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In 1984, the year I graduated from medical school, Libby Zion died.
According to the Washington Post:
After his 18-year-old daughter Libby died within 24 hours of an emergency hospital admission in 1984, Zion learned that her chief doctors had been medical residents covering dozens of patients and receiving relatively little supervision. His anger set in motion a series of reforms, most notably a series of work hour limitations instituted by the Accreditation Council on Graduate Medical Education (ACGME), that have revolutionized modern medical education.
Now, nearly 3 decades later, the results of those changes are in and they are an utter failure. In fact, reduced resident hours actually result in MORE mistakes, not fewer!
As a piece in The New Yorker by Dr. Lisa Rosenbaum, entitled Why Doesn’t Medical Care Get Better When Doctors Rest More?, explains:
… [T]wo recently published studies suggest that, right now, both quality of care and quality of education are suffering.
One study, led by Sanjay Desai at Johns Hopkins, randomly assigned first-year residents to either a 2003- or 2011-compliant schedule. While those in the 2011 group slept more, they experienced a marked increase in handoffs, and were less satisfied with their education. Equally worrisome, both trainees and nurses perceived a decrease in the quality of care—to such an extent that one of the 2011-compliant schedules was terminated early because of concerns that patient safety was compromised. And another study, comparing first-year residents before and after the 2011 changes, found a statistically significant increase in self-reported medical error.
Why have the reforms produced the opposite result from what was intended? There are two reasons for the failure:
1. The proximate reason for the failure is that Libby Zion didn’t die because the residents who cared for her were overworked. She died because they were grossly incompetent.
Libby was a college freshman with an ongoing history of depression who came to New York Hospital in Manhattan on the evening of Oct. 4, 1984, with a fever, agitation and strange jerking motions of her body. She also seemed disoriented at times…
[Later] Libby became more agitated. The nurses contacted Weinstein at least twice. Weinstein ordered physical restraints to hold the patient down and prevent her from hurting herself. She also prescribed an injection of haloperidol, another medication aimed at calming her down. Busy with other patients, Weinstein did not reevaluate Libby.
And that is malpractice. The woman had a fever. In no medical universe is it ever appropriate to ignore fever and neurologic symptoms in favor of restraining the patient and dosing her with powerful psychoactive medications. It had nothing to do with being tired; it reflected the doctors’ incompetence.
2. The larger reason, one we would do well to take to heart, is that the single most important thing patients need from doctors is their time.
The calculus is brutally simple. Reducing working hours without reducing patients numbers of increasing the number of doctors means less doctor time/patient and an increase in mistakes is an inevitable result.
Because, and this is the dirty little secret in medicine, being exhausted, overworked and irritated does not cause medical mistakes. Lack of time to talk with patients, both to listen and to explain, and lack of time to obsess about the details is what causes medical mistakes.
I will freely admit that the brutality of internship and residency did not make me a nicer doctor. When you are working 105 hours a week (staying up all night, every third night) you have little energy for being nice. But it did make me a better doctor.
I can hear younger doctors out there groaning about antiquated older doctors celebrating the hazing process, but the reality is that it made for better, safer patient care. As one of my chief surgical residents told me (actually he yelled it in my face) early in my career: “In medicine there are no excuses. YOU don’t matter; all that matters is what is good for the patients. I don’t care if you are hungry, tired or depressed. The only excuse for knowing less than everything about your patients is that you are currently treating a cardiac arrest or having one yourself.”
Rosenbaum relates the story of her own mother, also a cardiologist, who has the same work ethic that was beaten into me:
“Mom,” I said. “It’s 8 P.M. Why on earth are you going to the hospital?”
“I’m going to see my patient,” she said.
“But you have been working nonstop for five days,” I protested…
“Her boyfriend’s driving in,” my mom explained. “He really wants to talk to me.”
And then, without thinking, the words popped right out of my mouth: “But isn’t there someone covering you?”
“I’m her doctor,” my mom said. “I’ve been with her since the beginning. Don’t you think this is important?”
And it is only by providing long brutal hours of care and caring like these that doctors avoid mistakes.
It wasn’t the young doctors’ lack of sleep that killed Libby Zion; it was their lack of competence. It will only compound the tragedy if the legacy of her preventable death were more medical mistakes, not fewer.
My son was born over a holiday weekend. My OBGYN was on-call with three or four other patients, one of whom was a c-section, and I was having complications. The poor man looked exhausted and ready to drop, so my mother kept freaking out, afraid he was going to make some fatal mistake. But I trusted my OBGYN enough to know that if the fatigue were bad enough to cloud his judgement, he’d have found a colleague to fill in for him in a heartbeat.
Too bad we don’t live in a perfect world where doctors are able to get enough sleep AND get enough time being with their patients. That really is quite the sacrifice to make. I love sleep…
I do not see how sleep deprivation is good for a
anyone. Numerous studies prove otherwise. I have read an article on resident house issue last year and conclusion was that a) guideline are no followd b) studies are not done well. I am sure it is complicated issue but it was a sleepy yawning resident who wrote a wrong Rx for me.
Hmmm…I’m a bit ambivalent. On the one hand, I know it’s true that extremely long hours with fatigue can impair performance – both cognitive and procedural. On the other hand, nothing substitutes for clinical experience.
I also think there are other pertinent factors:
First, our tolerance for error has reduced over time. What were previously known as ”imperfections” in care are not seen as critical incidents. In general this is a good thing, but perfection is impossible and the strive to reach it causes a lot of stress and burnout.
Secondly, care is a lot more complex now, creating more potential for error.
Overall, I think there is a middle ground. Young doctors need to work a lot of hours to gain experience, but should not be pushed to the point of exhaustion or falling asleep on their feet. (Nor crashing the car on the way home).
First, our tolerance for error has reduced over time. What were
previously known as ”imperfections” in care are not seen as critical
incidents. In general this is a good thing, but perfection is impossible
and the strive to reach it causes a lot of stress and burnout.
