Asymmetrical Information

Jane:

1. Off the top of my head, it strikes me that one defense of long hours is that doctors don't do work that needs much thinking. That is, to varying degrees, a doctor is doing mostly scut-work. (Do you want your theoretical physicist working, as a normal matter, without sleep? No. Your doctor? Eh, maybe.) So, once-trained, maybe the doctor can be sub-normal in (whatever measure, IQ, etc.) and do fine.

I happen to have a lot of docs in the family. I happen to believe they are all very bright, and that such is useful to their jobs. They happen to believe they are very bright, etc. But if you listen to them (or any group of doctors) talk about a healthy percentage of their colleagues - well, I'm less sure that being bright is relevant to being a doctor.

(I note that the same is largely true of any class of professions - there are many more people doing it poorly and stupidly than there are people doing it well).

2. The health system is a system like any other. It almost certainly has different tolerances for different classes of mistakes. Kill a poor person with a stupid mistake, the cost is probably pretty small. Kill a star athlete with a stupid mistake - you're done. So as long as you set your sleepy doctors in the right place, the results will look essentially the same as with well-rested doctors.

(Am I right in recalling that there was a recent study suggesting that 30% of the deaths in hospitals were caused by relatively trivial mistakes?)

As one who is permanently attached to a 2nd-year medical student, I come down firmly in the "pre-doctors work too much" camp. However, I have motivations beyond a desire to actually see her from time to time.

She mentioned to me some big to-do over the fact that residents driving home from work were being pulled over by the police for driving poorly. The cops found, that despite not being intoxicated, the exhausted residents could barely drive. Some later research stated that a relatively small amount of sleep-deprivation was equivalent to an illegal blood-alcohol level -- and so proposed that the police be able to write tickets for driving while "intoxicated" by sleep deprivation.

Throughout the whole thing, I was struck by one thing: If the exhausted residents weren't capable of driving safely, why would they be allowed to administer drugs, perform surgery or counsel patients BEFORE they left to drive home? Surely this is a more pressing concern, especially as "Tim" notes the rising concern over trivial medical errors that lead to death or injury.

What it comes down is this:

The practice of medicine is a guild system, with its roots in the Middle Ages. Guilds are motivated to have overly-stringent requirements in order to minimize their competition and exalt their status. This leads to the "not enough doctors problem" as well.

The patent irony of doctors exhorting their patients to get a healthy 8 hours of sleep while demanding that residents violate these very rules of self-health is disgusting. Medical schools will chastise overweight doctors because they've found that patients will not take their nutrition advice seriously. The same principle should apply to over-work and sleep deprivation.

I think that the notion that doctors are smart is a myth. What it takes to get through medical school (and to pass the exam to get into it) is not smarts, but memory. I've met a lot of doctors of whom I was not impressed intellectually. I've met, in fact, some whose logic skills didn't seem to me to be up to being able to render competent diagnoses. I certainly know that's true of a lot of pre-med students.

SCMT,

If you haven't actually experienced significant sleep deprivation over an extended period of time (I'm not talking about the occasional all-nighter here), you can't begin to understand the effect it has on your thinking. Megan is not indulging in hyperbole when she says that being sleep deprived makes you stupid. I mean, your IQ is operating significantly lower. Sure, you can continue to do scut work, but not always safely, but one thing you can't do is learn properly, which is one of the reasons being touted for the necessity for long hours. And as for being able to recognize a pattern that you are familiar with, it takes much longer when you are significantly sleep deprived.

Another beautiful post, Megan. I have nothing to add, really, just want to second all you said. Another example of why we love you.

Sigh.

I mean this in the nicest possible way, but did you actually read what some of us docs wrote? Did you look at the ACGME accrediation website? Programs are supposed to follow the hours guidelines for residents, and if they are breaking them, the resident can report their program. This can result in possible probation for a program.

I am categorically against excessive work hours for residents, however, what some of us were saying (and I think this is what a lot of the other physicians meant in the last thread) is that sometime in their training, properly supervised of course, they ought to experience some of the tougher situations they might get into as an attending. No good attending wants to push their residents to the breaking point. I just sent one resident home today to take care of personal stuff, and the other off to a lecture. I let him off the service and am doing his work. We are talking past each other - we don't want to push them beyond what is reasonable, but we want them to be tough and able to handle themselves. We need to expect excellence.

Look at the ACGME website. If some of the residents reading feel that their programs are breaking the rules, well, you have options. Please read up on the rules to protect yourselves.

Also, as someone who grew up and trained in Iowa, one of the main reasons there are shortages of doctors in rural areas is because people don't want to live in Iowa. It's tough to recruit docs to live in rural areas, even if they grew up there, and especially married docs with spouses who work. They need to live in areas where they can both find good jobs. It's not necessarily a shortage of docs overall.

I meant to write 'don't want to live in rural areas'. I dont' want to single out Iowa, good former Iowan that I am :)

Open up medicine and let everyone compete -- that's fine with me. But you will have to change the payment system so that physicians can advertise quality and charge a premium for it -- and vice versa.

