Asymmetrical Information

The one point you miss;
Doesn't the argument you cite assume that the doctor losing a malpractice suit is by it's nature, a *bad* thing?

You're quite right, though; the reason such cases are won by the defendants so often is that the major quality of such cases can be found in lesser amounts on any stable floor. The costs of such nonsense to healthcare providers, and so to you and I, are not limited to the moneies exchanged as a direct result of losing such cases, but in the increased costs of doing business in insurance and in CYA medicine.... the kind of medicine designed to make sure one cannot be sued.

I hadn't heard the "ownership" argument before. It does, in fact, sound bogus to me too.

But having lived with a surgical resident in otolaryngology, I can chime in with this not-entirely-uninformed opinion: Sick people don't like to wait. If you show up at the emergency room at 3:00 a.m. with a peritonsular abscess, somebody better be gettin' out of bed.

Yes, residents need to work long hours. How long? I don't know. I'm not educated enough to say. How long is too long? Again, I'm not educated enough to say. But I do know that when the Parkland Hospital system in Dallas tried to introduce an 80-hour mandatory work-week limit a couple of years ago, it went over like a lead balloon. There's too much work, and there aren't enough doctors to get it done in a 16-hour workday.

Which may be another reason why breaking up the medical education cartel is highly desirable.
More docs are needed, and they need to be educated at a lower cost.

The question we must ask then is "Why aren't there enough doctors?"

It's a good, well paying job with a ton of respect in the community. It is not inherently more difficult than many other jobs where we have a sufficiency of people (certain specialties aside).

So why don't we have enough doctors? Why is the waiting time to get into medical school such an obstacle? Why aren't we opening new medschools, rather than closing the doors of the ones we have now? Why are we turning away good medical students in favor of foreign students who will never practice in the US?

A flaw in the reasoning here is that while trials may end up resolved in the practicioners' favor, the vast majority of medmal cases are settled out of court. Only those cases where the doctor has a reasonable chance of prevailing end up in a trial. Medmal lawyers are not playing the lottery as they bear quite substantial costs in bringing cases forward and only get paid when they win at trial or via settlement. Plaintiffs sometimes lose at trial, but they would not get to that point if their cases were meritless.

Arbitrary caps on awards would probably lead doctors to stonewall more cases and settle fewer cases out of court. I suppose if one is a bad doctor, this would be a desirable result.

Loser pays would more directly affect the "lottery" issue then caps.

But this is hardly a good sign. If the overwhelming majority are resolved in favour of the defendant, that means that a lot of weak cases are being brough to trial. Such cases are no less expensive to defend than cases in which the doctor is at fault. This represents an enormous cost to the system.

Probably not. A case where the doctor is clearly at fault is probably more expensive to defend since the doctor will have a harder time finding experts to defend what he did.

Assuming that attorneys are rational actors, and that on net the expected value of all verdicts in malpractice cases in a given year should not be less than zero (or a lot of medmal attorneys would go out of business), then this means that medmal attorneys are in effect playing the lottery: buying a lot of "tickets" that are unlikely to hit, in the hopes of a big payout.

Since lottery tickets are not a rational investment you should have stopped here and rethought this a bit.

1. Unlike lottery tickets, all cases are not created equal. A rational medmal attorney will pick cases that have a higher chance of winning thereby screening out marginal cases or low value cases.

2. Cases that go to court are only a fraction of all medmal cases. They are almost certainly going to be the toughest ones to decide. The ones that are easy to decide in favor of the doctor are likely to not make it through #1. The ones that clearly favor the patient are likely to be settled by the doctors insurance company. It's usually cheaper to settle a case where the doctor is at fault than to take it to trial and risk a large verdict plus endur the additional legal expenses in either case.

The problem with limiting higher verdicts is two fold. First it is rather arbitrary. Suppose a doctor removes your breasts for no good reason? Are you going to argue that you should only get 'economic damages'? Second there's no clear evidence that higher payouts are the problem. When NJ tossed around a $1M cap law it turned out that only a handful of cases even produced awards that exceeded the cap. What does appear to be the case is that the malpractice insurance industry is oddly inefficient. Like auto companies, one would expect malpractice insurance companies to rate doctors and charge higher rates to ones that have a history of screw ups. Even conduct research to lower medical mistakes just as car companies conduct research to improve auto safety.

One idea I read about would be a 'no-fault' system. Right now you not only have to the victim of a medical mistake but one that is egregious to sue and win. A 'no-fault' system would let you submit claims for medical errors & lawsuits would be reserved for ony the most extreme caes.

I don't know about "ownership" in general but the week I was in the hospital recovering from spine surgery the surgeon showed up way late in the evening -- seemingly after a day putting in office hours or other surgeries -- and both Saturday and Sunday afternoons. Granted he spent only a few minutes each time -- but given that he'd put five and a half hours of work into me on his operating table the average time per encounter was pretty significant. (And not HIS fault I wasn't awake to appreciate every bit of his attention...)

I happened to learn, swapping wallet photos, that my surgeon has kids about the age of my own. I know raising my own kids how much I value an hour at home with them, just playing Monopoly or reading a chapter of _The Hobbit_ aloud ... I know an hour in the evening or an hour on the weekend, at work, means nearly THREE hours away from my couch and my kids -- given getting dressed, driving in, setting up...

Atticus Finch on the jailhouse porch excepted, I'm having a difficult time envisioning circumstances under which a late or weekend hour of a lawyer's time means as much as the late hours a doctor puts in ...

For me there are only few relevant data point that never seem to get much press.

One, In those states that limit tort awards, how much have malpractice rates gone down?

Two, what is the rate of actual malpractice, regardless of whether or not a suit is initiated.

Three, what is the cost of providing medical care in states that have a limit on tort awards vs. states that do not (when other variables are normalized).

I don’t know the answers to these questions.

I would quibble with "legalized cartel". That sounds like a loophole written into antitrust laws which allows the AMA to engage in practices which would ordinarily be forbidden as illegal restraint of trade. Such loopholes exist for sports leagues IIRC, and of course (though the legal situation is complicated in about a zillion ways) for unions as well.

It would be more precise to say something like "government-imposed monopoly": the power to do things like prescribe drugs and do surgery is legally forbidden to anyone not in the officially sanctioned professional organizations. (And with this great legal power comes very little legal responsibility to avoid throttling the supply of competition to the point where even the bottom 2% in competence, or even bad actors who should have lost their licenses long ago, can command a fine salary just for their license. What a deal!)

Then, after *this* bit of linguistic precision is underway, maybe I can get people to stop saying "leader" and "citizen" -- instead of, say, "ruler" and "subject" -- for situations like North Korea...

William Newman - the doctors asked for, and got, the government-imposed monopoly. So in some sense, it *is* a legalized cartel.

Jeff Harrell - the need for medical services at 3am does not require people to work 80-hour and 100-hour shifts, any more than the need for police services or fire-extinguishing services requires police and fire departments to have 80-hour shifts, or the need for midnight munchies forces 7-11 employees to have 80-hour shifts. There is, obviously, a demand for medical care outside normal business hours, but why can't there be people working 42-hour shifts for four different shifts a week?

And why the hell is it so hard to get non-emergency urgent care services outside regular work hours?

I think the problem here is that doctors make mistakes (do they think they're human or something?).

They need an engineering, six-sigma type approach that makes it possible for airplanes to fly with such remarkable safety records despite thousands of possible catastrophic things that can go wrong. It's not fun to implement. Engineers at GE, P&W, Boeing, etc. complained quite a lot when implemented, but they have managers that can fire them and work in a competitive industry.

First step is to measure the mistakes completely (think feed-back loop, like riding a bike you need a sense of balance to detect the first hint of tipping over to make subtle adjustments. how many people without a sense of balance can ride a bike?) the medical industry appears to have a terrible mistake feed-back loop, probably because there is a huge penalty for every mistake. A no-fault system might be better.

as a lawyer (not in med mal), my view is that the cases which go to trial are those where either the facts (or appropriate interpretation of the facts) are hotly disputed, or where the clients (and/or lawyers) lose perspective on the purpose of the litigation.

either of these two factors could (in theory) adequately explain a defense bias in jury verdicts, without assuming that med mal attorneys are playing a lottery and gambling for a disproportionately large verdict.

from what little i know about med mal from the plaintiffs's side, i hear that it's a tough business where the doctors cover up and the insurance companies grind very hard. very very very few "lottery" cases exist.

I know a fair number of doctors and when I'm bored, I start asking them about the long shifts. Some will agree that they are stupid. Those doctors are no fun. Others will start defending them. Those are fun. They will argue that:

1. They need to follow cases all the way through to see how they turn out. (Like they can't read the file the next day or check back in later for a very long case. And that only helps for cases that happen to start at the beginning of their shift).

