an hour that we get paid.

That's why nobody cares how much you work and would make you work 150 hours a week if they could. You are so cheap that even as an intern you are extremely cost-effective. As a second year and beyond when you acutally start to be useful they could never get a trained physician to do your job unless they paid him 15 times what they pay you.

Working hard is good. I appreciate the opportunity to train. But let's not get ridiculous. (Or rediculous, the accepted SDN spelling.)

 

[8744]

Yes I believe the solution to this problem is going to come from lawyers. At some point they will discover this goldmine and start sueing hospitals for putting the equivalent of drunk doctors in charge of peoples' lives.

I'm surprised they haven't been all over this like a fat kid on a cupcake.

 

[Faebinder]

I'm surprised they haven't been all over this like a fat kid on a cupcake.

Cause it's hard to prove without solid studies... and no researcher wants to do a study that will result in more work for him/her because he has proved that the cheap labor aka residents need less work and he/she needs to do more.

Did I just criticized my profession? Silly me.... Don't you love being anonymous on the web?

 

[Hemisphere]

well, panda bear certainly has more restraint than i will
now exhibit... lol..

i am in IM intern now,
on a q4 medicine rotation so every 4 days I work a 30 hour shift,
then on the "regular" days you are jet lagged from
getting 0-3 hours or so sleep that night, so it seems
there is never a day I am "normal" or "rested" or
"at my peak" work 80+ hours a week 6 days a week.
on a typical night we will admit 5 or more new patients
from the ER, then we run around the hospital do CPR
and shocks if anybody's heart stops that night, answer
calls for miscellanouse questions from nurses at any time
of the night, appease complainnig patients, etc. etc...

seems turnover is higher than what it used to be.
= more dictations more discharge summaries
more paperwork...
about above comments that sleep deprivation
is an "angle" used by lazy residents, docs
in the "old days" had the luxury of leaving
there patients in hospital 2+ weeks for the flu,
plus EVERYBODY and their mom gets admitted
for chest pain it is more litigious more work more
rules, 3x as much info and treatment options now
you can't even compare what current residents
do to medicine in the old days.

the lifestyle specialties are just specialties
where you can have a life. because right
now i do not.

The reason most residents don't get sued
for sleep dep (my own opinion) is that
the patients they treat are econmoically
underpriveledged and uneducated. Not
the types to run to a lawyer unless
its for a disability reimbursement for not working.
it costs a lot of time, and a lot of money,
and jumping a lot of hoops to get a lawsuit
started. even educated people with the resources
would prefer not to spend their time in court
unless they were pretty certain of victory.

Most of the educated types with good insurance
get admitted to private hospitalist services or
have private docs who are not residents.

doctors (and residents especially ) are not encouraged
to be activists. we do what we are told or our
evaluations suffer. If we do not "finagle" our duty
hour logs we get into trouble.
Look at what happened to the whistle
blower the EM resident from hopkins a few years
back... He got ostrasized and had to leave.
We are taught to cooperate and graduate.
Just trying to make it through the system.

It is not an open job market
for residency positions. If you lose your match
position it is very difficult to reapply and could
put you months behind in the training...



COmpare this to the european system
where residents work reasonable hours
but stay residents for longer... salaray
increases are more gradual rather than
slave... attending. personally
i would favor that kind of system,
but many don't.

I don't think the system is going to change
anytime soon. Our own directors have
said it is not a democracy here but a benevolent
dictatorship. Sometimes it's not even benevolent
at that! lol
Only 6 months of internship left!

 

[8744]

I am going to give those who don't want to hear me talking out of my man-uterus a few seconds to click over to a Smurf Homage site or their usual marsupial porn.....OK....

Look, I like my new residency program. They treat us pretty well on every service and the hours are a lot better than at that malignant hellhole where I did my intern year which for propriety and to avoid calling down the Wrath of the Pure I will simply call "Earl."

But even 80 hours a week will wear you out. Fortunately, I rarely even come close to this but on the few rotations where I am Q4 call, I come close or go over regularly. For those of you who don't know, Q4 call is call on every fourth night. You come in early and leave at five-ish or six-ish day one and day two. On the third day you have call and work solid without sleep until between ten or noon the next day. You then go home and either drag around like a zombie until your normal bedtime or go to sleep when you get home, wake up in the late afternoon feeling like crap, and then go back to bed at your usual time to get up early in the morning. This wasted quasi-day is day one. Then two normal days and repeat. You're supposed to get a day off every seven days but sometimes they get you out early post-call and call that your day off which is a foul trick to play if you ask me.