In addition, consumers will have to wake up and learn about what they are purchasing -- because it will be their feedback that controls quality and outcomes.

And while we are at it, open up the physics and engineering (et al) PhD programs at universities (including Harvard); let everyone join in and let the market decide.

I have no problem with that. But are YOU ready?

Rand: Interaction with pre-medical students will permanently destroy any respect for the potential intellectual capabilities of physicians.

However, it should be noted as one who took the MCAT and did reasonably okay (33R, I think), it is NOT an memory test. The biological and physical science portions require a strong ability to analyze and interpret data. The verbal section again requires strong analytical capability; as a science type (I am now a chemist) who likes to read TNR and the ilk, the verbal section is HARD. The MCAT is not merely a 'regurgitation' examination...

When Navy SEALs and other special operation types go through training, training which often results in an 85% washout rate, they are allowed extraordinarily little sleep, because functioning in combat inevitably results in the most severe decision-making environment while often allowing nearly zero sleep. Of course, while being trained in this fashion, the most minute aspects of the trainees' behavior is supervised in an extraordinarily microscopic manner. SEAL trainees are not set out on live-fire training missions after forty hours with no sleep, while the supervisors are back in their racks. If some doctors need to learn to function as best they can in an extremely sleep deprived state, which seems doubtful to me, then they need to be very, very, closely supervised while doing so. It probably be more wise to break the cartels which keeps the supply of doctors lower that it would otherwise be.

CodeBlueBlogMD,

I don't think that Meg is arguing that EVERYONE who wants to go to med-school should get to go, but when I worked at a Medical Journal (briefly) I remember the editor writing an article about students who ended up going to off-shore medical schools and their quality. (I have searched for a link on-line and have been unable to find it posted, the article was written over ten year ago). In general the students were just as bright, just as hard working and did virtually as well as those students admitted to American med-schools. The problem might have been a bad sememster, a point lower on the MCAT score, a wrong major (even when there was a right minor) or just not enough volunteerism.

The truth of the matter is that we could easily have 20% more qualified doctors entering the system and the only problem would be that, with more doctors available salaries might drop for those out of a residency program.

The other problem is that you have terrible secrecy in the medical community. A doctor is rarely going to admit to a mistake. This is now due to all the Med-Mal going on, but in days of old it was just because doctors wanted to be Gods and admitting mistakes was not what a God did. If you want to fix the system then not only do you have to have tort reform, but you have to make doctors accountable (in an open, clear way) for every action they take.

In addition there is generally the institutional phylosophy that "if I can do it, so should you." I've seen this in industries other than medical ones. It is a terrible idea.

My best friend is at the end of her third year of residency in an emergency medicine program and she is the first one to admit that you need to learn how to work with little or no sleep in a crisis situation, but that does not mean you need to work with little or no sleep when there is no crisis for the first 4-7 years of your career.

Two final points, one of the reasons my friend decided to take a resident position in New York State was because of the Zion laws that require that a resident work no more than a certain number of hours in a row. She says that the problem with this is that often, when competing with residents from outside of the state, she has not had the same number of hours of experience as they have. One the other hand she says she actually remembers doing every procedure she has actually done, and most residents can't say that. She also says that they hour requirements do not allow her to be on hospital grounds after a 24 hour stretch, so while she would like to take a nap before she drives home, she is not allowed to. She says in the summer months she just lies down in the back seat of her car for a few hours before going home, but it would be much better if she were allowed to use a cot.

Rand Simberg:

I missed your post so I need to come back and comment on your observations.

What RAND thinks is called "anecdote." Incompetent thinkers generalize from anecdote (and personal anecdote is the lowest form of this logical fallacy); those who act on anecdote usually wind up with a severe penalty physically, professionally, or legally.

Studies conclusively show that memory is an important component of intelligence. Studies also show clearly that the average physician has an IQ one standard deviation above the mean, at around 115 (Stanford Benet).

You said:

"I've met a lot of doctors of
whom I was not impressed
intellectually."

What does this mean? To whose intellect are you referring, yours or the doctors?

You also said:

"I've met, in fact, some whose logic skills didn't seem to me to be up to being able to render competent diagnoses."

Do YOU have the training and intelligence to know what a competent diagnosis is and of what it is composed?

Finally you said:

"I certainly know that's true of a lot of pre-med students."

So this is ONE item you CERTAINLY know as a fact -- according to your statement. Can you share with us the tested data that lead to this (logical and competent, I'm sure) conclusion?

Or is this, again, someone with a tree-trunk-sized chip on his shoulder venting small ideas on the closed-captioned screen of his tiny imagination??

Interesting that you would explore this topic in the week that Elsa Zion died. http://www.nytimes.com/2005/03/05/obituaries/05zion.html?8br [Personal alert: I'm a friend of her husband, though I haven's seen him much since the anti-smoking rules in NY keeps the cigar-smoking Mr. Zion out of my usual haunts.] A propos of what Somecallmetim says, we don't care much about this situation until someone with a soapbox to shout from has a problem with it. 20 years since Libby Zion's death, and even with legislation passed, the situation has barely budged.

codeblu...

thanks, noone here had previously seen a definition for anecdote.. you've enlightened us immensely.

as for yourself, while you have added some facts (like the rules, and exhorting people to get their programs to abide by hours reqs.. ha ha ha) you haven't added much in the way of peer reviewed data yourself bub.

but thanks again for the useless foray into introductory logic... maybe you can speed it up next time eh?