2. They need to learn how to make critical decisions under pressure. (By doing so from day one?!?! And why? Attendings never work those hours.)

3. It weeds out those who don't really want to become doctors. (This one is just dumb.)

They never have a good answer to my asking about increased fatigue and how detrimental it is on (pilots, truckers, etc...) and why doctors are special. I also like to ask them how they'd like their mother to be treated by an intern in the 35th hour of a 36 hour shift...

Bolie IV

It is meaningless to look at or cite the proportion of cases that are won at trial. The payouts are sometimes based on judgments after trial, but most often based on settlements before trial. The process of discovery and investigation is geared to identifying those cases which should be resolved before trial, for many reasons. Some of those reasons have to do with the medical merits of the claim, but others do not. In general, the defense will want to take only defensible cases to trial. Hence the high number of defense wins.

From my own experience pulling every third night call at Parkland, I can tell you it was a valuable experience. Smirk all you want about it, but every GOOD physician has to learn to feel the lump. I don't mean feeling a mass in someone on exam, I mean feeling a lump in your throat at 3am because you want to close your eyes and go to sleep- but the lump in your throat is telling you you are doing the wrong thing for the patient unless you get up now and go see them. At 3am, it's not the hierarchical system keeping you awake, it's not the "legalized cartel", it's the lump. And physicians who never have to wake up at 3am never learn to listen to it, and never become true physicians.
Physicians are not a commodity, you cannot build a plant in Mexico to get cheap versions of the same. Now that I am an attending, I guarantee that my patients want a tired ME taking care of them at any hour over a doctor who was trained to forget them at the end of his shift.

David Hall is right. Part of what you learn by pushing the boundaries of human tolerance is that no matter how bad a day or night you're having, you have to focus and do what's right for your patient.

Also, Jane, attending physicians ARE pulling those kinds of shifts. If one of my patients is in extremis, I'm there full time until the crisis is over, no matter the hour, and no matter how long of a day I've already had when the crisis hits. And I'm nothing special, most doctors will do it when it's necessary.

DD

"More docs are needed, and they need to be educated at a lower cost."
I remember reading somewhere back around '95 that, similar to agriculture policy, the U.S gov't paid med.schools to produce fewer md's (really!). Why? I think it is a mechanism (perverse, especially considering it was a Repub Congress) to reduce total cost because (again, I think) a cap on medicare/medicaide payments to an individual physician.

When there is no limit on medical expenses or loss of income from employment but a drastic one on "pain and suffering" then what penalty is there when malpractice results in the death of a child? If real reform was the goal why not either take it out of the courts and into a system of impaneled judges and medical experts? Or perhaps exempt legitimate research expenses and similar things from those limits (audited expenses, of course) of the winning attorney?

As an aside I was recently on a jury in a malpractice suit. While I felt for the family of the person who had died there was no way I was ruling for them. The simple fact was that every symptom that they claimed indicated the injury that caused his death was just as readily explained by a more common and generally non-fatal occurrence. IMO, he did follow protocols and I was disappointed when they settled. On the last day of the trial they settled. Sigh.

My employer once had to defend in a product liability suit. The item was made to order per customer print, and the injured worker had warned the foreman that the assigned misuse was hazardous. Still cost $40,000 to get out of it. I would think that the situation is similar in medmal.

A few points on malpractice:
- some residencies don't require the long hours. My spouse is an anesthesiologist and the standard practice is to go home after a 24 hour call shift, and to only work those every 4-5 days.
- there are a number of factors that work against weeding out bad doctors, including the inability for other doctors to complain about them (it will get you sued for restraint of trade - happened to a family friend), the limited resources of the medical examiners boards in each state, the long time it takes to get a final hearing at the boards except in the most extreme malpactice cases (a good attorney can delay a final judgement for 5+ years), and a lack of good data on what is going wrong.
- a few steps have been taken to look for how to improve the practice of medicine. There is a long running program in anesthesia where every closed malpractice claim is stripped of presonally identifying information and reviewed (as well as all intraoperative deaths) and "lessons learned" are gathered to improve practice standards. As a result, anestheia is many times safer than it used to be.
- the best proposal that I've seen is one that is followed in Scandinavia - No-Fault Malpractice Insurance. Run like worker's comp, claims are sent to a review panel and awards made via formula. By cutting the courts out, costs are substantially reduced and the monies that actually go to those harmed are increased. The valid claims are then reviewed separately by a discipline group to see if the physician needs to be counseled/suspended.

Of course, no fault malpractice won't happen because the tort bar will fight tooth and nail.

yclipse --

Conversely, any rational contingency-fee attorney has an incentive to drop or settle for low amounts any weak cases, because he makes no money on cases that lose. So while the defense should be settling the cases it's likely to lose and thus removing the easy-win ones from the pool, the plaintiffs' bar should, similarly, be dropping all the easy-to-defend ones (except for the handful where the client is wealthy and can pay per-hour legal fees, in which case it doesn't matter).

The result is that any severe tilt to unsuccessful cases indicates, in and of itself, the plaintiffs' bar has an incentive to pursue cases that are likely to only cost them money; the weak cases that unpredictably win are sufficiently lucrative that the contingency fee from them more than pays for the costs and time the many failed weak ones impose.

Which would be fine if they were spending their own time and money alone; this is how venture capitalists work, after all. However, they are also imposing costs, without compensation, on the defendants in the disproportionate number of failed cases they pursue. The logical counterincentive, to me, would be a loser-pays rule for losing law firms representing plaintiffs on a contingency fee basis. This would put all the costs inflicted by weak cases on the legal experts who are supposed to decide if the case is worth pursuing.

That won't eliminate the imbalance; the award in successful cases is always likely to be sufficiently higher than court costs that we have a definite tilt to the pursuit of weak cases by the plaintiff's bar. But at least the economic costs of weak cases pursued by the plaintiffs' bar wouldn't be improperly inflicted on blameless doctors.

One night I was at home taking call and my 17 yo son was listening to me give orders over the phone for a patient with shortness of breath. After I hung the phone up my son asked me what was happening and how I knew what to do. As I started to go into a long explanation I paused and realized that I knew what to do because I had seen it happen many times. But the first time, was as a resident on one of those all night shifts when I was there to personally witness the patient's improvement to the treatment. And that is something that has to be seen and experienced, you just can't teach it. The other thing that is difficult to teach is how to tell who is sick and who is not. The only way you can learn this is by following multiple patients as their illness progresses or improves. You just have to be there to see it and disease doesn't work in eight hour shifts. That way you know when it is time to get up and go see the patient in person, the proverbial "laying on of hands".

I could bore you to death about the malpractice problem but I believe the real monetary savings would be in decreasing the defensive medicine costs. However as long as the current situation continues everyone who has a headache is going to get an MRI and there are going to be MRI centers on every corner in town.

"It is not inherently more difficult than many other jobs where we have a sufficiency of people (certain specialties aside)."

Being a physician requires high intelligence, dedication, perseverence, good communication skills, and 6-8 years of schooling followed by 4-8 years of 100 hour work weeks (while being paid around $35,000/yr), followed by years of hard work, billing and regulatory hassles, dealing with difficult patients, and dealing with insurers and lawyers.

The only persons who believe that a physician's work is not more difficult than many other jobs are non-physicians.

A couple of points about the long hours for residents.

The doctors who have posted here have made interesting points, but I think that there are some flaws in the logic.

1) In regards to the argument that you need to see how a disease progresses:

You're right, disease doesn't work in 8 hour cycles. But it doesn't work in 24 hour cycles either. It is unpredictable. And it could be in 48, 56, 78, etc hour cycles. That's not a reason to work 56 hours. And the reason why you don't, even though some (possibly even many) diseases require that, is that you would be too tired to perform competently. So the question, in the end, does boil down to whether or not you perform competently when sleep deprived for X hours and what the optimal X is. This brings me to:

2) How can you honestly say that being up for 24 hours does not affect your response time? Again, would you want your mother to be examined by a resident on his 23rd hour?

3) There is too much pressure to discharge a fixed number of patients per resident. I have several friends who are in residency, and they constantly complain that the fixed number of patients per resident rules in ER's create a situation in which errors are likely. How can you compare a resident who had four gunshot victims in a night with one who had eight "my back hurts" which resulted in a simple advil perscription? If you need to discharge X patients, then when you're towards the end of your 24 hour shift, and are at the X-1 patient, you're going to be pretty shoddy. It's great that the guy writing about the lump is so noble. But honestly, doctors are people like everyone else and it's silly to assume otherwise. When you've been up for nearly 24 hours, you're going to be tired and will cut corners to get out of there ASAP no matter how noble and selfless you claim to be.