Repeat that for two months and you'll see what I mean about getting worn out. Last month, because of the way the call schedule worked and the transition from one rotation to another I had no days off, even a quasi-day , for four weeks. I'm not complaining because I got two full weekends off (one a three-day weekend) at the beginning of the month and we usually don't work those kind of hours in my program.

But imagine you are a poor, sorry sap at "Earl" or some other old-school program where they treat you like dirt. It get's old fast.

 

[Igor]

Eventually, residency ends, Panda Bear. After that, you have the right to get a job and no one will tell you to limit your hours.

Most docs have some sort of deal where they get paid a base salary and an additional fee per case. Most people like to earn a large salary.

No one can have it both ways. Either you earn a large paycheck and work hard (read - high census, high acuity, long hours) or you earn less money.

Few recent graduates (in any specialty) have expressed interest in earning smaller paychecks.

In other words:

Most young attendings will be working long hours, with high census (or very busy clinics, or both) and less help than they had in residency. Unless they gain the skills in residency, they won't be able to do this for very long. I know internal medicine hospitalists who see 30 pts a day. Not many can handle that pace for more than a year or two.

We need to prepare our residents for world with no caps, no hour limits and tremendous expenses where employers expect results (and bills!). You can't learn that unless you're forced to preform under under high stress when you're exhausted.

It should be that after residency, everything else is easier.

 

[margaritaboy]

Eventually, residency ends, Panda Bear. After that, you have the right to get a job and no one will tell you to limit your hours.

Most docs have some sort of deal where they get paid a base salary and an additional fee per case. Most people like to earn a large salary.

No one can have it both ways. Either you earn a large paycheck and work hard (read - high census, high acuity, long hours) or you earn less money.

Few recent graduates (in any specialty) have expressed interest in earning smaller paychecks.

In other words:

Most young attendings will be working long hours, with high census (or very busy clinics, or both) and less help than they had in residency. Unless they gain the skills in residency, they won't be able to do this for very long. I know internal medicine hospitalists who see 30 pts a day. Not many can handle that pace for more than a year or two.

We need to prepare our residents for world with no caps, no hour limits and tremendous expenses where employers expect results (and bills!). You can't learn that unless you're forced to preform under under high stress when you're exhausted.

It should be that after residency, everything else is easier.

I guess this is just a difference of opinion, and perhaphs a difference in the training philosophies at our respective programs.

Persoanlly, when I did 120 hours a week on internal medicine as a student, I wasn't learning ANYTHING after 40 hours of work. It kind of deafeats the purpose of 'graduate medical eduation' if the environment is so hostile that even basic patient care cannot be learned.

For the record, all my job offers have thus far included mandatory hour caps. Some of my friends and colleagues have had them written into their contracts when they join a group. Again, I'm not sure what specialty you are from, and this may just be a difference between specialties.

Don't get me wrong, I understand there are strong feelings on both sides of this issue. It is interesting though that truck divers and airline pilots recognize the effects of fatigue on their occupations and have caps on the number of consecutive hours they can work...why are we different?

 

[dutchman]

Eventually, residency ends, Panda Bear. After that, you have the right to get a job and no one will tell you to limit your hours.

Most docs have some sort of deal where they get paid a base salary and an additional fee per case. Most people like to earn a large salary.

No one can have it both ways. Either you earn a large paycheck and work hard (read - high census, high acuity, long hours) or you earn less money.

Few recent graduates (in any specialty) have expressed interest in earning smaller paychecks.

In other words:

Most young attendings will be working long hours, with high census (or very busy clinics, or both) and less help than they had in residency. Unless they gain the skills in residency, they won't be able to do this for very long. I know internal medicine hospitalists who see 30 pts a day. Not many can handle that pace for more than a year or two.

We need to prepare our residents for world with no caps, no hour limits and tremendous expenses where employers expect results (and bills!). You can't learn that unless you're forced to preform under under high stress when you're exhausted.

It should be that after residency, everything else is easier.

I disagree. That is not a good justification for putting people's lives in the hands of drunk doctors. For goodness sake you don't need scientific data to prove that on your 24th hour of work without sleep you are more likely to make mistakes, and in this case mistakes that could jeopardize people's lives. If you say that the job has to be done and there is not enough manpower, then I might agree with you, but to suggest that the training residents are recieving on the 30th hour of a shift is in any way helping their skills is ludicrous. I dare to say that if you exclude sleep deprivation from medical education you would still have similar or better quality doctors. We apply a lot of scientific facts in medicine but how about applyng this fact--PEOPLE THINK AND PERFORM BETTER WHEN THEY ARE RESTED.