Codeblue, you are more than a little touchy, and you may think a 115 IQ score to be notable, but many do not. I've known (yes, yet another hideous, horrific, anecdote) more than a handful of bartenders who scored higher. Then again, hooch-slingers are generally better company, and better mannered, than physicians, and thus less inclined to self-aggrandizement, so I may be underestimating their numbers who are blessed with a high I.Q..

Hey, Hey:

"as for yourself, while you have added some facts (like the rules, and exhorting people to get their programs to abide by hours reqs.. ha ha ha)"

I wish I knew what the hell you are referring to (or what the hell you are smoking!), but thanks for the nonsense, bub.

Will:

I don't think YOU get it, but the mean IQ of the entire US is 100 -- 1/2 the people are below that and 1/2 the people are above that. So 115 is a CONSIDERABLE diffence in means, and a standard deviation of this size is quite significant.

The real problem I sense in this nest is class envy --

What kind of site is this I stumbled on? Are you all part of a society or a clan of some sort??

115? Is that right? That's distressing. Really.

Clearly what Megan's talking about is unnecessary, and there's probably a significant "I did it so you do it too" component to the phenomenon, as someone above noted. I have no data to back this up, just 42+ years of observing the human animal.

115? Damn. So after a 24 hr shift, we're looking at someone who'd have trouble getting out of high school. If I ever have to take my son into an emergency room, I will be overseeing and questioning EVERYTHING.

Actually, code blue, if one half are above 100, and half below, then 100 is the MEDIAN IQ, not the mean. Maybe you didn't come across that sort of thing at med school. I sense you may have gained a better grasp of this by spending more time in saloons.

Anyways, I still don't think an IQ of 115 is all that notable.

My last year as an undergraduate, not so very long ago, I was editor of a bi-weekly libertarian rag. The longest period I ever spent in the office was 67 hours straight on no sleep, just a steady diet of energy drinks and sugar. After about hour 24 I couldn't spell, after 48 I could barely function to do layout, around 60 I was practically useless but still plodding along slowly. By the time I left the office I was so addled from sleep dep and caffine that it took me 20 minutes to remember where the bus stop was.

It wasn't uncommon for me to pull 36-40 hours straight on the magazine, but every time near the end I was practically useless. If it's nearly impossible to spell correctly and perform simple computer tasks after that sort of time awake, I certainly don't want anybody who's been up that long anywhere near me if I'm in the hospital.

Rex:

I think you (and others) are mixing up a few issues. I have had (years) of experience functioning on no sleep; it's not good. Anyone who claims that they aren't stupider after X hours of work, with usefulness dropping off a cliff at some point, is either lying or began so stupid that differences seem negligible to them.

But if we are roughly happy with the quality of care that we are getting, why do we care? Some number of people get benefits from visiting a hospital and some number are harmed. If we want, perhaps we can let significantly stupider people into med school and let everyone work fewer hours with no effect on the benefit/harm ratio.

Personally, I like smarter doctors. I also like med-mal lawyer who create some accountability for medical mistakes (I realize that accountability is no longer a Pub virtue, but this is just me). I suspect that accountability and better/smarter doctors go hand in hand.

So let's handle this all at a state limit. If Red America wants all medical liability claims capped at $5 and an unlimited number of hours for residents, fine with me. It may be that doctors will rush to your states to practice as freely and well as they've always wanted. Or maybe we'll get the good doctors who are less concerned about making mistakes, and Red America will get the problematic ones. And even then, maybe it's OK - maybe Red America values different levels of health care differently. I don't know what will happen. But I have my suspicions and I'd be interested to find out if I'm right.

As is often typical when discussing doctors, this comment section has quickly denerated into the usual "docs aren't so smart" animosity stuff.

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. (Note: some MDs are indeed scary-smart, unbelievably intelligent folks. We should be glad for that.)

What any of this has to do with sleepy doctors is unclear, however.

What worries me about the reformists is Bastiat's warning that the immediately seen effects of suggested change is often "dazzling", but the real danger is in "what is not seen". The unintended side effects of this move have been ignored, and those who discuss what is lost when this system is changed are derided . I've brought these negative outcomes up in these threads before, to no avail.

I very much hope this works out, but I am already seeing the negative effects, and we will no doubt be discussing those as "problems with doctors" in short order.

I just want to say, as one who still pulls the occasional all-nighter of necessity, that anyone whose life depended on my decision-making at the end of one of those stints would have good cause to be very, very afraid. Fortunately, all I'm doing is writing and editing, not medicine, so I haven't left a trail of bodies in my wake.