4) In regards to the artificial limiting of medical school enrollments, this is not true. Rather, it might be true, but it has no effect. Until, I believe, 2003 or 2004, med school applications were down. In some parts of the country, it's not particularly profitable to be a doctor, especially with high malpractice insurance costs and rising rents. I knew of a number of people who got completely discouraged in college from becoming doctors by the practicalities of the profession that were becoming more and more unpleasant.

5) Hospitals exploit residents as cheap labor and this is a huge problem in my opinion. I understand that hospitals have gotten squeezed in terms of money. I know this would be counter to the hippocratic oath, but maybe we should consider turning people away who refuse to give their social security numbers, names, etc. A number of ER doctors and residents I know in NYC have told me of countless cases of people coming into ER's with serious problems requiring expensive care and refusing to give their SSN's, making it impossible for the hospital to collect. These costs get transferred to the rest of us and onto the residents (because they have to work as cheap labor). This is a huge problem, in my view. I think it's insane that we allow people to get away with what amounts to legalized medical shoplifting.

Megan, I hope you don't mind that I've posted my story in your comments section before. I hope I'm adding something to the topic of the problems that result in long resident work hours. I've posted a link to this story in the past in your comments when you discussed resident work hours; if you don't want me to post it again, please let me know (you can always email me through email-for-life).

That said, I'd like to introduce my story. I personally believe that resident work hours are often onerous beyond any need for patient care, but I don’t think that’s necessarily a disaster in and of itself. I believe that the long work hours are, in fact, not a problem, but a symptom of the real problem, which is the total control residency programs have over medical licensure and board certification. This control can be misused in many ways, like making residents work long hours for cheap; to me, however, the greater misuse of that control is the ability of residency program directors to demand unethical and arguably criminal behavior from their residents.

My own story of a residency program demanding such behavior, as well as descriptions of other such unethical behavior, is here. A story of more traditional healthcare fraud allegedly perpetrated by my internship program is "above" (i.e. more recently posted) at the same site.

You're missing a HUGE part of te equation here:

When a Physician has a malpractice suit brought against them it does not matter ow frivolous or unwarranted or injustified it is, and it ammters very little in the long run whether it is successful or not.

It is a huge black mark against you, it stays in the state medical records, it can double or triple your insurance premiums and it badly damages your future job prospects.

My wife is a Board Certified Emergency Physician, and we have seen over and over good freinds and good doctors get nailed by some ambulance chasing clown with unfounded lawsuits and even when they are fully vindicated and the case is tossed out on it's ear the record remains.

A superb internist we know was named in a suit where she didn't even see the patient. The lawyer went in and took down the names of every physician mentioned in the file, and someone had written something about possibly consulting wit "Dr. X", altoug it had not happened.

It took a year for her Attorney to get her name removed from the suit, and even afterwards the malpractice insurance premium for her entire group went up 40%. She offered to leave the practice but they refused to consider it and finally found another carrier, although they do pay more than before.

It's simply not true to assume that "No harm no foul" is te rule here. The lawyers just move on to the nest case and the next, but the suit stays on the docs' record forever.

nobobdy else here thinks the problem is the number of mistakes made? many industries know how to reduce mistakes by orders of magnitude.

Well, I am an OB/GYN and I'd like to comment on the hours issue. I'm an attending now, having finished my residency in 1994. I am in a group of 3 in a small town in KY. WE ARE IT. We have to cover the OB floor 24 hours a day seven days a week. We have no residents. I'm on call every third day and every third weekend. (That means from 7AM Friday to 7AM Monday morning. A shift that it much longer than any I ever did in Residency.) So the long hours prepare for the long hours that you have to work when you become an attending. Could the 3 of us only work 12 hour shifts at a time? Or could one of us take the night shift for a week at a time and take the day off? IF we did that we couldn't see patients in the office and the already long wait for an appointment would get even longer. Since we earn only what we reap, if nothing much happens for the week that we are working only at night income would go down, while still having to cover the office overhead and malpractice insurance. I wouldn't be able to do elective gyn surgery that week either as only emergency cases are allowed at night.
A cure might be to have an OB hospitalist, someone who is paid to be in the hospital at night. However this an expense that the hospital doesn't want, again it can hurt income if your patients are delivered by someone else who is not in your group.( The main part of the OB fee comes from doing the delivery, if you miss that then you get only about 15% of the money despite having seen the patient alot in the preceeding 40 weeks) And its hard to recruit for a little town in KY so that will probably not occur.
I don't think that there are enough OB docs to just do shift work in all the hospitals in America that do deliveries.

There are a lot of good comments here underscoring how complex a thing it is to train a physician.

I am a pathology attending and at our program we do follow the guidelines for resident work hours (ok, I can hear the medicine and surgery docs laughing already, and yes, while we can always go home and sleep in our beds, it's by no means a nine to five job. If I had a nickel for all the times someone has called me in my office after five and said," You're still there?" Or expressed surprise that sometimes I do get up in the middle of the night to do a frozen. I mean, yes, it is a much more humane lifestyle, but you still spend a lot of Saturdays and Sundays in the office :) )

I think the work hours and case loads that residents have traditionally worked have not been beneficial to the resident or the patient. That being said, following a patient throughout the arc of illness, as it were, is a good experience to do sometime in your career. Residency ought to train you for tough situations and give you as much experience as possible, while still remembering that humans are fallible and operate best on at least some sleep. But medicine a tough job and there is no way to 'legislate' away all of that toughness.

It's true that attendings don't always follow the patient in the same way as the resident, but then attendings have experience which you can get no other way than, well, experiencing things. Residents often ask me, "how did you see that cell?" when I see something atypical on a slide at 20x instead of 40x. Well, I've been doing it longer and I went through the process of staying late at night to really 'learn my cases' in residency. In my first year of training, because I was so new to things, I might stay till midnight and then come back to work at four in the morning to get my cases looked at and ready for the attending the next morning. I didn't have to do this, and it only lasted a few weeks until I got better and faster (and an attending always looks at your all the cases in pathology, the resident is just pre-screening), but I'm glad I did it. It was an invaluable learning experience. I learned to manage a service no matter how difficult and not to panic if I had too much work and that I could make myself a good resident through hard work.

Residents in teaching hospitals often lack the good ancillary services that private hospitals have - so you end up doing the task yourself. But ancillary services cost, and labor is the first thing to get cut when administrators are looking at a budget.

I think the best way to keep teaching hospitals functioning and resident education focused on education (and not using them as slave labor) is to let some of the administrative decisions come from the physicians themselves in terms of hiring and organizing staff. Have a good clinical core whose main purpose is teaching and clinical care and promote them for performing those services (if they do it well). How about bonuses for good work? My institution has done that, and boy, does that make me try even harder to make the service run better. Incentives do motivate. The better the clinical services, the more invested the young clinician in the service; the more power they have, the better the hospital will run. Give residents more time off, but also, focus on the basics. I see a lot of programs that want to teach a resident about every new bell and whistle instead of focusing on the nuts and bolts. They need to learn to walk before they can run.

So, to sum up (sorry for the bloggorhea):

1. Better and more efficient computer systems.
2. Better ancillary services.
3. More physician, and less administrator, control.
4. Incentives in teaching hospitals for clinician-educators to work and teach - bonuses for good clinical service, more power over day to day decisions affecting clinical services.
5. Work hard at retaining young physicians - the constant turnover in teaching hospitals doesn't help to solve problems that require a long term committment.

It sounds like more money, but the thing is, the more smoothly you run things, the less money you waste.

Oh, and Mark (OB/GYN) makes a great point. I work a lot more hours as a pathology attending than I did as a resident. The work has to get done somehow, and there's no one to fall back on.

Megan,

The new rules limiting work hours have effectively done away with much of the "long hours" problem cited above, so the discussion is moot, to a large degree.

However, there have been unintended consequences. The worst has been the adoption of a "shift mentality" by new doctors. Patients are no longer their own, but belong instead to "the hospital" or "the attending". This viewpoint follows them into practice, where patients are viewed as part of the piece-work they do for pay. I have seen it now frequently, and it is far worse than a tired doctor, especially in the long run, and is an error multiplied over and over again.

The push for 'sane work hours' suffers the modern error of presuming that collective planning of institutions is superior to the current method which *appears* to have arisen without a plan and is therefore considered to be not only inferior but probably of malign intent. The pertinent economic question should be, "Why has (had) the social institution come to be thus?" There is a reason why we speak English instead of Esperanto; planned social institutions are, in the end, monstrous things.