 

[8744]

Eventually, residency ends, Panda Bear. After that, you have the right to get a job and no one will tell you to limit your hours.

Most docs have some sort of deal where they get paid a base salary and an additional fee per case. Most people like to earn a large salary.

No one can have it both ways. Either you earn a large paycheck and work hard (read - high census, high acuity, long hours) or you earn less money.

Few recent graduates (in any specialty) have expressed interest in earning smaller paychecks.

In other words:

Most young attendings will be working long hours, with high census (or very busy clinics, or both) and less help than they had in residency. Unless they gain the skills in residency, they won't be able to do this for very long. I know internal medicine hospitalists who see 30 pts a day. Not many can handle that pace for more than a year or two.

We need to prepare our residents for world with no caps, no hour limits and tremendous expenses where employers expect results (and bills!). You can't learn that unless you're forced to preform under under high stress when you're exhausted.

It should be that after residency, everything else is easier.

Hey, if you paid me 100 bucks an hour I wouldn't mind the hours so much. As I am making $7.45 an hour there is just no appeal to working 34 hours straight, especially since if I work 12 or 34 I get paid exactly the same amount.

Now, I understand that many residents went straight from high school to residency without ever having worked at a normal kind of job so there is a tendency to accept this kind of thing as, well, normal. But I don't know anyone who puts in the kind of hours residents still put in without some kind of compensation. Hell, the cafeteria lady slopping my chili mac told me she made "double-time and a half" for working on Christmas. Obviously the hospital values her service (which is important, don't get me wrong) more than ours.

You also, as you pointed out, have the option to work longer hours or not as an attending, something you do not as a resident where your program has you by the 'nads. I don't know too many FPs, internists, or even OB-Gyns who work 80 hours a week. Those who do probably find some satisfaction at work that the rest of us find with our families. Also, call as an attending, from my observation, is not the constant scut-hell that call as a resident has become.

It is also not a regular thing for attendings (except OB, of course) to not sleep one night out of every four week in, week out. It just isn't.

 

[8744]

Eventually, residency ends, Panda Bear. After that, you have the right to get a job and no one will tell you to limit your hours.

That's a funny choice of words, the implication being that until that time residency programs have a right to inflict cruel and unusual punishment (sleep deprivation). I imagine anywhere else in the world on any job except, maybe, as a Sudanese Christian slave to a Moslem warlord, asking people to miss a night's sleep every fourth day for their job would be greeted with hoots of laughter.

 

[Faebinder]

That's a funny choice of words, the implication being that until that time residency programs have a right to inflict cruel and unusual punishment (sleep deprivation). I imagine anywhere else in the world on any job except, maybe, as a Sudanese Christian slave to a Moslem warlord, asking people to miss a night's sleep every fourth day for their job would be greeted with hoots of laughter.

I'm pretty sure the warlords let their slaves sleep at night.😀

 

[3dtp]

I'm pretty sure the warlords let their slaves sleep at night.😀

Naaa, they just work 'em to death and get new ones, just like residency. Arbeit macht frei!

Let's see, $100/hour * 110 hours/week * 49 weeks = $539,000.

Panda, I'm sold! Let's do it!

Or, maybe even just overtime.

$40k/2080 hours in a typical work year is around $20/hour.

40 * 20 = 800/straight time week + 40 * 20 * 1.5 = 1200 which is 2000/week * 49 weeks is 98k. Not a half a million, but not so bad either. And just think if we made it double time for work beyond, say 16 hours on a shift...we'd probably be in the $200k range. hmmm...Tell me again why we need work rules? It's all about the Benjamins!

 

[Faebinder]

Naaa, they just work 'em to death and get new ones, just like residency. Arbeit macht frei!

Let's see, $100/hour * 110 hours/week * 49 weeks = $539,000.

Panda, I'm sold! Let's do it!

Or, maybe even just overtime.

$40k/2080 hours in a typical work year is around $20/hour.

40 * 20 = 800/straight time week + 40 * 20 * 1.5 = 1200 which is 2000/week * 49 weeks is 98k. Not a half a million, but not so bad either. And just think if we made it double time for work beyond, say 16 hours on a shift...we'd probably be in the $200k range. hmmm...Tell me again why we need work rules? It's all about the Benjamins!

How dare you!!!!! Unlike slaves.... Residents ARE disposable/replacable... just ask ECFMG.. It says so right there under the visa manual... heh.

Sir, you are suggesting that the poor slaves are as worthless as residents and that's just not right... slaves are people too you know.