Someone up above mentioned a study comparing sleep deprivation to alcoholic intoxication. I rather think it was a 60 Minutes piece, a couple of years back; they took a bunch of volunteers and had them run the same course (delineated by traffic cones), once after a couple of beers and once after staying up all night. The drunk drivers seriously outperformed the sleepless ones.

"And while we are at it, open up the physics and engineering (et al) PhD programs at universities (including Harvard); let everyone join in and let the market decide."

How exactly do you think this would be different from what is presently the case? Any accredited university is free to have a physics graduate department. There is no limit on the number of grad school spots in physics.

In fact, there's a tremendous oversupply of physics Ph.D's relative to the number of jobs available for them.

I didn't read any of the responses to this article, I just read the article itself and, as a nurse, I absolutely agree. This is a practice that has to be changed. At some point, attendings and chiefs are going to have to accept that their residents aren't going to go through the hell that they did. It's just dangerous, and, quite frankly, stupid. I graduated from West Point and was in the army for 11 years in a combat arms branch. I know about sleep deprivation and I know how to perfom under those conditions. But nurses rarely work past a 12 hour shift. Why is it different for doctors who have more responsibility? I have several times hesitated in the middle of the night to call our resident for a patient's deteriorating condition because I knew she had been awake for 18 hours and had just lain down to go to sleep. The only time I did have to work an unusually long shift (and a different one than I was accustomed to), I started to get "punchy" near the end of the shift and intentionally avoided my patient because I was afraid of what I might do. So, short story long, absolutely we need to change the way we treat our residents, and soon.

-Eric Prichard, RN

I work in the election office. This principle could explain more problems than hanging chads, black box voting and deliberate malice put together...

Ignoring all of the condescension in some of the critiques of my post, I stand by what I said. Memory is a component of intelligence, yes, but it's not the whole banana, and one can have a good memory and still not be able to think well. And yes, dumb people don't pass the MCAT.

My point is not that doctors aren't smart--many of them, as another commenter noted, are in fact brilliant--it was that they aren't as God-like as popular mythology would have them, that we shouldn't automatically assume that they're brilliant simply by dint of having gotten medical degrees (as was pointed out, perseverance counts for more than IQ), and they're not someone to whom we should automatically defer when it comes to decisions about our health. Or about whether it's good for doctors-in-training to pull thirty-six-hour shifts.

I am certainly for a more sane sleep schedule for residents; there is no real debate on this, and, given the national rules, moot to a large degree.

Some unexpected outcomes of the reduced hours, however:

(1) increased costs (the free labor is replaced by either MDs or nonphysician providers; hence medical cost inflation)
(2) reduced experience (residents see fewer patients than in the past, and consequently are exposed to less)
(3) reduced "ownership" of patients by MDs (residency shiftwork begets a shiftwork mentality; the patients are no longer "theirs", but "the hospital's" or "the attending's"
(4) reduced professionalism (the rigor of residency and "priesthood" mentality, howevermuch derided here, produced a dedication to service with long hours and neglect of personal concerns; this has been replaced by "an eye on the clock", where the MD is gone at 5 pm.

Something's lost and something's gained.
I am not sure the radeoff is what we want, but there it is.

why is there such a debate about the effects of sleep deprivation on mistakes made?

because real statistics don't exist, so all we can rely on is andecdotes, which is to say data points one-by-one in uncontrolled experiments.

if there were proper statistics regarding medical mistakes and their circumstances to analyze, real solutions could be indentified and mistakes could be reduced using well-known engineering techniques.

if the data-based conclusion requires more doctors, so be it. this is possible based on the fact that several negative externalities (lots of debt + de facto hazing by existing system) are associated with medical training that must deter some percentage of qualified candidates who instead opt for a free phd in science. remove these negative aspects and you'd have a richer, deeper applicant pool for med school.

"(1) increased costs (the free labor is replaced by either MDs or nonphysician providers; hence medical cost inflation)"

What free labor? These residents invested a huge chunk of change in their medical education, and they'll need to make that investment pay off. If they're not permitted to do it now, they'll do it later, with interest, when they become real doctors. If they're somehow prevented from doing so even then, then the next generation of potential residents will decline to get similarly ripped off.

There ain't no such thing as a free lunch.

The long-hours pattern in residency is as much social as it is a financial, "boot-campy," or an experience-promoting policy. My residency in pediatrics was not as demanding because pediatricians tend to be less fast-paced. The metropolitan public-hospital programs, and a majority of the most prestigious programs show the most abusive patterns; it's a social perspective, an attitude even among the residents - about how one OUGHT to experience residency.

It ought to change, for the better. It affects how physicians practice after residency, even long after they're board certified.

What do you call a med. student who graduates last in his class?

A doctor.

I don't know the exact data off the top of my head, but I recall hearing from a med. school friend that most malpractice suits were being brought on the same few doctors. Now, I don't know the procedure, but how about we find ways to work on the ones that cause the majority of the suits? Yes this is too simplistic, but as an issue of public safety (and not premiums), I find it compelling.

I agree with most of the original post, but some of these comments seem to have gotten out of hand. It bothers me that so many of these threads attack doctors as thinking they are "GOD." I don't know one doctor like this.