These don’t have to be mutually exclusive. A decreased willingness to tolerate errors could lead to systematic changes that would reduce errors and stress. For example, programs that automatically flag any potential drug interactions can both reduce errors and reduce stress because the person writing the prescription doesn’t have to worry about whether he or she has kept up with every last bit of the data with respect to possible interactions (which is impossible.) Make life easier for the doctors, nurses, pharmacists, and other practitioners by providing automatic fail safe mechanisms to help protect patients and they’ll be less stressed and more able to concentrate on the big picture without losing control over the details.
Electronic medical records do flag drug interactions, but a lot of times they don’t really help. A lot of the “flags” are ridiculous things; so many false alarms and one tunes out the possible “real” alarms.
It’s a good point. I often go through the flags on semi-autopilot. But that suggests that we need better programs to identify interactions, because I don’t see any way that we can reasonably ask people to know every drug interaction at this point. There’s just too many and too varied.
http://thederangedhousewifeonline.blogspot.com/2013/07/dr-amy-to-speak-at-september-acog.html?m=1
OT but apparently you’re not a real dr. Her retired family member is-but because you’re so mean and hurt their feelings you don’t get to be respected. The double standard amuses me a great deal.
/reads rantlink
/eyes wander to upper right corner of Dr. Amy’s blog.
/ponders the low bar for ‘misrepresentation’ in the homebirth blogosphere.
“ACOG itself argues that they feel the hospital is the safest setting for
giving birth, but admits that it ‘respects the right of a woman to make
a medically informed decision about delivery.'”
With the key phrase here of course being “medically informed.” Not “Googly informed.” Big difference, folks.
This is also an exercise in neuroticism: http://cord-clamping.com/2012/07/29/birth-story-woman-centred-emergency-c-section-with-delayed-clamping/
I should clarify it’s about “natural Cesarean section”
A “natural cesarean” is one in which the woman whose abdomen is ripped open dies of shock and sepsis. I’m happy with my unnatural one.
Other thought on this link: Wow. Just when you thought the crazy had reached bottom, it turns out that there’s more…
I stopped reading at “Delayed incision to delivery time.”
It’s a freaking hole all the way into your abdominal cavity. How on Earth is leaving it open longer than necessary a good thing? How does this not increase the risk of infection and bleeding?
I am terrified of being awake for a c-section if needed, the last thing I’d want is for it to take EVEN LONGER.
NIGHTMARES.
NCB and “natural c-section” types have all this enthusiasm for watching the surgery and lowering the drape and getting the baby before it’s been wiped off. I don’t understand it, personally.
I had an emergency c-section, and I was grateful for the drape, and pleased that I didn’t have to see any more blood (I’d seen plenty), and that they handed my husband our clean, dry, hatted and swaddled daughter so that that first moment when we met her didn’t seem as much to us like more emergency.
If the drape was down, I would probably pass out. Hey, then I’d get my wish to not be awake!!
Right? I mean, logically speaking, the longer you’re open, the longer you bleed. I want my surgeries performed with appropriate deliberation, care, and efficiency.
WTF? So much stupidity I don’t know where to even begin. The whole idea of a “natural cesarean” is oxymoronic, emphasis on “moronic.” And can you imagine trying to bully an OB into doing major abdominal surgery the way you think it ought to be done? That’s so obnoxious. And what’s with calling contractions “rushes?” Is that supposed to make them seem more spiritual or less medicalized or covered with chocolate sprinkles and glitter or something? Or imply that they aren’t supposed to be painful? And don’t even get me started on all the rest of the nonsense … she felt fear and that led to adrenaline and that led to pain and that interfered with her magical hormones which I guess would have saved her and her baby from a placental abruption somehow, if only she hadn’t given into fear and trusted birth! Back of hand on forehead!
This case would be worth a few rounds of drinks at the bar afterwards. I’ve been at a lot of C sections with moms that had homebirth gone bad and none of them ever thought to tell us how to do the operation! We did do skin to skin in the OR but that’s it.
The funniest bit of that whole train wreck was where she said that her doctors planned to write a paper on the experience. Yeah, “How to Deal with Bossy, Demanding, Obnoxious and Unreasonable Patients.”
What the hell is the benefit of performing the c-section slowly? Because I don’t for a minute believe the “recruit blood volume” BS – what does that even *mean*? Is a baby attached to an abrupting placenta magically able to suck more blood towards him just because he’s not out of the uterus yet?
When I watched my second c-section in the reflection of the operating theatre lights, I was a little appalled and amazed at how my obgyn seemed to just hack away and then flip the baby’s head out. It was done within minutes. I don’t know what I was expecting. More caution? More thoughtful pauses? More mopping of his sweaty, furrowed brow?
Once upon a time I thought an OB explained to me why it all goes so fast but I forget. Maybe Dr Amy or an OB commenter can explain it.
A doctor friend of mine once said that, if the mother has had any type of general anesthesia, you want to get the baby out of there before too much of the drugs get into his bloodstream. (If it’s epidural only, that doesn’t matter.)
I think the other issue is that the uterus bleeds a LOT when cut, and you don’t want to leave it open one moment longer than necessary.
You know, every time a hear a woman lament that she wanted a “gentle” birth for her child, I just want to point out to them that a cesarean deliver has got to be the easiest way to go for the baby. When my son was being born, my husband yelled that his head looked like an accordion compressing while the midwife and ob were panicking about his dropping heart rate and pushing/pulling him out. Not gentle. At all. I think a cesarean would have been a lot easier on both of us, and my birth really wasn’t a complicated delivery at all.
If your primary motivation is a gentle birth, shouldn’t a maternal request cesarean be your first choice?
I like a natural cs. Okay, not during an abruption, but during an elective case? Why not? Most of the included steps are super easy. We put the IV and the BP cuff and the pulse of on one hand so the woman has the other completely free for baby cuddles. We put the EKG patches under her shoulders so they are non obtrusive. We let the parents pick the music. I don’t mind dimming the lights during the spinal (it’s a tactile not a visual technique) but clearly we need lights after that for the I. And out cath and the surgery. Baby goes on moms chest for skin to skin and bf or dad can do skin to skin in the OR if that is preferred by the parents. The part with the slow extraction is meant to mimic vaginal squeeze and decrease Transient tachyons a of the newborn. We dunno if it works but if the OB is willing to take the extra 60 seconds…and the extra 90 seconds of delayed cord clamping so what? It’s not going to appreciably increase the risk of infection. I suppose bleeding could be an issue but then you would have to argue that residents shouldn’t be closing the uterus because they take longer than an experienced OB and that’s extreme. This woman may have been demanding and have her priorities confused but in general what she wanted isn’t that extreme or ridiculous for most cs.