The life of an attending is not always peaches and cream, despite the popular press to the contrary. Mark (OB/GYN) made some excellent points about the time on call - and it will vary depending upon the specialty. My boyfriend is part of a general surgery practice that also provides trauma/critical care coverage to two local hospitals. One of their residents joined their practice two years ago - he just quit last month because he didn't want to work the hours and have the call schedule that the attendings have. His lifestyle was much better as a resident.

As a surgical attending I can certainly testify to "the lump" described in an earlier comment. Such is the motivation to "do the right thing" that it will get you out of bed at all hours.
In addition to the "shift mentality" the 80 hour work week has served to create a "residency bubble" in which the rules of the real world do not apply, as Mark the OB/GYN points out.
The rigors of resdiency teach a physician how to "do the right thing" when tired, hungry, and smelly. They teach you to recognize when you are tired and emphasize the need to be careful. You learn these lessons while under the supervision of attnendings so mistakes are caught before they happen, or do any damage. The junior physician then can apply that lesson to the next patient.
But what happens when the first time you have to "work tired" is when you are in the real world and don't have backup?
I don't think residents spend too much time in the hospital, but that there time there is poorly spent such as performing ancillary tasks like patient transport.

As a practicing general surgeon, I will withhold my views regarding malpractice suits; everyone knows what they will be, and others have explained them more eloquently than I.
However, I can attest to the importance of "ownership" in the care of patients. A conscientious physician cultivates both a relationship with and a thorough knowledge of his/her patient. That allows a much more complete understanding of what to do in case something goes sour at 2AM. Those with a "shift" mentality never get this point, and expect that all the modern marvels of medicine will permit an almost instantaneous diagnosis and treatment plan. It never has worked this way, and never will; there is no substitute for knowledge and experience.
To come full circle to the malpractice arena, those physicians who practice "shift work" are becoming increasingly exposed to lawsuits because of the delays inherent in not knowing the patients they cover, not knowing all of the information about those patients, and not having the experience necessary to make appropriate decisions about their care in an emergency.

I am more than a little distrubed by the use of the "lump" anecdotes and such by doctors. Surely, as scientists, they know the difference between mere stories and actual data. If they think the studies which show that fatigued physicians make more mistakes are flawed, then by all means, out with it and let's have a go.

But in trials of the clinical efficacy of a new drug, for example, physicians would, for good reason, never get away with an argument to the effect of: "Well, it looks like this drug works no better than a placebo, but for Susie it seemed OK, so let's give it for everyone." They would be rightly pilloried. We shouldn't allow self-delusion (a malady under which every profession suffers) get in the way the proper analysis of evidence. Physicians rightfully demand this professionalism of others. We should expect no less of them.

So let's hear it. Are the studies (I'll have to look them up to link them, but the doctors here must know them) methodologically flawed? I know little about it, and would love to hear the evidence. But actual evidence only, please. The kind with numbers.

As a surgeon in his mid-fifties, I am amused by much of the posturing regarding extended working hours.

So it's really special if you see a patient with some bad condition at 3 am, as opposed to 3 pm? You really think you learn more from that when you're really fatigued?

Great!! Why don't we extend this to ever other field? Why not require pilots to fly longer than 12 hours, rather than limit their shifts to 12 hours? If not that, why not require that pilots undergo simulator training when they have been up 24 hours? Maybe we should schedule trials so they go 24 hours.

Would the judgment of the judge, lawyers, and jurors be adversely affected? Certainly not any more than the judgment of a physician trying to decide at 3 am whether the SOB (shortness of breath) that the patient is having is merely an asthmatic flareup or the first stage of severe congestive heart failure.

And as far as making sure you get a good night's sleep before you do a six hour liver resection or an aortic aneuyrism resection? Forget it!! It's not necessary -- just like it's not necessary for locomotive operators to have a certain number of hours of rest before starting a shift.

The medical system is inaltarably screwed up. There are so many different problems that I don't think any actual fix is possible.

Physicians work those type of hours for two reasons; first, it's always the way it's been done, and second, if doctors limited themselves to 40 hour weeks there wouldn't be anywhere nearly enough to go around.

What I find amazing here is so many doctors have one standard of performance they would expect everyone else to meet, and a separate one for themselves. Imagine if, instead of talking about residents and patients, we were talking about nuke engineers and reactors? Both are specialized skills requiring lots of education. Both are involved in life or death decisions. But noone in their right mind would make the statement that working 80+ hours per week is necessary to making a better nuclear engineer, and absolutely noone would ever claim that the risk of a fatigued staff monitoring a fission reactor is worth the gain in experience that the staff would attain. Why is it that physicians seem to think that the immutable effects of fatigue affect everyone in the human race except for physicians?

Re: "Why is it that physicians seem to think that the immutable effects of fatigue affect everyone in the human race except for physicians?"

It's not just MDs, John. Nor can those who have not gone to boot camp understand why it might be a valuable, although difficult, process. There are are other similar comparisons(e.g. police & fire training, professional & college sports), but the military has the closest mindset.

The fact that you don't get it, and the participants cannot convince you of its value, does not lessen its importance. It only makes the unintended consequences of changing the current method beyond your grasp.

I missed most of the fun, but up yonder the question was raised as to why we don't have more doctors. I think there are two answers to that.

First, being a doctor is hard. Maybe one person in a hundred thousand is suited to being a doctor. We don't just want more people to get their MDs; we want more doctors, and we're kind of limited by the number of potential doctors there are out there.

Second, in order to train one doctor, we have to employ (estimating off the top of my head) a couple hundred doctors as teachers. If you think the number of potential doctors is small, the number of potential doctors who are also potential teachers is microscopic. If we wanted to train more doctors — assuming we could find suitable candidates — we'd have to ramp up the training infrastructure, which all by itself would be a massive investment. It takes decades to establish a medical school.

It kind of reminds me of folks who declare, as if it's the easiest thing in the world, that we need to recruit more soldiers. They rarely stop to consider that our training facilities are already running at capacity, and that if we wanted to expand them we'd have to find and train new instructors, build new facilities and so on. The argument usually starts with "let's hire more troops" and ends with a raw dollar figure representing what it would cost to pay them. The costs of ramping up the entire infrastructure are rarely considered. I think this is a similar situation. "Let's hire more doctors," some say, without thinking the implications through.

My final thought is this: Despite all the complaints, does anybody deny that our country enjoys the finest health care in the world? I'm not necessarily saying there's a link between how we do it and what results we get … but the possibility is at least worth considering.

Thanks to Bard Parker at Cut to Cure for directing me here. Great comments. Like Mark (Ob/Gyn), I finished my Ob/Gyn residency in the early 90's. I have been an attending maternal fetal medicine specialist since 1993 in an academic medical center, and my schedule now makes residency look easy. We as a profession are without a doubt doing this wrong. As attednings, we are the ones really making the decisions. My residents get to go home after 24 hours, but like Mark, I can go 36 to 48 hours with nothing more than the occasional cat nap, and still be the one ultimately responsible for my patients. The system is overburdened, and there is a physician shortage, which I believe has been well documented. Another aspect of what drives this system is how we are compensated. Physicians are pushed to see more and more patients as reimbursements decrease. And there comes a point where the quality of care decreases, and then nobody benefits, and mistakes occur.

I know too many doctors to believe that they are any smarter or tougher than a lot of non-doctors I know. To be fair, I've been educated at top-notch institutions, so just about everyone I know is in the 99th percentile or higher.

I've also been in hospitals for the births of my two children and to spend time with family members in routine and emergency visits.

Unless someone can provide a study showing that doctors perform just as well after 36 hours awake or with not enough sleep for a month, then they are putting their patients at risk needlessly. To you doctors who tell me that you have to work those long hours, do you honestly believe that you perform as well after 36 hours with no sleep as you do after a good night's sleep?

As to the OB above who explained in great detail how the long shifts are necessary because of insufficient staff, well, you're short staffed. You are taking on patients even though you know you don't have enough staff to adequately cover their needs without taking excessive shifts. Is that responsible?

To be fair, there is a big difference between on-call when you are home sleeping unless you are needed for an urgent situation and on-call when you have to stay at the hospital and work the whole time. I don't mind so much on-call doctors who get to go home over the weekend and sleep unless something happens. Especially for OBs, babies come when they come. But working 80 hours in one week or 24-36 hours straight with no sleep is just reckless and irresponsible.

Bolie IV

Re: "But working 80 hours in one week or 24-36 hours straight with no sleep is just reckless and irresponsible."