See my commments at my blog.

Rand Simberg - your last post where you clarified your view was spot on. That's as well put as I've ever seen it.

And there's no need to focus on anecdotes when it comes to sleep deprivation. There are oodles of studies and controlled experiments concerning the effects of sleep (and lack thereof) on cognitive abilities.

Hey, where'd CodeBlue go all of a sudden? Will, I think you might have scared him away for good...

Jim at March 7, 2005 05:58 PM wrote:

why is there such a debate about the effects of sleep deprivation on mistakes made?

because real statistics don't exist, so all we can rely on is andecdotes, which is to say data points one-by-one in uncontrolled experiments.

if there were proper statistics regarding medical mistakes and their circumstances to analyze, real solutions could be indentified and mistakes could be reduced using well-known engineering techniques.

While there may or may not be "real statistics" on physician error correllation with sleep deprivation, there are certainly statistics on driver errors.

Just to scratch the surface, see

http://www.tfhrc.gov/humanfac/sleep/sleepweb.htm

and

http://www.tfhrc.gov/pubrds/janfeb99/effects.htm

Perhaps physicians aren't as susceptible to error when sleep deprived as ordinary automobile drivers, but the burden of proof for that is upon those who make the claim.

Have any of you actually been in a hospital bed lately? I've experienced the results of sleep deprived docs and weekend shift nurses. I think the residency years make even the brightest of the bunch STUPID. I don't know the solution..some good ones have been suggested, but "ownership" of patients seems odd since most hospital stays are now down to a couple of days and during those days, who sees the doc??

Ooh, this is good stuff. I love these discussions.

"that we shouldn't automatically assume that they're brilliant simply by dint of having gotten medical degrees (as was pointed out, perseverance counts for more than IQ)"

I'm a grad student in biology at a fairly major university, which means as part of my education I have to teach premeds. And believe me, the experience makes me never want to enter a hospital again if I can help it. The med schools better be doing some serious weeding out, 'cause at least three quarters of the kids I taught can't be trusted with our lives. These are supposed to be among the brightest students in the nation and they're fucking CLUELESS. And unfortunately, many of the most competent ones want to be scientists, not doctors.

I don't include myself in there- I make a good scientist, but I'd be an awful doctor, partly because I really just don't like dealing with the public very much. And I'm not very good at explaining complex technical matters to people who don't have the necessary background. The problem with the premeds I know is that they aren't good at this either - and it's because they don't understand the science! All of these kids approach learning like they can just try to memorize the textbook and pass the test without understanding anything. Zero capacity for analytical, creative thought, or for rapidly assimilating new scientific information. I shudder to think what'll happen when one of them comes across some malady they don't have a flashcard for.

I'm increasingly thinking the cause of skyrocketing malpractice insurance rates isn't too many lawyers, it's too many crappy doctors. I'm gonna ask for a complete transcript before I let any of these hacks cut me open.

Real statistics do exist.

There's a nice collection of references here:

www.amsa.org/hp/rwh_cov.cfm

Using them, I found this:

"In our study, we tested the hypotheses that an intervention schedule that eliminated interns' traditional 30-hour-in-a-row extended work shifts would improve their sleep, decrease failures of attention, and decrease serious medical errors in intensive care settings. We found that interns on the intervention schedule worked approximately 20 hours per week less, slept nearly an hour per night more, and had fewer attentional failures while working at night. In addition, compared with interns working on our intervention schedule, interns working the traditional schedule made 36% more serious medical errors, and more than five times as many serious diagnostic errors."

The arguments for the status quo don't especially make much sense to me.

Quantity of experience needs to be adjusted for ability to learn. There is a demonstrable breakdown of attentiveness and of cognitive ability after periods of extended wakefulness and after periods of chronic sleep deprivation. Our ability to learn decreases. Everyone's.

Interns with less sleep and fewer handoffs make more errors than those with more sleep and more handoffs. Improve the handoffs. Is boot camp sleep deprivation really the best way to handle that issue?

And an IQ of 115 puts you just inside the top quintile. Outliers distributing in either direction. On average, above average, certainly; but not above error, not above question.

People die because of this.

I totally agree with the need to reduce hours spent without sleep by residents, but I think the underlying notion that doctors, especially residents, are carefully following the progress of their patients is completely bogus. I feel that the medical system would be better served by increasing the number of nurses, so that actual patient contact could be increased.

Because my mother recently spent a month in the hospital and two weeks in a skilled nursing facility, I had the privilege (not) of spending twelve hours per day by her bedside for the latter four of those six weeks. (Some combination of her physical problem -- seizure as a follow-on to a stroke, her medication, a urinary tract infection due to catheterization or simply being confined to a hospital bed caused delirium. She was happier and less agitated with me there).

I can tell you that the attending doctors in the hospital did not read the charts, did not hand off the patients to their fellows with full info, and the residents were worse. The nurses were overburdened with too many patients and couldn't provide the hands-on care that a severely ill patient needed, and substituted sedation and restraint, which worsened my mother's delirium/confusion. We hired 24-hour certified nursing assistants (CNAs), at great expense, which allowed the restraints to be removed, but only my presence really ensured that shift N didn't contravene a decision made in shift N-1, especially with respect to use of sedation and choice of PRN sedatives.