Well as long as it’s not mandatory… if I require a c-section I want the baby out and me closed up ASAP and the baby cleaned and wrapped up before I hold her. Actually I wouldn’t want a resident closing me up either because I have such bad anxiety that if they won’t agree to knock me out, I want it done in the fastest possible way.
That’s my preference though. I like the part about choosing music though since if I have to be awake for surgery I am going to have bad anxiety.
I had a natural c-section and it was great. I got to cuddle my baby immediately after she was born and they didn’t take her away until I was moved into recovery. I don’t see what your issue is. It is standard at my hospital.
My issue is with the term “natural,” which is impossible to apply to major abdominal surgery. Also the tone of the piece, implying that she could have prevented an abruption with her magical hormones if only she’d just trusted birth more. But my primary “issue” is that she tried to bully a trained obstetrician who was attempting to save her life and the life of her baby into doing things *her* way during a medical emergency. Sure, if you can make a c-section more pleasant and you want to have hospital procedure that ensures that that can be done safely, I’m all for it. But I think bullying your doctor into taking stupid risks so you can have your c-section go the way you personally want it to is seriously obnoxious.
I think I would have been yelling at the surgeon “Get my baby out!” not “Respect my birth plan!” – says it all really.
”The only thing they could not do for us is use our sterilised hemp string as clamp, so they had to use the usual big plastic one.”
Charming.
Interesting post. Funny that statistics can disprove our gut hunches!
On an unrelated note, I thought you would find this post interesting, Dr. Amy: http://www.mamaandbabylove.com/2013/08/15/how-to-make-the-best-of-cesarean-birth . To me, it’s more obsession with the act of birth rather than the life of the baby, and giving women unrealistic expectations.
Love this post, although it confirms that I am now an antiquated Doctor. My equivalent statement to Doctors in training is “eating and sleeping are luxuries”. As much as the reduced hours have affected training, the advances in medications and medical technology have limited their exposure to major surgery and major complications. I am not saying it is a bad thing, but its something (those in Australia can see I’m paraphrasing Julia Gillard when commenting on being the first female Prime Minister and the difficulties she encountered). There is talk of extending the length of training, or spliting up ob and gyn, or training either office based vs surgery based specialists. Who knows. I know I was scared stiff when I finished my training that I might not be ready, but I was much more prepared than they are today.
I’m also a sucker for the 10,000 hour theory. You wanna get good at something? Work at it for 10,000 hours. So, residency needs to be grueling and long.
Only if you want to reach 10,000 quickly. I’m a top-notch at crochet – been practicing for 18 years.
I’m pretty darn good, but keep finding new techniques in crochet. And I started learning 35 years ago.
Current limits in place for hours to be capped at 80 per week (on average not absolute) some of the basic residencies are 3 years for the primary care specialties and up to for nine for neurosurgery. 52*80*3 = 17,300 hours.
This excludes the two years of exposure during med school clerkships or the common place duty hour violations. Likewise new doctors start with usually with a background in nursing, army medic, EMT, or volunteer service to even get into medical school. A new grad fresh out of residency will have 25 thousand hours of experience. Is that enough for you?
“I can hear younger doctors out there groaning about antiquated older doctors celebrating the hazing process, but the reality is that it made for better, safer patient care”
Hmmm. I’m perhaps one of those younger doctors you refer to. And I do think it was hazing. Maybe you were able to overcome sleep deprivation by relying on your strong sense of professionalism or something, but I am pretty sure my work performance suffered. I know it did. I finished my residency training shortly before the first wave of reforms were put in, but I supported the first reform and support the second reform.
I teach part-time in a residency clinic and I feel things are so much better. Residents arrive rested and curious and willing to dig and also NICE (treating our patients and support staff nicely is also a part of professionalism in my opinion). I can barely remember some of my residency clinic shifts. I would work for 24 hours straight as part of a q3 or q4 OB shift and then drive (drive!) directly to clinic and work an entire clinic day. Medicine shifts didn’t usually have post-shift clinic (unless we were short on staff) but they often lasted 30-36 hours. I am pretty sure that what I was supposedly learning after 36 hours of being awake was neither making me a better doctor nor improving the health of my clinic patients.
I have a friend who became a PA (physician’s assistant) about fifteen years ago. She described being on call and having to sleep near the hospital for 6 hours after putting in a full day of work, but only getting 2 hours of sleep because the beeper kept going off.
She said the hospital decided to hire more staff after one PA fell asleep while assisting with surgery.
She also remembers getting pulled over by police while driving home because they thought she was drunk, when she was just really tired from working a 36 hour shift with the purported “six hours of sleep” which was closer to two hours.
I think one really, really important thing to point out about the studies in that New Yorker article is that they don’t ACTUALLY measure the quality of care that patients received–they both essentially relied on surveys about health care workers’ PERCEPTIONS of safety. That’s so flawed as to be basically worthless when you’re trying to draw real conclusions about the impact of duty hours restrictions. Until someone actually does the research using real patient outcomes, this is all just speculation.
Bingo.
Although I agree with you, indirect evidence would suggest that medical errors have not improved much in general, and without patting ourselves on the back too much, the outcomes in ob/gyn are so good that it is hard to show a significant change in morbidity and mortality when those outcomes are so rare (as opposed to comparing to homebirth deliveries which have somehow manage to kill and injure enough moms and babies to actually be statistically significant).
so what do you do with the info from NSQIP that M&M is increased if you have your surgery on Monday, Friday or nights and weekends…isn’t that sort of indirectly supporting this fatigue=worse care hypothesis?
Um, yes. But these kinds of studies have so many confounding variables that I admittedly struggle to give them the weight that they may deserve. Again pointing to me being an antiquated Doctor
From my experience, the issue with weekend care is more about labs, radiology etc.