Remember your conclusion when, like the EU, we make work rules prohibiting such long hours and find ourselves (1) paying more for care and (2) even more short-staffed. England has forecast that they will be short over 3500 MDs because of such limits.

Strange how, when you push on one end of a system, the other end pops up and hits you in the head. Hayek and Mises had much to say on this.

I doubt very much that Hayek would have supported a system by which licensing agencies control your ability to enter a profession until you have fulfilled their requirements to work ludicrous hours for little pay. Nor would he like the restrictions of supply that have resulted in an increase in supply from U.S. medical schools of only 2% (from 16,307 to 16,648) in the past 11 years, even as the demand explodes.

But maybe I'm wrong on the supply end. I have always read that it is mostly the doctors themselves that prevent any increase in supply, although frankly I confess I may be way off here. Any physicians out there: I'd be delighted to hear why the supply is expanding so slowly (I'm acutely interested because as a third year college student, I am watching many of my good friends go through the process right now of preparing for applying, and some might not make it because the competition is so severe.)

Bollie IV wonders if I am irresponsible by seeing too many patients. Well as I pointed out there are only 3 of us here and the next hospital over is about 40 miles away. We have a NICU so those surrounding very small hospitals send there preterm labors and pre-eclamptics to us. We have no MFM here to see the really high risk patients so we have to send over a 100 miles to Vandy down in Nashville.

I could limit the number of patients that I see in the office, but then they would just show up in the ER without any prenatal care with who knows what is wrong with them problems. I think its better for them and for me if I am busy and see them and become familiar with them. There ain't nobody else as they may say around here.

Bolie IV also needs to remember that I am in a very small town in KY and it is very difficult to recruit new doctors here. I'd love to be in 1 in 6 or 1 in 7 call cycle. Hell I'd be the OB hospitalist if they decided to start that but that's a long way off.

Also and I mean this is the nicest possible non-misoginest way, there is a growing shortage of OB's as more and more women come into the field. Studies show that they are far more likely to work part-time and they tend to drop OB much earlier than male OB/GYN's and this exacerbates the shortage.

Why are we turning away good medical students in favor of foreign students who will never practice in the US?

What does this mean? The medical schools don't train many foreign students. Moreover, so many foreign medical graduates come to the US, take boards and go through a residency over again so they can practice in the US and make lots of money.

As for why we don't increase medical school output, part of it has to do with the limitations of training resources like cadavers and patients willing to be examined by a medical student.

I note the comments by Mark, replying to Bollie IV, and the excellent points he makes.

The issues he notes do not just exist in small towns. I work in a large, tertiary care medical center, performing subspecialty care (pediatric cardiac anesthesia and intensive care). I too work long hours at times. If my hours get too long, I call my colleagues to give me a break. However, even in an institution such as mine, there are not that many colleagues who do what I do. If I had more colleagues doing the same work, I'd not have the occasional long hours. I'd still have work and pay, as there are plenty of adults I could also care for, so financially there would be no penalty. It sounds great, in theory.

Of course, then those colleagues would have to care for the same limited number of patients as do I. I would care for fewer patients in my subspecialty niche, and so would they (more doctors treating the same patient pool means each doctor sees fewer of that type of patient).The price would be paid in experience. We, as doctors, wouldn't pay the price, our patients would. No one caring for those children would have what I would consider adequate experience. At least this way, there's a critical mass of experience...and that saves a lot more lives. I know when I'm needed at the bedside, based on experience, and I know immediately what to do when I'm there; again, based on a lot of experience. When seconds count, there's no time to dither about and look things up; one must act, act immediately, and be correct every time. If correct, timely action isn't taken, a child may needlessly die. Another example: if someone with less experience is trying to place catheters in large, central blood vessels, there will be more complications...again, patients will pay.

There is a difference between what I do, and what medical residents do, in terms of work hours. In the past, the residents had no choice, and no recourse. I have choice, and I can get needed rest by just asking my colleagues. We also arrange our schedules to allow for rest. Still, there are times when the hours can get long (i.e., a 24 h+ shift, with catnaps on my couch in my office). I'd be happy if someone mandated shortening those stretches, as long as they also provide for my relieving colleague to magically have the necessary experience to care for the patients.

It's not just MDs, John. Nor can those who have not gone to boot camp understand why it might be a valuable, although difficult, process. There are are other similar comparisons(e.g. police & fire training, professional & college sports), but the military has the closest mindset.

The fact that you don't get it, and the participants cannot convince you of its value, does not lessen its importance. It only makes the unintended consequences of changing the current method beyond your grasp.

The comparison between residency and basic training, frankly, is lacking. Basic training subjects recruits to sleep deprivation in training so that they can deal with sleep deprivation in combat. If the standards of residency were applied to the Marine Corps, a recruit would spend two weeks in a classroom learning how to field strip an M-16, then get dropped off in Fallujah for two weeks of non-stop combat.

Residency is the opposite of military training. Residents are asked to work 80+ hours per week while treating patients. The Marines don't put recruits into combat, and the SEALS don't perform missions until they've finished training.

Re: "I have always read that it is mostly the doctors themselves that prevent any increase in supply, although frankly I confess I may be way off here."
You are incorrect. Government reimbursement fixes the number of available residency slots. While indivudal specialties have in the past expanded or contracted the total graduated from, say, anesthesia, the greatest impact is from government diktats. In the 1980s, complaints of an impending glut of doctors led to national limitations on training. These predictions were wrong, a such central planning efforts always are.

You are correct about Hayek and restricted entry into the field. There has been a huge end-around this restriction however, given the massive expansion of nurse practitioners and physician assistants in the past 20 years (both of whom prescribe and can practice independently).

Re: "Residency is the opposite of military training."
Then you understand neither, which was my point.

If interested in justice, cap legal fees.

If interested in justice, cap med. insurance profits/premiums/gatekeeper kickbacks and force the amortization of drug/machinery investments over longer periods of time - give corporations the incentive to do 'the right thing'.

If interested in protecting injustice, limit the ability of those maimed by the negligent and substandard to receive what a jury of their peers deem a 'fair' settlement.

If the AMA didn't facilitate the highway robbery commmited by the insurance and re-insurance fields...not to mention effectively overseeing their own membership...much of this issue would simply vanish.

Unfortunately, everyone is safely ensconsed in their own little fifedoms. Doctors and their lawyers plead poverty from the golf club, Big Pharma pleads poverty at $10 a pill, the Insurance and Re-Insurance Empire pleads poverty from Omaha NE, and HMO's plead poverty whilst stuffing pockets full of cash into $3000 dollar suits on The Hill.

If the doctors won't attempt to fix things by taking responsibility and boycotting systems that do more harm than good, we all can stand by for third rate healthcare and corporate protectionism boondoggle akin to our northern neighbor. It's well on its way down here.
End of rant. :~(

still, nobody else thinks the problem is too many mistakes.

six-sigma folks

doctors are trained to treat patients, not manage. A large body of very smart people of figured out the right approach to incremental improvements in process to reduce the number of errors.

part of the problem (and this goes for any intelligent professional) is that being such smart people they assume they know how to manage.

David Hall, DD(Doctordisgruntled), Duanebs, Dr. T, Peter Banos, Mark, MD, Bard Parker, Aggravated DocSugrg, Narniaman, Tom Wigton.

Perhaps you could explain to me and others here why is is that the Medical Profession does such a terrible job of policing itself?

From 1990 to 2002, just 5 percent of doctors were involved in 54 percent of the payouts — including jury awards and out-of-court settlements — according to the National Practitioner Data Bank of the Department of Health and Human Services. (The data bank allows hospitals and medical boards to see the records of individual doctors but, thanks to pressure from the American Medical Association, Congress forbids it to release information to doctors or the public.)

Of the 35,000 doctors with two or more payouts during that period, only 8 percent were disciplined by state medical boards. Among the 2,774 doctors who had made payments in five or more cases, only 463 — one out of six — had been disciplined.

Part of the problem is that no one keeps statistics. Part of the problem is that privacy laws prevent some of the data from being collected. But more of it is just that doctors don't keep the data required to really determine what causes mistakes.

I have a friend who is an anaesthesiologist and apparently they have a database of every claim ever, so you could actually aggregate data on their malpractice claims. Not all specialties do that.

He also pointed out that long shifts, per se, weren't the problem, it was continuous long hours. He was a resident under the old system and he would work a long day, then work on call all day, then work another long day, then continue working long days and then be on call again with no break to recover. Some rotations didn't get weekends off, they just continued working long days and overnight calls for a couple of months. The other problem is that attendings, who are supposed to double-check the tired residents, aren't always around at night. They are on call but not always present at the hospital. This means they won't catch mistakes that the residents don't realize they are making until the next day, which may be too late. If overworked residents were supervised around the clock by attendings who were getting enough sleep, there would be a much lower chance of mistakes.