The skilled nursing/rehab facility was worse, in that the "attending doctor" was never seen until I complained that noone was paying attention to the appropriateness of the psych meds my mom had been given. The CNAs had 15 patients each to care for. The nurses each rolled a cart down a long corridor administering meds and taking blood samples/testing blood sugar, but gave no hands on patient care.

This is funny, coming from conservatives who pushed through tort reform a few weeks ago.

Now, when these inferior sleep-deprived doctors cut off the wrong appendage, you'll have no recourse to right the wrong.

Brilliant, just brilliant.

meagan,
great post.

I've blogged about a doctor who was in is 24th hour of his shift when he discharged a young girl who had a fall.

Point 1: He was following the hospitals protocols
Point 2: The girl later died
Point 3: The girl's father was a doctor (I'm not certain, but I think he was actually working as an administrator of some sort)

Well folks I was on call last night. I am an OB/GYN attending. We have no OB/GYN residents. I've read a previous post somewhere where someone felt like taking phone calls at home wouldn't matter much. Went to bed at 9, woken up by phone at 10:45, by a patient who wondered if she should go to the ER as she was developing a fever. I asked what her temp was, it was 99. I told her that that was not considered a fever (must be greater than 100.4) and she proceede to argue with me. Took about 1/2 to get back to sleep. Got a call at 1:36 AM from a nurse at an outlying hospital who wanted to transfer a set of twins in pre-term labor. Asked to speak with the doc, not there , I said have him call me. Lay awake for 20 minutes until phone rings and doc explains patient. Call my L&D to let them know about the transfer. Struggle back to sleep about 2:30. Phone rings at 3:45 am, pt has arrived, only a few contractions (thank God) so I didn't have to go back in, Give orders. Phone rings @ 5:10 with results of some of the tests. Alarm would go off in 30 minutes so I get up and start my day. I have to work in the office all day and I am tired. A fairly typical night on call.

I think that limiting the residents work hours is good, but to get the experience that they need the length of training will need to be extended. What to do about my hours. As I pointed out on a previous thread there are only 3 of us here....training more docs would be good, but it is very expensive and probably won't add to the doc numbers in rural areas like where I am.

I graduated from med school in 1990 owing $105,000 in student loans. I only made $21,000 as an intern and was up to $32,000 as a chief resident so I deferred payment. So in 1994 I owed $160,000. I have since paid back $340,000 and I still owe $21,000. If more docs cause a loss of income I don't know how anyone will be able to pay for med school and buy a house and a car.

Just some random tired thoughts to leave you with

Mark OB/GYN

"If more docs cause a loss of income I don't know how anyone will be able to pay for med school and buy a house and a car."

By also driving down the cost of medical school, through increased competition and economies of scale?

Rand:

I don't think that that will drive down the cost of medical school. The cost was quite high when I went and there were 4 applicants for each spot. Since they are part of larger universities you'll need to come up with a way to cut the cost of higher education in general and not just medical school. Part of the high cost is the time committment. I spent 4 years in college, 4 in medical school and 4 in residency to get where I am. By cutting residents hours, (which I agree with, even though I averaged 110 hours of work/week for 4 years while a resident) I think we need to extend the lenght of training. This will also increase the cost in both time and money. The cost of training one doctor is huge, which is why medicaid give each teaching hospital about $80,000/year to train one resident.

Finally if we increase the numbers of docs and decrease the salary who would want to do that much work if the reward is a job that pays only $60,000/year where everyone expects you to be perfect, and expects you to always be available....

We could always just import our non-research doctors from other countries, where the costs of training docs are(a) cheaper, and (b) borne by the other country.

Tim,

All states require US or Canadian residency training before granting a license. The reason for that is that the US and Canadian programs can be monitored, while those of other countries can not. So is their training good or bad? I don't know. It seemed fine in New Zealand when I did a 4th year medical school elective there.

Mark:

But didn't all of your debt come from pre-residency schooling? If we troll for potential residents in foreign countries who have completed med school, we can keep residency wages low (or even cut them) and require service in rural areas. Driving this is the suspicion that the dollar costs for training someone through med school in China, India, Romania, etc. is substantially lower than the dollar costs here.

It really impossible to seperate the medical education cartel from the larger college education cartel. It produces some of the largest and most damaging distortions in our economy.

I hate to say this, but there is no evidence that increasing the number of docs will decrease the income of docs. In the 60s the Feds made a concerted attempt to increase numbers of docs which resulted in absolutely no loss in the incomes of docs. On the contrary. Docs are able to drive their incomes through a lot of factors.

As for importing docs, we already do so and we make them serve in less desirable residencies and/or rural areas before they can get permanent residency. In my opinion it stinks as we skim the cream from other countries to allow us to under-invest in our own medical education system.

We also exploit residents shamefully, using them as de-facto and underpaid saftey net at a huge cost to their personal lives and families. The only reason is precisely that we are too cheap to fund a real health care system in this country.