Not every service in the hospital runs 24/7.
Glad it wasn’t just me who thought this! I actually had a long conversation about this with my parents (both retired, both trained in the UK before the European working time directive – on call Friday afternoon until Monday morning followed by a regular shift) and they said that the problem with the exhaustion wasn’t so much the obvious things like drug or dosage errors. It was more about flawed decision making – convincing yourself that you don’t really need to go and check on that patient, they’ll be fine until morning, the nurses will be able to handle it, or not calling for help because you know it means waking someone up and they’re just as sleep deprived as you are. Pretty much exactly what this article from an NHS doctor says actually. http://www.theguardian.com/lifeandstyle/2013/aug/04/nhs-must-not-back-exhausted-doctors But, I would expect the former would get self-reported as ‘errors’ more often than the latter.
Actually, the major problem they remember is that when you’ve been awake for 50 hours you just. don’t. care. about anything except getting through it, and that isn’t good for anyone.
The calculus is brutally simple. Reducing working hours without reducing
patients numbers of increasing the number of doctors means less doctor
time/patient and an increase in mistakes is an inevitable result.
So why not reduce the number of patients each doctor covers? That way the doctors could give adequate care to all patients without spending so much time working that they end up hating their jobs and their patients.
(Puts on tin foil hat): We don’t spend too much money on medicine. We spend too little. Medicine is simply the thing we need to put most of our resources into now. We don’t need many people or resources for farming–nor have we needed to for a long time. We don’t need a lot of people or resources for manufacturing-robots are cheap and efficient. We need a lot of people and resources to help sustain our health. Why not provide them?
It’s not that we spend too much or too little on health care. We spend money on the wrong shit in health care. We need to spend more on clinic and consult hours, more on behavioral preventive measures, more on modernizing support systems (like better sanitation, etc), less on wasted items, less on middlemen, less on advertising, and less on fucking profit. Our medical system is fundamentally broken because while doctors may care a lot, the system around them cares about one thing, and it isn’t patients.
Agreed.
Things that I think could go from the hospital where I work:
1. The people who are hired for the specific purpose of making sure every last note is timed, dated, and signed. Seriously, they have no other purpose. Replace with electronic charting that automatically times and dates notes and get the people currently auditing it a real job.
2. The CEO’s 1.8 million dollar salary.
3. The people who spend their time trying to shake money out of the “self-pay” patients. There is no blood in that turnip. It hurts the patients to try to make them pay for care that they can’t afford and in the end hurts the hospital and society: they don’t get necessary care for early disease or screening and come back with something expensive and nasty.
But I still claim that we’ll need to put more resources into health care. Research if nothing else. When we all live to an average age of 1000 we can talk about cutting back or automating or whatever. While we can barely manage to keep people alive 80 years on a good day…we need more.
If you are “self-pay”, you can call the doctors ahead of time and shop around for a better price.
Also, there are clinics with sliding-scale fees based on your income. You need to research to find the best clinic in your area.
I think that is ridiculous. Patients shouldn’t ever have to shop around for the best price. Why should a given procedure cost more at one clinic than another? Prices for health care can and should be set, standardized and regulated, as they are in many countries with national health systems.
Patients should be able to chose their health care options based strictly on medical criteria, not finances. Medical care should be, in my opinion, a basic human right, not a consumer product.
I will tell you this: Doctors of the same caliber will charge less in upstate New York than they do in New York City, because price of living is lower upstate.
I personally have driven upstate to save myself a few hundred dollars.
Lisa you are absolutely right that prices are different in different areas, but you are wrong about the reason. Insurance reimbursements, even for private insurance, are pegged to Medicare rates, and the Medicare rates are based on what was the ‘usual and customary’ fee in an area in 1964. Therefore, reimbursements across the board vary widely across the country. As you can imagine the fee scales are quite antiquated….
Also, private for-profit insurance needs to just go away. They’re overtly evil.
There are many doctors who take private insurance but not Medicaid.
Could it be that private insurance pays more?
Sometimes. It depends on the insurance. Those that do that take a very selected types of insurance that do pay more. But tend to act very bizarrely. I’ve had patients with private insurance and a chronic illness with acute complications come in to clinic for treatment with the exact same problem and get the exact same treatment-and have the insurance pay 100% one time and 0% the other. Go figure.
I feel we need to stop seeing medical residents as free labor and actually put their training first. When I was in residency, I had a Norwegian foreign exchange student on one of my medicine rotations. He thought our system was nuts. IIRC he said their work weeks were capped at 50 hours, and almost all training occurred during the day. He said their reasoning was that residents were there to learn so we should teach them during the hours that they were most alert so they could learn best. He said that night-time shifts were only done by fully trained doctors and the reasoning was that why would you place a learner in a situation where they were also having to fight fatigue? High risk hours should be covered by the strongest docs, not the weakest. He said that his training had good hands-on training each day as well as much better didactics (lectures) than we got in the U.S. He was not impressed with us.
“I feel we need to stop seeing medical residents as free labor and actually put their training first.”
Hear, hear!
If I knew then what I know now I would never in a million years have gone to medical school. And I will never do a residency if I can help it. I felt trapped in an entirely demeaning and demoralizing process the entire time. I cried the majority of days during my clinical years. I left med school feeling much stupider and with much lower self esteem than I started it with (and I have never been one with high self esteem).
There are some serious problems with our medical training in this country. I don’t know what the answers are but I hope for the next generation of students/residents/doctors we find some soon.
You know, I think the same thing. How would it hurt our society if we did spend, say, 25% of our GDP on health care? We’d have fewer toys, but we’d probably be better off, assuming the burden was distributed reasonably.
And yes, a lot of money that we are spending is essentially wasted, from direct-to-consumer advertising of prescription drugs to the army of billers and coders and insurance agents who provide no care, just push money around. (These aren’t bad people, my MIL was one of them. Most of them are hardworking lower-middle-class folk. But the fact is, the USA as a society is spending a lot of money on them and not getting anything in return.)