And if reducing extreme hours exposes a shortage in residents, than that's something that should be exposed.

I'm not arguing that all doctors and medical students should work 40 hour weeks with no overtime. I've worked a week continuously with no breaks before when I had to. I have a real problem, though, with working residents for long shifts and long hours without sufficient down time to recover. And I have a problem with doctors who deny that fatigue is a problem. It's quite easy to work long shifts periodically to see the full disease progression and then take a day off.

I should also say that you OBs out there are in a bad situation. I understand that malpractice insurance is out of control and we have an OB shortage, so you guys are doing what you have to do. Unfortunately, babies come when they come and they like to come at night from what I hear...

Bolie IV

Dear Joe Bagadonuts,

I can’t answer your question, but I’d like to point out that it’s not just the medical profession that is doing a bad job of policing itself. It’s the rest of society that is also doing a poor job of policing the medical profession. If you look at my story, you might wonder why 23.5 million dollars (!) of pretty obvious overcharges (claiming that attendings did work that occurred when they weren’t in the hospital) didn’t result in criminal charges. You might wonder why doing research on unwitting patients hasn’t resulted in criminal prosecution. You might wish to know that I contacted the hospital administration, the FBI, and 20/20 and 60 minutes with complaints about what I considered blindingly obvious fraud or mismangement such as this on the part of my internship program and got nowhere. It’s not just the medical boards that aren’t doing anything; it’s everyone else as well.

So, I am going to be starting a residency in the summer--and a surgery one, no less (one of the hardest!). I am in complete agreement with the work-hr restrictions, as are almost every single recent med school grad I have ever met! The fatigue incurred from an excessive work schedule creates an unacceptable level of risk to our patients and is just plain inhumane!

But...it has to be understood, we residents NEED a lot of exposure to sick people to learn how to be a good doctor! We need to be there to see what happens over time to an illness--and reading about it in the chart the next morning is not the same.

My teachers and attendings have spoken to me a lot about the "art" of medicine--that part of practicing that is not pure science. And that cannot be learned in a book or on a part-time basis--the "art" of talking to patients, giving bad news, understanding what will happen next or just "knowing" something isn't right and we need to find it--that is developed only by doing and seeing it again and again and again. So we residents need to be there long enough to see a disease or illness progress, from the start to the finish.

However, this needs to be balanced with the need of the resident to be well rested, so they can think clearly, learn well and give proper and SAFE care!

Yes, residents are a source of extremely cheap yet hightly educated labor for hospitals--a tradition that started long before the current "health care crisis" I might add. There is a mentality going around that "if it ain't broke, don't fix it!" I say just because no one pointed it out, that doesn't mean the system wasn't broken!

The 80 hour work week is creating a lot of growing pains, but after some time goes by and the procedure is tweaked a little, I think the medical education status of our country will be better than before, and we will have better, happier physicans! The system must change--and sometimes the band-aid needs to just be ripped off because peeling it back in stages just isn't working. Beyond getting some health insurance and just enough money so we don't have live in our cars, there have been no major changes in the way residents are treated for decades! I look at the 80 hr work week as a shock to the system to create change for the better.

So many senior residents I have talked to are bitter, cynical and beaten down by a system that doesn't need to be this way. They started like I am now--hopeful, dedicated and eager for the future. I am hoping I can finish residency and start practicing the same way I started.

Perhaps you could explain to me and others here why is is that the Medical Profession does such a terrible job of policing itself?

From 1990 to 2002, just 5 percent of doctors were involved in 54 percent of the payouts — including jury awards and out-of-court settlements — according to the National Practitioner Data Bank of the Department of Health and Human Services. (The data bank allows hospitals and medical boards to see the records of individual doctors but, thanks to pressure from the American Medical Association, Congress forbids it to release information to doctors or the public.)

Of the 35,000 doctors with two or more payouts during that period, only 8 percent were disciplined by state medical boards. Among the 2,774 doctors who had made payments in five or more cases, only 463 — one out of six — had been disciplined.

Perhaps one reason is because the medical profession realizes that there's virtually no connection between "payouts" and performance. If you penalize those who have been sued, you're penalizing the unlucky, not the incompetent.

Oh, and Pogo -- your logic is confused if you think that arguments about residency and boot camp are related. You misunderstand both.

Re: rant by John Galt de Sieyes "If the doctors won't attempt to fix things by taking responsibility and boycotting systems that do more harm than good, we all can stand by for third rate healthcare and corporate protectionism boondoggle akin to our northern neighbor. It's well on its way down here.",/i>

I am in agreement with your conclusion that our insurance system is messed up. However, your tired assertion that doctors are somehow in collusion with this is based not on information but envious assumptions bearing little relation to the truth. "Doctors" are merely atoms, making individual decisions based on the current environ. You seem to know little of the history of the repeated government intrusions into insurance and health care that have yielded this monstrosity. The AMA is not the monolith you suggest, and now represents less than half of all MDs.

Moreover, the majority of MDs agree that change is needed, and many doctors have advocated a true market approach with a return to affordable insurance. The idea that we are moving toward a single payer system is far more of a threat to each citizen than it is to doctors. Why people are willing to walk down that failed and dangerous road is a mystery to me.

Re: Mr. Nieporent's comment, "and Pogo -- your logic is confused" Not much of a retort, David. It does little to support that you understand residency training any more than prior comments suggest.

I notice that no one has mentioned the enormous importation of doctors from overseas. Every year we're importing more than 4,000 “international medical graduates” (500 per year from Canada alone). In some specialties 40% of all residents are IMG's.

Many of these doctors were trained at public expense and come from countries where they're desperately needed.

Willingness to pay in the United States is sucking up an enormous proportion of the world's medical resources and the trend is not positive. We need to change our total system. Our current system is abusive, it's immoral, and it's bad medicine. Don't believe it's bad medicine? We pay a lot more per capita than the closest competitor (Switzerland) and have poorer stats.

Being a doctor is not always a well-paying job. Medical school leaves the new doctor as much as $250,000 in debt for those 4 years alone. You then must complete a 3 to 7 year residency, with an average salary of about $35,000. This means that you either 1) defer payments, letting interest accrue on your quarter million dollar debt, or 2) live in a hovel and try to make payments on a crap salary.
Oh and let's not forget that some people like to drive cars (say, an extra $20,000 debt) and live in a house (add on an extra $150,000, minimum) and pretty soon we are seeing some real money. Divide by the average starting salary of a new doctor, which is in the neighboorhood of $120,000, and it takes forever to pay it off.
And respect? I can't count how many times people in my ER sass me, telling me I don't know what I am doing, and that they are going to a real doctor. Yes, perhaps you respect the doctor, but the next 5 people in line do not.

Re:"In the 1980s, complaints of an impending glut of doctors led to national limitations on training. These predictions were wrong, a such central planning efforts always are."

But those predictions came from doctors and their organizations as well. The policy paper of the American Association of Medical Colleges is posted at:
http://www.aamc.org/workforce

It starts off saying, "In the 1980s and 1990s, workforce analysts and public policymakers, with few exceptions, predicted the United States would experience a substantial excess of physicians by the beginning of the 21st Century. In light of these analytical studies, the AAMC and other national organizations recommended steps to reduce physician supply in order to obviate the predicted surplus."

I agree 100% that planning ends in disaster, but more often than not, as seems to be the case here, doctors were supporters of the planners.

Re: "I agree 100% that planning ends in disaster, but more often than not, as seems to be the case here, doctors were supporters of the planners."

Dead on correct. The "MD" confers no special abilities outside of medicine, but that rarely deters a surfeit of MD academicians from trying to tell everyone else what to do. As Mencken said, "The urge to save humanity is almost always a false front for the urge to rule."

I've been through boot camp. Yes, we had to learn how to function with damned little sleep. But we didn't have any important decisions to make. We hardly had any unimportant decisions to make! And when they issued live ammo, it was on the shooting range, with several experienced NCO's who went home at night to sleep watching us very closely to ensure we didn't ventilate ourselves or our buddies. We didn't camp out on the shooting range with loaded weapons while most of the supervisory staff went home. And finally, the range was located and constructed to ensure that misplaced shots didn't fly off and hit civilians.

Maybe the attendings try to watch the residents just as closely. But it sounds like when something happens at night, there is often no attending there - and if there is, he's likely to be sleepless and worn out too. And when doctors make mistakes, it isn't themselves who get hurt.