And yes, there is scads of research to back up what I said above, I just don't have time to look it up and cite it now. Take it or leave it, that's the way it is.

I work in an OB/GYN training program and just returned from a conference dedicated to resident education where the 80-hour work week was a primary focus of conversation. I know that the ACGME is VERY serious about regulating resident work hours. They periodically send an on-line survey to residents that specifically asks about work-hour issues. If even one resident in a program indicates they work more than 80 hours in a week, that program receives a citation. If multiple residents indicate work-hour violations, the program will be short-cycled for a site review (if a site visit isn't already scheduled) and the Program Director will have to provide evidence that the program is in compliance (or have developed mechanisms to ensure future compliance).

Most programs have instituted a night float system so that 24 hour shifts are not very common (our program's only has a 24 hour shift on Saturdays and the resident gets Sunday off), and residents must get one day off in seven (averaged over four weeks) with absolutely no clinical responsibilities. It is also my understanding that after a 24 hour shift, a resident can still work up to six additional hours, but that is generally intended to be for checking out to the next team, completing paperwork, attending lectures, or seeing continuity clinic patients. Performing surgery is not on the list of things residents can do during that time (the exception being if the surgery had started during the shift and would end before the six hours expired).

Faculty must also be trained to recognize symptoms of fatigue in the residents and respond appropriately. Residents too tired to drive have the option of taking a nap in one of the call rooms before going home.

I don't mean to downplay the importance of sleep, especially regarding how a resident in a surgical specialty functions. I have worked with tired, grumpy residents before the work-hours mandate went into effect, and I KNOW there is a difference. Currently there really are solid safeguards in place regarding fatigue, and ample opportunity for residents to report noncompliant programs.

I think Mark OB/GYN is right to point out that if we further decrease the hours of service (thus decreasing the level of experience per resident), the length of training will have to increase. It is becoming increasingly difficult to recruit medical students to our specialty due to lifestyle, legal and insurance issues--I fear that even fewer will choose OB/GYN if the training requirement goes from 4 years to 5 years.

We could always just import our non-research doctors from other countries, where the costs of training docs are(a) cheaper, and (b) borne by the other country.

One of Dreck's relatives weighs in as follows:

this November was the first time I was the attending under our new resident hours restrictions where they no longer spend 36 hours in the hospital on each call night. The resident got to go home at 9pm and the interns stayed overnight but left in the morning. It was nice having an awake resident the next day who was actually willing to think about what was going on with me and didn't groan inwardly every time I suggested we needed to do something more for one of the patients.

Some complain that they don't take enough primary responsibility for their patients when they aren't there all the time but I think that is a separate issue. It seems to me that who takes responsibility for a task (and indeed whether anyone does), and how well they do it should be a major ongoing project in any workplace which is not necessarily related to how many hours you spend at your workplace.

[comment removed by author for irrelevance and stupidity]

USA Today on the doctor "shortage":

For the past quarter-century, the American Medical Association and other industry groups have predicted a glut of doctors and worked to limit the number of new physicians. In 1994, the Journal of the American Medical Association predicted a surplus of 165,000 doctors by 2000.

"It didn't happen," says Harvard University medical professor David Blumenthal, author of a New England Journal of Medicinearticle on the doctor supply. "Physicians aren't driving taxis. In fact, we're all gainfully employed, earning good incomes, and new physicians are getting two, three or four job offers."

Source: http://www.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm

Here is a great article that encompasses a lot of the points residents and physicians have made on these two threads. There is data, not just anecdotes: read for yourselves and see how we in the academic-teaching world of medicine are doing. It's not perfect, but it is a start and ACGME is serious. Medicare re-embursements, etc are on the line.

http://www.ama-assn.org/amednews/2004/07/19/pr1107719.htm

Excerpts:

"Residents say programs are in compliance for the most part, but sometimes they are not...

ACGME enforcement of the regulations has garned mixed reviews....

Teaching physicians facing longer days...

Attending physicians have seen their workloads increase as residents' hours decrease...."

If you read the whole article, it's a mixed bag, and a darn complicated problem. Apparently, some of the data on resident work hours is fudged to make it look ok, but if you read the article you will see the reasons are varied and complicated and ACGME is aware of it. As with all such programs, some think it's working and some not.

It's a start though. It's a start in the right direction. It's easy to complain. It's darn hard to create and build something and make it run well. Bottom line: we need to do better. And: we will.

ddffdfd fggfh g ghg

Megan, why were you working such long hours and not getting sleep? If you only got 2 to 4 hours of sleep per night for months, then your schedule was much worse than my internship, residency, and fellowship. I always got catnaps, and I learned how to cope with emergencies the way people ride bicycles. And I think that was the point, really. The patient's heart stopped? Do this, this, and this. Night call makes this stuff second nature.
The people who are truly unable to sleep are the sick patients, whose illnesses won't let them, and their families, whose minds (often) won't let them. And if a doctor hasn't walked through those moments with patients and families, as sleepless and adrenaline-filled as they are, then you will see a very different kind of doctor. You will see doctors who truly don't "get it" (or get it even less than they do now!). If you care enough, you'll stay extremely awake and alert, and take care of your patients. And not screw up.
Now, as an attending, I have no residents or interns, so I take my turn at night. It's easier for me now, because of my training. I know very few docs who want to work night shifts permanently, as nurses do. We take turns at night, to spread the burden. And, really, it's not that bad. But if I had to get by on only 2 to 4 hours of sleep, for months? Parents of newborns do that. That's harder than being a doctor.