How would it hurt our society if we did spend, say, 25% of our GDP on health care
I advocate about 50%. I don’t think we’d suffer at all, not even fewer toys. Toys are cheap thanks to automation and e-distribution. We’d also have lower unemployment since quite a lot of the cost of medicine is staffing. That means more people ready to buy toys and manufacturers able to spend money finding more efficient ways to do things, and so on. All we really need is to mobilize the resources currently rotting unused in the hands of the super rich.
The people who are implementing the billing and coding rules are not bad people, they’re just stuck in jobs that are not helping anyone. Allow them to do something useful and interesting and they’d be a lot happier and make a greater contribution to society. The ones making the billing rules, OTOH…need to examine their motives and the effects of their decisions more carefully.
Dr. Amy – I think you’ve hit a nail upon the head that few want to admit and I also think you’ve touched upon something that is critically important in relation to maternity care. A lot of women are opting for the midwifery model of care – not because the providers are better educated, but because of the time they get with their provider and the continuity of care. Many women who choose midwifery know who will be delivering their baby and they will have developed a relationship with that care provider. Many women who choose the medical model (at least in Canada) – get neither the time with their provider nor the guarantee that their provider will even be there for the delivery.
So if we want quality care – are we going to be willing to pay more for each episode of care (reimbursing more for a patient visit) or are doctor’s going to be willing to earn less? You are absolutely right though – it’s not just exhaustion that results in errors, it is a lack of time and a lack of caring and sometimes it is just sheer incompetence.
The midwives I work with don’t guarantee they will deliver anyone’s baby. They deliver as per a call schedule and that’s that. One of four, same as the ob group. Despite that, it’s what patients say is their main reason to choose a midwife. I wish I could take more time per patient, but that would mean working to pay my overhead and taxes with not enough left over to pay off my loans and save for retirement, really. No thanks. It’s frustrating to work in health care.
Re: Hospitalists. Is this new to some of you? Because it’s not to me. My children have had prolonged stays in the hospital and we never saw or heard from their pediatricians (and over the years we had different pediatricians). During one stay my husband asked me, “Who is his doctor here?” and I said, “Well, it’s Tuesday at 11:00am so I think Dr. Smith is on today.”. And he asked, “No, who’s the main doctor? The one overseeing our son’s case?”. I had no idea if there WAS any one doctor primarily in charge.
I’ve only ever trained in teaching facilities and now work in a unit that is 24/7 neonatologist on unit coverage. I felt spoiled that I never had to contact an out of hospital doctor. The response time was short. Maintaining consistency in treatment can be a challenge with no one doctor in charge of making decisions. As the primary nurse for a patient I spend a lot of time making sure we don’t spend weeks going back and forth while parents pull their hair out trying to understand what’s going on.
There is ONE particular type of error that is prevented by doing away with on calls in favour of shift based rotas.
There are apparently people who can hold coherent conversations on the phone while still asleep.
Not good if the conversation in question is “Hi super sub specialist , history is X, should I do Y or X?” “Do Y”…and they have no recollection of the conversation the next day.
My husband and I occasionally have that exact problem just at home (one of us will seem to be awake, but have no recollection of the conversation the next day). Good thing neither of us is a doctor doing life-and-death phone consults.
I had an entire conversation with a friend like that. She had no idea it had happened.
I did that once. Apparently I gave reasonably coherent advice, but then said something completely weird before I hung up the phone. The (very kind) nurse called me back and had me come out of my call room and down to the nurses station to make sure I was fully awake, and then asked me again.
Exhaustion. Not good.
I remember calling a physician with blood gases on my patient one night in the NICU. The response was a set of completely non sensical settings for the oscillator. I hung up and was going to call him back to wake him immediately when he called OMG WHAT DID I JUST SAY PLEASE TELL ME YOU DIDNT DO THAT!!! I would never want to be a neonatologist, I would stink at 24 hour shifts.
My partner has this skill/curse. Good thing he’s a jazz musician and not a doctor.
Oh yes, had this happen before! I also had one MD fall back to sleep during a late night phone call mid way through his orders. Just kinda trailed off mid sentence. At first I thought he was just pausing to think but then I noticed that deep, regular breathing and realized the bugger fell back to sleep.
I did that once. I gave excellent advice…except my mom was not my patient or pregnant, let alone preeclamptic. She did hang up and call back later.
Yeah, I can do that with my husband when he wakes up to cover a farm call at night.
Because, and this is the dirty little secret in medicine, being exhausted, overworked and irritated does not cause medical mistakes. Lack of time to talk with patients, both to listen and to explain, and lack of time to obsess about the details is what causes medical mistakes.
Yes, yes, yes!
Naw, *ALL* of the above cause mistakes. How can we lecture our patients about the importance of sleep, but then believe that somehow the advice doesn’t apply to us? We have many many studies that show that everyone from students to truck drivers to factory workers to airline pilots make more mistakes when they are exhausted. But somehow we doctors are immune? Come on, we’re doctors (or CNMs), not gods.
I see hope in that the anesthesiologists have come around to admitting that we are human. But anesthesiology never did have quite the same macho culture as some of the other specialties.
its because the gas makes us mellow…;)
he he he he he
In Michigan, if you have not slept in 24 hours, you cannot drive legally.
As a teacher, we take sleep seriously. Teachers who do not get enough sleep are much more likely to make factual errors while teaching and are more likely to make mistakes in classroom management. I do not believe that being a medical professional makes a person immune to the mental fogginess and emotional malaise that chronic sleep deprivation brings.
Personally, I wonder if self-selection plays a part in increased mistakes. In other words, people who made the decision to go to medical school and then matched in surgical residencies 30 years ago knew they would be working 36 on/12 off for years on end. It takes a very driven (perhaps to the point of mental instability) person to agree to such an arrangement.
Don’t get me wrong, surgical residencies are still brutal. But people who are not 100% dedicated are no longer weeded out by the hours like they once were.
There is an alternative possibility….which is that doctors (now more female, with a bigger emphasis on a culture of openness and honesty, and reflective practice) may be more willing to admit mistakes…
Or that doctors who are less sleep-deprived are more aware of the mistakes they make because they have room in their brains to notice it.
It’s hard to miss a mistake when your chief resident yells in your face about it.