Finally, the military damned well knows that with all the training and planning it can do, many mistakes will still happen once the troops go into combat. They can't eliminate the mistakes. They can try to keep things simple so not as many mistakes happen, to provide chances for our troops to recover from their mistakes, to make the enemy even more tired and hungry than our men, and to exploit the enemy's mistakes.

So, what does the medical profession do about mistakes that happen when residents and attendants are foggy from fatigue? Pretend they didn't happen?

As for whether physician shortages are caused by limits on med school or residency slots, or by a shortage of qualified candidates, it can be settled very simply by one observation. Do medical schools normally start the year with empty seats because they didn't get enough qualified applicants? Or do they fill every seat and turn away others?

Hey Pogo -

"However, your tired assertion that doctors are somehow in collusion with this is based not on information but envious assumptions bearing little relation to the truth. "

The assertions are not solely mine, nor are they in any way 'tired'. To remain 'in collusion' with a bad system, one has simply to stand by and do nothing...which is what the vast majority are doing.

Your ad hominem that I am somehow envious of Doctors is a rather blatant attempt at moving the focus from where it squarely belongs, so so let's drop that pretense shall we!?

The facts are that doctors make quite a good living, that training costs are very manageable if the new doctor has the foresight to put together a competent financial team, and that doctors aren't the only part of the problem...just a significant part of it.

Hmm, it seems some of us are talking past each other, which is a shame.

There are very strict regulations for residency programs regarding working hours and there are penalites for breaking them. I don't think the draconian work hours of the past are a good thing at all and I'm glad that we are getting rid of them (or should be) - but I do think we need to be tough with our residents when they are on service and expect nothing less than excellence. They should have some experience of long work hours, if only for a short time and as an educational experience, but I stress only for a short time, and not as the dominant pattern of work.

http://www.acgme.org/acWebsite/home/home.asp

ACGME accredits residency programs and has the requirements you must follow.

Okay, I'm going slightly OT on this post, but I'm curious what you think of the new bankruptcy bill going through Congress. I figure since this post is about medicine, and that bankruptcy is closely related to medical bills...it might be close enough.

Josh Marshall even has a guest commentator from Harvard posting on it, and Instapundit is against the bill going through as well.
http://instapundit.com/archives/021597.php
http://talkingpointsmemo.com/bankruptcy/

This is something that blogs might be able to get reported if loud enough.

One fact that has to be taken into account is that the vast majority of suits are settled before they get to trial. One major insurer in TX reported that they settle over 90% of malpractice suits. It stands to reason then that the ones that go to trial are the ones they're confident of winning. They should win virtually every case that goes to a jury. So deeming malpractice suits trivial or claiming there's no problem because of win rate based on jury decisions isn't valid.

"Being a physician requires high intelligence, dedication, perseverence, good communication skills, and 6-8 years of schooling followed by 4-8 years of 100 hour work weeks (while being paid around $35,000/yr), followed by years of hard work, billing and regulatory hassles, dealing with difficult patients, and dealing with insurers and lawyers.

The only persons who believe that a physician's work is not more difficult than many other jobs are non-physicians"

Way to miss the point. I wasn't comparing Doctor's to the local clerk at 7-11, but to Architects, Engineers, or high end executives. Doctors require a lot of schooling, but so do many other disciplines. They require above average intelligence, but so do many other professions that require equal amounts of study, training, and hard, laborious work.

Medicine is a tough job, and it requires a lot of dedication. Fine, but my point was that currently the barriers to entry in the field are largely artificial, not ones necessitated by the job.

Or can you tell me why I've known several honors students waitlisted and ultimately refused entry into medical school? Let me be clear. I want more doctor's, and the biggest barrier to entry into the field isn't the rigors of the work (tell it to an infantryman doc), it's the petty, artificial rules that deny promising students the opportunity.

On the subject of medical malpractice and statistics and QA, I was flabbergasted when my wife's OB couldn't tell me how many episiotomies she performed.

She then went on to assert that she only performed them when absolutely necessary and that allowing natural tearing was vastly more devastating than the episiotomy. I'm not sure how she could know this if she wasn't keeping track of how many she performed (and, therefore, could not know how they affected recovery times, etc...).

When we asked her about them, she got defensive but had absolutely no statistics to back up her assertions.

Is this typical? Do doctors keep track of their procedures and the outcomes? My other doctor friends indicate that doctors typically do not, with a few exceptions.

Bolie IV

"One fact that has to be taken into account is that the vast majority of suits are settled before they get to trial. One major insurer in TX reported that they settle over 90% of malpractice suits. It stands to reason then that the ones that go to trial are the ones they're confident of winning. They should win virtually every case that goes to a jury. So deeming malpractice suits trivial or claiming there's no problem because of win rate based on jury decisions isn't valid."

While it is true that many of the cases that make it to the jury pool are there because they are weak, others are there because they are strong engouth to warrant a plaintiff's verdict, but not so strong to justify the demand made by plaitniff's counsel, at least not in the mind of the adjuster/counsel/client on the defense. Some of these cases don't belong in the jury pool simply because the defense has underestimated the strengths of the plaintiff's case and has refused reasonable settlement offers.

A few posters have commented in a way that implies that they actually believe the 80 hour / week restrictions are real. While they may be real in some settings, no one should be surprised if residency programs are willing to break the law on this matter as they do on so many other matters. Here's a quote from doc Russia at http://bloodletting.blog-city.com/read/157521.htm:

"....hospital administrators, faced with multi million dollar shortfalls found a way to break the law without getting caught: just ignore it. If a resident blows the whistle, then they are going to be blacklisted by hospitals who do not want to take on someone who could expose their own infractions. They will not be fired; they will fail their residency. They will have to reapply for a new one. In hospitals where one is required to clock in and clock out, residents are told to sneak into the hospital to see their patients. Hospitals also only count time starting when the attendings round, and ignore the hours before when residents must see their patients to prepare for rounds. The list of devices used by hospitals to squeeze more hours out of their residents goes on and on ...."

I think Bollie is one of the few people here who seem to get the real issue (IMHO).... it's about statistics of mistakes. without statistics saying who, when, where, why, doing what the mistakes happened, you can't really fix the problem.

and good statistics don't really exist in medicine, and the huge liability associated with mistakes presents a disincentive for full disclosure.

deaths from medical mistakes would look insignificant next to deaths from airplane crashes if mistakes on the machine shop floor making jet engines were handled the same way mistakes in the operating room currently are....imagine machinists with liability insurance and lawyers

An addendum to my own post two posts up, which ended with "The list of devices used by hospitals to squeeze more hours out of their residents goes on and on." Just because it amuses me, I'd like to recount one of my favorite devices used to squeeze more hours out of me and of the other intern I was sharing a service with at the time.

During my approx. 2nd month of residency, on an inpatient service, I was relieved to find that the residency program had set a limit of 30 inpatients per intern (my memory is fuzzy on the exact number, but it was a high number). The program let it be known that, in the interests of education, it was just too much to expect anyone to learn while trying to keep track of more than 30 patients worth of scut at once.

That made a lot of sense to me, and still does, so I approved of the policy. The policy, however, lasted only until the 31st patient showed up in the ER. At that point, the policy was temporarily waived, and our census grew to (as I recall) approximately 40. Not to worry, though; the no-more-than-30-patients rule was promply reinstated when the census again fell below 31. From that point on, I never bothered to check the status of that particular rule on call nights.

Well, Peter Banos, you do have a point. Anonymous complaints are not considered under the ACGME guidelines, which makes it hard for residents to complain. I'm sure some programs are breaking the rules - the thing is, how best to catch them without creating more regulatory burdens?

Bollie,

I rarely perform an episiotomy. I haven't kept track of them since I was a resident, and at that time I was required to do so.

Unlike your wife's doc, though, I think natural tearing is much better than an epi. They rarely extend to the rectum, they hurt less than an epis and tend to be easy to repair. (For example, take a piece of paper and grab it at both ends and pull apart, it virtually never tears, make a small tear in the middle of the paper regrasp the ends and pull, the tear will ususally extend to a much larger tear...now imagine that that piece of paper is your wife's bottom, would you want an episiotomy?)

So when do I do them? If the baby is stuck and has a shoulder dystocia, or if the strip looks like hell and I want to get the baby out quickly.

The complaints I made were not anonymous. I talked to a hospital administrator in person. When I talked to the FBI, I gave them my name, pager number, and home number. Same thing with the letters I sent to 60 minutes and 20/20 (to the best of my recollection; this was over a decade ago, so I can't say I know exactly what info I gave them).