Totally agree with you Jane.

And if a doctor hasn't walked through those moments with patients and families, as sleepless and adrenaline-filled as they are, then you will see a very different kind of doctor. You will see doctors who truly don't "get it" (or get it even less than they do now!).

So instead of being primarily responsible for a patient's health and wellbeing, the doc is supposed to be a therapist for that patient's family? Hey, give me a medical staff which is cordial and makes an effort to gently connect -- please. But above that, give me a staff which is sufficiently alert to make proper diagnoses. I've seen immediate family members mishandled in the course of routine outpatient care, in one case introducing an infection that required said outpatient to temporarily become an inpatient. I really don't want that happening when, say, someone is hanging by a thread in the ICU.

If you care enough, you'll stay extremely awake and alert, and take care of your patients. And not screw up.

"...that's the power of love!"

No really, that's garbage. Maybe it works for you in particular, but as a general principle, it's garbage. In case the point hasn't been made strongly enough already: Humans cannot function properly without a minimum amount of sleep. I pulled a couple 30-hour days back in college and have done a few (shorter) all-nighters since then. Even with food and caffeine available to shunt the immediate instinct toward aquiring avian-style sleep positions, your thought processes still slow down; your motor skills become clumsier; important decisions are clouded by apathy; and your learning abilities plummet through the floor, leaving a sizable crater somewhere in the sub-basement.

It doesn't have anything to do with "caring;" it has a lot to do with the average human not having the stamina of Clark Kent. In fact, when I'm sleep deprived I often tend toward extreme irritation with even such innocuous things as ambient music. Unless the medical profession exclusively draws people who are very unlike me, that's not a good position from which to interact with the public, especially if they are also under stress and/or sleep deprivation.

Good God, Jane, I think this has to be the very first post of yours I've ever read where I was nodding in wholehearted agreement from beginning to end.

Damn right! (Not only am I in general agreement with your very sensible comments, I'm also in personal agreement: my brother's a doctor, and he's still virulent about the system in force of "training" junior doctors by having them work killer shifts.)

Now, if I could just get you to agree that socialized medicine is the way to go... ;-)

The issue of sleep deprivation has also come up in regard to railroad engineers who also work very erratic schedules. Partially as a result of accidents attributable to fatigue, train crews are prohibited from working longer than 12 hours at a stretch. One would suppose that diagnosing patients in an emergency room would be more intellectually taxing than driving a train, although the consequences of mistakes while in command of several thousand tons of metal can be severe.

Even with the 12 shift limit, problems occur due to the constantly shifting work hours that disrupt any pattern of sleep. It still is a safety issue in the industry.

How can working 24 hours in a row work for doctors but not for anyone else?

When I was in flight school, we had a whole series of classes, some of which were taught by doctors, about how fatigue affects different dimensions of performance, and why being alert and rested was critical to survival.

Consequently I've always wondered how the resident system made sense to anyone. Certainly I would avoid a teaching hospital with residents if I were in need of medical care.

When pilots make fatigue-related errors, it may cost dozens, even hundreds of lives, as well as the loss of a multi-million dollar aircraft. Residents only kill them one at a time. I figured that was why they were subjected to the endurance drills.

Pilots also get the stress and endurance training - just not while responsible for other peoples' lives.

Wow – good discussion, this is great. Although I still believe we need to lighten up on residents to a degree, I like hearing opposing viewpoints, especially Mark’s discussion about being on call – for residents going into OB that’s something they really need to get used to. Most of our OB’s let us triage on the deck, though – I mean the first call a patient makes is rarely to the doc because our docs trust us and our patients know that someone (several people) is always awake on the labor deck which isn’t necessarily true of their doctor.

I also think that JohnN has a valid point about the number of people that can die at one time based on pilot errors or resident errors. But it’s a point I understand as a former army officer – the fabled and oft used “cost of doing business” which is MUCH more acceptable to the military community than it is to civilians. This is why we in obstetrics get sued so much – patients are under the false impression that every delivery should be a relatively simple, no-risk event – not true – not even close.

So – I’ve had experience with and have read here that different specialties have different experiences as attendings. Should the residencies for those specialties differ accordingly, or will that give us significantly uneven numbers in certain specialties?

yeah - I mis-referenced CW as JohnN - you probably figured that out

The continuation of this brainless practice simply proves that the medical class isn't as uniformly brilliant as it believes itself to be. It also disqualifies that class from running the rest of our lives. Their influence over legislation and non-legislative policy is too great and should be curtailed. They are simply another interest group trying to put government force behind their values.

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