If the chief resident is always yelling in your face, it becomes very easy to block out. I have strong memories of when certain mellow and laid back chief residents told me quietly, “Don’t do that” whereas I have essentially no memory of what the constant screamers wanted me to do.
we all learn differently. Humiliation was very effective for me. But if I use that now, 99% of the time I end up having to apologize for my behavior. Again, I am antiquated.
you need to be in an optimal state of emotional arousal to learn. Too much yelling people turn off. Fear inhibits learning and retention of new information.
“It’s hard to miss a mistake when your chief resident yells in your face about it.”
I have no doubt that is true. But I bet it’s hard to learn to *self-report* mistakes if you are being yelled at and ridiculed for making mistakes.
Here’s a question: If being yelled at in your face (let’s call it the “Tiger Chief” style) was such a great method for helping you learn, why didn’t you use that method with your own kids?
The facts- patients are more complex now than they have ever been.
When my mother did her training in the 1970s you might admit 20 patients in a night, but you actually didn’t DO much to them- there was an awful lot of watchful waiting.
There was no lysis of strokes, or primary PCI for MIs, or NIPPV for the end stage COPD patients (who then require hourly ABGs).
When I was working the equivalent of a 2nd year resident job in acute medicine in a small general hospital I was doing 13hr night shifts in charge of 75 inpatients- of whom 4-8 would be on NIPPV, and 6-10 would be in acute coronary care, with 20 admissions to see coming through A&E and only one intern to help me ( and they usually spent all night doing bloods and gases and writing up fluids)…and no senior doctor on site.
13*60=780
780/100=7.8
Less than 10 minutes per patient… not counting the 30minute handovers at the start and end of shifts, and assuming I needed no food, drink or bathroom breaks.
Because the admissions each took 20-30 minutes to sort out minimum, the coronary care and NIPPV patients usually needed similar amounts of time… and most nights there was at least one cardiac arrest…well unless you were seriously unwell between 8pm and 9am, I didn’t see you.
If you want doctors to do better you need more doctors.
You cannot try to do more with less.
On his urology rotation at the VA, my father admitted 20+ medically complicated patients per night for TURPs in the morning. After the first week or so, the H&P was:
Hx: Multiple medical problems
Plan: 1. NPO p midnight
2. TURP in AM
🙂
So yeah, quantity is often incompatible with quality.
I remember the typical A&E Friday night nursing home turf.
Hx:elderly person, background hx dementia- nursing home report more agitated than usual, generally unwell
Plan: broad spectrum antibiotics, strict I/O chart, diuretics, small amounts IV fluids.
Also known as the “Co-Amoxi-Frusi-cillin” plan- try everything and hope something works.
You also need more nurses, and the nurses need better training. Whoops, we’re not supposed to use the term “training” any more — that implies reaction without thought, rather than “education” which means endless theory and a minimum of practice during said education.
Experience I never want to repeat…
Bagging a patient while nurses held 2 phones to my face, on one was the cardiologist – arranging to transfer another patient of mine to the cath lab in another hospital, on the other was my senior, who I was telling to get out of bed and get themselves in, meanwhile the intern is in front of me waving an atrocious blood gas result and asking about NIPPV settings for a third patient who was trying to die.
I’d have willingly swapped 7 hellish night shifts in a row like that every 6 weeks for one 36hr on call every 6 days.
Motherhood is NOT the most stressful job.
My wife, a Doctor, might disagree with that last statement. The one thing that I think has changed is that you have better support. Ie- the consultant (attending) are much more involved than in the past. Those kind of nights made you confident that once you completed your training it was very unlikely you would have one of those patients to manage in a night, let alone three or four.
That night was 5 years ago…not the dark ages in the mists of time, and on a EWTD compliant 48hr week (average) rota.
As I said, at 2nd year resident equivalent, I had no senior cover and was essentially singlehanded for the medical/respiratory and cardiology take and inpatients because the intern was also looking after surgical patients. For the part of the rotation when I was working the ER I was the only doctor in the emergency department from 2am to 9am.
No it wasn’t supported, and no, I don’t think it was particularly safe.
There is one nursing school in my area that gives me a headache. I’m not sure how they maintain certification. Their med surg rotation is a few shifts in a nursing home. Their peds rotation has zero hospital experience. Their psych course is a few week tutorial by computer, and 10 shifts in an actual psych hospital. They are not allowed to speak to the patients in any way. Their OB rotation at least is in hospital but they don’t learn newborn assessment. Then as their capstone project I have 200 hours to teach them how to be a NICU nurse. I spend the whole time teaching them the bare basics. When I get students from other schools I feel like I at least have someone who knows the basics and doesn’t have to be told how to change a diaper.
Yep, it’s called “work compression”.
http://archinte.jamanetwork.com/article.aspx?articleid=1672290
It seems that an interesting answer to the problem is buried in this blog post: More doctors! That way, the doctors that are there can spend adequate time with each patient without working a 30 hour shift.
Also, I wonder if you can really assess whether or not overworked, insanely sleep-deprived doctors are NOT a hazard from this study. It would be good to compare Overworked, sleep-deprived residents (with time to talk to their patients) with residents doing a 12-hour shift who also have adequate time to talk with their patients.
Only then can we get to the bottom of the problem. If it turns out that the well-slept, non-exhausted doctors do better given an appropriate patient load, then the answer is more doctors, not crazy hours.
In regards to Libby Zion, you must also take into account the negligence of the nursing staff in not questioning the physicians orders. No nurse is legally obligated to follow an order she feels is unsafe, and if the physician won’t come reevaluate the patient there is a chain of command to follow to ensure patient safety. Of this is all in an ideal world, and the culture of the facility has to be considered. As a nurse I have been reprimanded for daring to question a physician’s order. It is very seldom the fault of one person or even one group when mistakes are made. Until we learn to evaluate the effectiveness of healthcare from a comprehensive system based approach I don’t think any changes that we make will ever really work.
As a nurse I have been reprimanded for daring to question a physician’s order.
I would fire the person who reprimanded you if I had the authority to do so. It is virtually never wrong to question a physician’s order. Nurses, pharmacists, etc are the second line of defense against mistakes. Not allowing them to act as such is simply wrong.