As far as how to fix this problem, the answer is simple, though not "easy." The only reason it's not easy is that the current system provides a tremendous benefit to senior personel and, in some cases, to the State itself (my internship and residency were through the University of California). Nevertheless, the answer is still simple. That answer is alluded to in Megan's closing sentence in the post that started all these responses, and it's alluded to in my own blogger postings.

The answer is to remove, or at least reduce, the legal power of the residency cartel over licensure and board certification. Within my lifetime, it used to be possible to be board-certified in emergency medicine, for example, without going though an ER residency, but instead by piling up hours while working a job at market rates, avoiding lawsuits, then passing a test. I think that should be possible again. It's not as though residency is the only way to learn, or even the best way to learn, and it's not as though attendings at residency-operating institutions are neccesarily all that good at clinical practice, let alone at teaching proper clinical practice. I can name attendings to whom I had to teach clinical pearls, and in one case some pretty basic medicine, while they were nominally supervising me (although, granted, in at least one of those cases, involving a post op case, urosepsis and a urologist, I believe the urologist knew that the patient's infection was urological in nature, but just didn't want anyone else to think that). Further, it's not as though all residency-operating institutions even have attendings present all the time, even during surgical procedures (yes, gentle reader, when you talk to a surgical resident who thanks a particular attending for "teaching me to operate on my own," that may be what is meant).

Letting less-trained people work work towards licensure, or at least board certification, in a larger universe of hospitals and clinics, rather than those institutions that are part of the cartel, could ensure better sleep (and thus greater alertness), less deference to incompetent-or-crooked-but-residency-controlling staff, greater availability of health care in currently underserved areas, and thus an overall increase in quality.

To: John Galt de Sieyes
Re: "Your ad hominem that I am somehow envious of Doctors is a rather blatant attempt at moving the focus from where it squarely belongs..."

It is strange that you ignored my entire argument but for two words, "tired" and "envious". Well, the argument is a tired one, at least to me; one I've heard repeated ad nauseum in the past 10 years. Eye of the beholder, I guess. And 'envious'? Come, come, sir. Surely you do not think this outpouring of dislike for MDs is based on a purely rational discussion of the merits pro and con in re: MDs, do you?

As for: "The facts are that doctors make quite a good living, that training costs are very manageable if the new doctor has the foresight to put together a competent financial team, and that doctors aren't the only part of the problem...just a significant part of it.".
Glad that's settled. No, doctors aren't poor, but what that has to do with sleepy residents and malpractice costs is unclear. Except if you consider envy, but look where that got me last time. No thanks.

Peter Banos - that is very sad and very disheartening. I just brought up the point about anonymity because I know some residents are afraid to speak out.

Anyway, I do think medical education could be improved drastically - one of the ways is for those of us who are on the clinician-educator track, and really enjoy it (and make service our primary responsibility) to have more say in the day to day running of the service.

This is a truly fascinating conversation.

The husband holds "Yes and No together cellular phone service online with one hand/ while parrying the words johnny depp of wife." The wife marvels "at her husband's buy online dating online ability to place the world within brackets." britney spears Sensibilities unravel and reassemble as online college degree contradictions beget tautologies: "If I investing online could kill you I would then have to make jessica simpson another exactly like you./ Why./ To tell health insurance

Yeah, I suppose my story is sad and disheartening. It's nothing compared to the stories of some of the patients involved in the events described in my blog, or other patients involved in other such events. I had lunch with the father of a young man who had been a sucessful college student until recruited (apparently without his knowledge) for a UCLA study on psychoactive drugs. It was horrible listening to this father describe how his son deteriorated, how the father asked his UCLA physician for help (which never came), how the son eventually broke completely with reality and was found in a south central LA ER, how the father eventually found out that his son had been a research subject, and how this father and other parents had spent years in court trying to get justice. That was a case which involved state and federal lawsuits, NIH reprimands, a writeup in the Yale law review, and stories in the LA times, none of which were anonymous, and none of which seem to have any significant effect. So, in retrospect, I'm not surprised that my complaints, anonymous or not, had no effect.

Whoops, should have specified that last post was a response to "MD's" post of March 7 05:23pm.

MD,
Just remembered: that UCLA case which involved unwitting participants in psychoactive drug experiments, state and federal lawsuits, NIH reprimands, a Yale law review writeup, and LA times stories, also involved a plot to kill the President of the United States. I can't disclose any identifying details, but one of the Nuechterliein-Gitlin victims, in his induced state of psychosis, developed a plan (obviously NOT sucessful) to kill the POTUS. Just wanted to mention that, in addition to all the other things involved in this case which had no significant effect on UCLA.

A neurologist, who'd been in practice for 18 years failed to give me a proper diagnosis (stress & depression is what she labeled it).

I went to the ER, having fallen late one evening.At the insistance of the ER doctor, I saw a resident for the local medical college. He after about 15 minutes pinpointed what was wrong. A couple of days later, when the diagnosis of the rare disease Myasthenia Gravis was confirmed, the attending doctor asked him how he'd managed to catch 3 Myasthenia Gravis diagnosis' when most doctor's never even see the disease. He meant it as a rhetorical question, but this young resident answered it ...
"Because I was too tired to listen to the logic of 'when you hear hoof beats think horses not zebra's'. I was so tired, all I could think of was the zebra with each case."

With each case, he changed our quality of life, if not saved our lives.

It's true, of course. Lots of professions have people with higher IQs than many doctors have. But physician training is rigorous, and not for everyone. IQ only carries one so far. Determination and delayed gratification take over in importance, to be sure. In the end, somwhat higher on the IQ bell curve than average, but much higher than average in pursuit of this goal.

As a related example, a younger sister of mine is in her third year of dental hygiene. She has absolutely no interest and relatively little aptitude in the 'hard' mathematics or sciences, but she has put in a level of dedication and effort that dwarfs anything I did in engineering school, and has a long string of 'A's to prove it.

I feel that the medical system would be better served by increasing the number of nurses, so that actual patient contact could be increased.

They would if they could, but nurses are in short supply. My other sister went through nursing school and graduated with a $50k/year employment contract already signed.

(This presumes, of course, that whether a case pays off is directly related to doctor culpability, rather than essentially random. But if the latter is true, then we need medmal reform more than ever).

Ah, but as I've pointed out before, whether a case pays off is essentially random (and consequently, as Jane says, we do need medmal reform more than ever).

If malpractice claims were the result of bad doctoring, then bad doctors would have higher claims (on average) than good doctors, and therefore would pay higher rates for their malpractice insurance -- just as "bad drivers" (those with lots of accidents) pay more for auto insurance. This is called "experience rating" -- your claims experience affects the rate you pay. But medical malpractice insurance is not generally experience-rated -- a given doctor's premium depends only on his/her specialty and ZIP code.

There is no law or regulation that prohibits experience-rating in medical malpractice insurance. The lack of experience rating is an outcome of a market process. Surely, if past malpractice claims were a good statistical predictor of future claims, insurance companies could increase their profits by offering discounts to doctors with fewer claims, thus attracting more "good risks" into their pool (that is, more customers from whom they'd collect premiums but for whom they'd not have to pay claims). This would, in turn, force premiums up for "bad doctors" and encourage doctors to practice better medicine to avoid insurance rate increases.

However, this doesn't happen -- insurance companies have not found it profitable to take case histories (as they do for drivers) to determine which doctors are likely to be sued. This means that, essentially, malpractice claims are a random event, statistically unrelated to bad medical care. Sure, some claims are due to incompetent or negligent doctors or hospitals -- but not enough, percentage-wise, to make it possible to identify bad doctors or hospitals through their malpractice claims, or to use that information to set insurance rates. This shows that the malpractice problem is systemic, and is the due to a faultly legal system rather than bad doctors.

In regards to the medical profession not policing itself:

I see all sorts of bad examples in my specialty locally. I could never say anything about it for fear of restraint of trade accusations, since my group is the dominant one in the area.
Also, most of the subpar practioners are osteopaths, and were I to make a stink, I would never see another referral from a DO primary doctor again.
Tough situation, but I don't see a way out.

Also, Joe Bagadonuts seems to have the Bar association talking points down.....

Different River, you start with the wrong assumption. There is no malpractice "problem." Claims have remained consistent, or increased with the rate of population growth and in some jurisdictions even decreased, and payouts have increased at about the same rate of inflation.

The legal system, whatever its faults, isn't the driver behind the recent sharp premium increases. What exists is a misinformation crisis. Unfortunately the truth has been coming out too late for some.

http://www.washingtonpost.com/wp-dyn/articles/A22197-2005Mar9.html

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