My wife is a first year medical resident, so I read this article by my friend Kevin O’Reilly with interest. Until I started dating a med student, I didn’t realize how absurdly overworked medical residents (recently-graduated doctors going through mandatory apprenticeship) are. In 2003, the medical profession instituted rules reducing residents’ hours to a maximum of 80 hours per week. And rumor has it that some hospitals (although thankfully not my wife’s) pressure their residents to work significantly more than 80 hours per week and then lie on their timesheets to cover it up.
Kevin interviews some folks who argue that the long hours are necessary because the alternative is an increase in the number of handoffs. That is, if hospitals had (say) three 8-hour shifts instead of two 12-hour shifts, that would mean that each patient has three different doctors per day instead of two, and the odds of miscommunication will increase accordingly. This argument makes a certain amount of sense to me, and I think it helps explain the idea of 12-hour shifts. But it doesn’t explain the 24-hour weekend shifts my wife works about every other weekend. If two handoffs a day is too much, then residents should be working 24-hour shifts during the week too and get more days off. Contrariwise, if two handoffs a day doesn’t endanger the patient during the week, why force doctors to work 24-hour shifts during the weekend? More generally, what’s the justification for forcing doctors who’ve just finished five long weekday shifts to work weekends as well?
Some of the people Kevin talked to also say the research on sleep and safety is inconclusive, but this just doesn’t seem like the kind of question that requires a lot of empirical research. My productivity declines sharply if I haven’t gotten a good night’s sleep the previous night, or if I try to work longer than 12 hours in a stretch. I don’t think I’ve ever worked sucessful for 24 hour straight. So I think it’s completely obvious that a resident who’s nearing the end of a 24-hour shift, and who’s worked every day for two weeks straight, is going to be less alert and think less clearly than a resident who’s well rested. It would be nice to have empirical evidence showing this, but if the evidence is inconclusive I think we can still be pretty clear that the effect exists.
The reality, I suspect, is that hospitals simply aren’t able or willing to shell out the money for the additional doctors they’d need to hire in order to give their residents sane schedules. Which, frankly, should make patients angry. I certainly don’t want life-or-death decision about my care made by some girl who’s fighting exhaustion.
Yeah that seems to be a self-evident truth. It has certainly become an accepted fact that driving while tired can impair the driver in much the same way as alcohol intoxication. I assume that hospitals don’t want their doctors self-medicating with a flask of Jim Beam on the 7a-7p shift.
It’s a barrier to entry. There’s less competition for existing doctors because few people want to suffer through a residency.
Yeah, unfortunately it’s a non-uniform barrier to entry. Many specialties have far less exploitative residencies, which is funnelling doctors towards them. Sadly this means less general practictioners and geriatricians, which we need more, rather than less of.
“The reality, I suspect, is that hospitals simply aren’t able or willing to shell out the money for the additional doctors they’d need to hire in order to give their residents sane schedules. ”
There’s also an interesting issue in that medicare/aid reimburse hospitals for each resident they have, but only up to a certain limit. So hiring a resident up until that limit (or forcing one you’ve already hired to stay) is very profitable, but hiring one beyond that limit may lose you money.
Look up GME medicare resident payments, or stuff like this:
http://www.allacademic.com/meta/p_mla_apa_research_citation/0/9/3/4/5/p93452_index.html
The incentives are completely out of whack, especially when you realize that lots of the limits on those subsidies are designed with the assumption that we have a physician surplus (!!!), and we want to de-incentivize more of them.
So, for more than one reason, I am completely in agreement here. 🙂
http://www.forbes.com/forbes/2009/1116/opinions-medicine-doctors-health-heads-up.html
Randomly saw this and thought it was applicable.
In the days before advanced computing technology, it was true that the doctor coming in on the next shift wouldn’t know anything about the patient he was being handed. But these days, we can get past that. If American hospitals would just get up-to-date with electronic filing, doctors could share patients, remain in touch, and update the same database with what they’ve learned. Doctors would be less likely to accidentally kill patients because they didn’t know what drugs the previous doctor gave them, and doctors who did fuck up like that wouldn’t have an excuse.
That’s really tiknhing out of the box. Thanks!
I don’t know what the best solution is to the riisng cost of healthcare services or the riisng cost of healthcare insurance premiums but I certainly do not believe that denial of healthcare services based on the ability to pay is a humane solution. The biggest problem seems to be that those who do not have healthcare insurance and are unable to pay for healthcare services are going to hospital emergency rooms for treatment of minor illnesses and routine care. I think maybe government-sponsored free clinics with healthcare services paid for by Medicaid might relieve the overcrowded hospital emergency rooms and move those who are unable to afford healthcare insurance and unable to pay for healthcare services to a healthcare facility where the cost of treating indigent patients is much less than at hospital emergency rooms. Those government-sponsored free clinics can easily be established at hospital out-patient clinics and staffed by licensed nurse practitioners under the supervision of a physician. I think it is the excessive cost of treating indigent patients for minor illnesses and routine care at hospital emergency rooms is what is largely responsible for riisng healthcare insurance premiums because the hospital losses for treating indigent patients is passed on in higher cost of treating those patients who do have healthcare insurance.