Well, since it was the CNO that told my supervisor to tell me that I shouldn’t have called the physician and requested to transfer a 33week preterm infant with multiple risk factors out of our nursery which is only equipped and staffed to deal with healthy newborns over 35 weeks I’m not sure what else I could have done.
That’s awful. I guess you were just supposed to wait for your patient to crump before calling the MD?
In a word, yes. Since he was doing quite well at the moment, the physician didn’t feel that a transfer was warranted. When I mentioned the staffing, training, and equipment issues I was told that we would just have to pull a nurse from M&S. Fortunately he did well, since -as the saying goes- most patients get better no matter what we do to them.
Sorry, I seem to have written in a very unclear manner. You absolutely should question any order that doesn’t make sense to you. The person who censored you (and the physician who presumably asked for you to be censored) were extremely wrong. You did the right thing for your patient.
Preach it Dr. Amy. As a current intern, I would bet that there is another factor you didn’t account for. Patient handovers/sign-outs are way more dangerous than 30 hour shifts, because the team is now making decisions about a patient that they did not admit and get to know themselves. And, like you said, just as many patients and work but in a “12 hour shift.” And then fewer large chunks of time at home so that all I do there is sleep for 6-7 hours and come back to the hospital. Everyday.
“And then fewer large chunks of time at home”
Are you under the impression that the old schedules contained large chunks of time at home? ha ha ha ha!
This is front and center in the minds of medical educators like myself. (I am an educator at both the undergraduate and graduate medical education levels.) I completed my training prior to the 80 rule and despite its brutality, it had advantages. There are aspects that I don’t think were good. I don’t think anyone is at their cognitive best after being awake for 36 hours. But, I completely agree that we might have gone too far in the opposite direction. I was steeped in caring for patients and learning about their diseases. I was also steeped in the expectations of the profession, particularly that you are never really “off the clock”. I am dismayed by the attitude of some of my learners. We have turned medical education into shift work. We have increased the level of required faculty oversight to the point that we have essentially turned the intern year into a fifth year of medical school. The level of supervision I had for the amount of responsibility I took on as intern probably wasn’t ideal but what I have seen is learners being far too reliant on faculty for decision making and handling the workload. I was just talking with a fellow faulty member who trained at the same time I did. We were talking about how we used to see 12-15 patients overnight in the ER while some of our learners now see four even through the ER volume has risen. I hope that the new data about handoffs and medical error will prompt a shift in ACGME policy in a way that will indirectly impact the professionalism aspect of training.
I took a year’s leave [1965] from nursing school, and during my time away, the teaching model changed entirely, from “task-centered” [i.e. one nurse was assigned all medications for an entire ward during her shift, someone else did observations, yet another did treatments, etc.] to “primary care” [one nurse cared entirely for a couple of patients]. What developed was that whereas the “task-centered” system produced nurses capable of running entire wards during their senior year as students, the “primary care system” resulted in nurses who needed at least a year after graduation to become really functional. This was especially true if the nursing student never got assigned to complicated patients through the “luck of the draw”. I remember having to bone up on more than 75 medications the night before I was “meds nurse”; in the class I graduated with there were actually students who’d never given an IM injection because they’d never had a patient who needed one.
And it’s worse now with the academic emphasis of working toward a degree replacing hands-on practical nursing during the period of being a student.
I graduated from a BSN school in 2001 and was able to take on the role of a fully functional RN in all of the standard rotations. I did end up getting hired in an ICU so it did take 12 weeks orientation there, same as the experienced nurse moving specialties. Some schools are doing a much better job than others.
I’ve had nursing students who didn’t even bother pretending to be interested in patient care. They were getting their BSNs and would put in a couple of years on the floor before going into management…at least that was their plan.
The VA still has med nurses, at least on some units. Personally, I like doing total patient care, especially if stays are long enough that I either have a patient for multiple shifts or one of my coworkers has taken care of that patient and can help mid shift if anything comes up, as they know the patient too.
This sounds crazy, but I’m finding it oddly comforting that these kind of wackos exist in medicine as well as education.
In teaching, some teachers teach for exactly two years before bailing to become administrators. As administrators, they give ambitious plans to “change the way education is done” which I find deeply ironic since they were pretty awful teachers in the first place.
As a nurse who often gets pulled to another floor to pass meds, I have to say that I hate it. To me it’s very scary passing medicines on patients that I don’t know well and haven’t received report on.
This! How one nurse could safely pass meds for an entire ward of patients is beyond me. There is no way you can know the history on all those patients, not to mention the new lab values and what meds to hold for pending procedures.
Amazingly, you can. In my day we got report on ALL the patients on our ward, not just those to whom we were assigned. It required a different sort of mental organization. However, I do grant that today’s patient care is far more complex than it was nearly 50 years ago. [But there were a LOT more bedside nurses then, too — as salaries rose, the concept of one RN supervising several nurses’ aides began as a way of saving money] I remember that, in 1964, the staff for a 24 -bed “open” medical ward was 6 RNs, plus a gaggle of students, and 2 nurses’ aides, for the day shift. The head nurse did not do any patient care but only administrative work]
There are pluses and minuses to both models. On the plus side, one gets a huge amount of experience, and learns how to work with the big picture. You know where everything is, and how to do everything — which comes in handy occasionally. On the minus side, working with only a couple of patients can mean that entire types of experience, during the student years, remain theoretical. I, for example, have NEVER done colostomy care [I went straight into OB after graduation, and never had a patient with a colostomy while a student]. And I’ve worked with many graduate L&D nurses who had to be taught how to catheterize a patient, having never had student experience. Etcetera. When my mother was terminally ill, it was a bit of a shock when I discovered that the RN “team leader” had never even noticed a bad decubitus ulcer on my mother’s back and didn’t know what it was [“Is this another cancer?”], let alone what to do about it.
Having worked both before and after the 80 hour rule, I will say that I prefer the latter. At about 18-20 hours into my shift, I stopped caring. But that is why I do shift work in the ED now (max 12hr shift). I know what MY limits are. The hand offs are an issue, though. So how do you balance sleep deprivation mistakes with hand off errors?
I agree with this. What we are seeing is likely hand-off errors. No matter how long your shift is you are going to have to eventually hand off patients to the next shift. Perhaps the problem is inadequate communication or inadequate time for debriefing.
Also there was an increase in “self-reported errors”. Are more rested doctors more likely to catch their own errors? In other words, are we seeing a real increase in errors or a reported increase in errors?
I saw that too. I wonder what the hard numbers for morbidity and mortality looked like.
Perhaps the solution isn’t to go back to the old days, but to improve handovers.
I wonder, though, whether handovers are merely the symptom and not the actual problem, that being the lack of thorough knowledge of the patients that comes from caring for them for many, many hours.
Communication is still key, though, IMO. If its a 12hour shift or a 36 hour shift there are still going to be patients that were just admitted that you won’t know well and patients that will need to be discharged as soon as you arrive. It’s not just communication with the residents giving report but with the bedside nurses, RT, PT, etc that has to be included. If you’re relying on just the resident to know what’s going on then there’s a much greater likelihood of something being missed than if all the people involved in the care are communicating.
Good point. The residencies that have managed to do it most successfully are those that have been able to employ enough clinicians (sometimes NPs or PAs) to keep an eye on the bigger picture and help with continuity. You can’t rely on just the resident to know what’s going on.
I think it’d be really hard to know. It makes sense to me that the more awake you are during your teaching time, the more you would get out of it. Could comparing the performance of doctors that went through the old and new systems in exams (both written and the type where you have to demonstrate your clinical skills) provide some of the answer/
My concern is that long hours make medicine even more inaccessible to anyone with kids, any kind of disability or family members that require care. Obviously the priority has to be patient care, but if that can be maintained, the more medicine can be accessible to the most talented DESPITE their circumstances, the better.
I suspect the work hour issue is going to be with us for a long while. The simple fact of the matter is that handoffs and care transitions are risky and communication errors and omissions introduce risk. But a fresh look at the patient can also catch elements that were missed by the previous team. For example after case handoffs in anesthesia, the discovery of errors goes up. Of course how you define an error can also influence the data. We have evidence from my specialty that vigilance dramatically drops off after 8 – 10 hours. Vigilance is important for us, not so important for a slower paced practice. This was a big reason why we went to 12 hr call shifts.
With the changing climate in medicine with respect to medical error, it doesn’t surprise me that more errors are being reported now – especially with self report. As we decrease shame and blame culture under reporting of errors goes down which could be a confounder in one of the studies you mentioned.
As both the US and Canada move towards competency-based training as opposed to time based training we may find a balance. I will be curious to see the data on competency based training when it comes out.
Several of you doctor-bloggers have written about this over the years–do you think there’s any chance that there will be an evaluation of the current system and the doctors it has produced? And if the evaluation finds the quality of the doctors wanting, is there any chance at all residents’ hours will be increased back to what they were?
Yes: http://www.acssurgerynews.com/fileadmin/content_pdf/sn/past_issues/sn201305.pdf
I’m one of the older doctors looking at the new work schedules and thinking, “Holy Crap! How are people going to learn to manage stuff that unrolls over hours if they don’t see it unroll?” (Also, I think we may have had the same chief resident.)
Exactly, it’s continuity of care. My long-time GP just changed careers to become a hospitalist and even I’m concerned about continuity. The doctor taking over has all my records, but still.
Also the trend of hospitalists coordinating patient care – will this be a good change or a bad change? I’d prefer my own doctor but maybe that’s being spoiled.
There are some doctors who hang up on you if you call them at night (and they ARE in fact on call), or breath into the phone but never speak, let alone give orders.
When those doctors are on call, yay for hospitalists! In almost every other situation, I really don’t like it. Gets to be a “too many cooks in the kitchen” kind of issue. It is one thing to get an appropriate consult, it is quite another to pass the buck to the hospitalist and not deal with/manage your patients’ care.
I think hospitalists are a good change overall. The amount of knowledge in medicine keeps growing and growing. Forty years ago maybe a doc could do a good enough job of both hospital care and outpatient care (with some OB and basic surgery thrown in for good measure). But now each area has so much more to do that it is very difficult to do both well. I know only a few docs that do both well. I know some more docs that *believe* they do both well, but I have seen their outpatient work and I would disagree.
in re: Libby Zion, yes they should have evaluated her and not restrained her, but Libby basically torpedoed her own care by failing to ‘fess up what substances she had ingested before heading to the ER.
Was she attempting suicide?
Maybe she was altered? I have a lot of patients who aren’t good historians about what prescriptions they are taking. On a good day.
It’s a good point. Her symptoms when she came in (fever, “jerking movements”) are suggestive of pre-existing serotonin syndrome, which means the demerol wasn’t what caused her SS, though it may have made matters worse. One could argue that the residents should have recognized it, but seriously in 1984, who knew even knew what serotonin syndrome was?
But…in 1984 they presumably did know about encephalitis.
That is your big differential for fever with focal neurology, and it is not treated with antipsychotics and restraints either.
I’ve actually never seen restraints used, and I’ve worked in ER, psych and geriatric medicine. Tying people to the bed is not an appropriate alternative to good nursing care.
I have plenty of patients whose drug history is “I take a white pill for my heart in the morning. I think the dose is 5. I might be allergic to something beginning with T”. They’re usually just forgetful and elderly with poor literacy skills rather than delerious.
You have to work with what you get, and assume it may be inaccurate or incomplete.
I’m not even a medical person and and when I read “fever and jerking movements” my first thought was “meningitis? encephalitis? I dunno, but it seems neurological and infection-y.” Absolutely surprised the response was haloperidol and restraints.
Also…didn’t they use this as the plot for an episode of ER?
I recall an episode about serotonin syndrome and Demerol.
True. I was kind of wondering why LP wasn’t mentioned as a part of the workup. I assume that she denied headache or stiff neck and that she was fairly coherent and not in apparent distress when she came in, but still…Especially when things started to go bad. It wouldn’t have made much of a difference, since antibiotics don’t treat serotonin syndrome, but would at least have made a better case for their acting correctly. (Though I note that all charges against them were ultimately dropped, except that they were censored by the board due to Syd Zion’s pressure.)