Sunday, January 2, 2011


I promised you content... and here is the first of many, I hope.

Recently there was a kerfuffle over allowing medical residents to work shorter hours. In the end, the law remained the same such that residents are only permitted to work 80 hours a week; the major change was that the shifts went from 30+ hours to about 16, though senior residents can do 28 hour shifts with "strategic napping".

This would seem to be painfully obvious to anyone halfway paying attention: tired doctors don't necessarily make the best calls for a patient that needs and deserves excellent care. Especially if the tired doctor in question is, in fact, in training.

With good reason, there has been public outrage about the number of hospital-associated mistakes. Unfortunately, the bandwagon has been made available to sensationalist media coverage of the number of times that people at hospitals screw up. It seems as if the culture that loves to find fault with an educated elite absolutely adored punching holes in the godlike facade of doctors. People like Faux news seemed to take childlike glee in exposing the idea that yes, doctors are people too. Yes, doctors are not infallible. Mistakes are made, and it is a shame, but the best that humans can do is to try an minimize the potential for such mistakes.

Now mind you, there are all kinds of systems in place to minimize mistakes. Nurses ask for I.D. and papers before drawing blood or doing any kind of procedure, due to a mishap at Mt. Sinai in New York with a woman going in for the wrong surgery. It is awful and deeply regrettable, and so we learn from these mistakes. We ask for I.D., discuss the patient's understanding of the upcoming procedure, answer questions, and try to have redundancy programs where if one nurse or doctor misses something, then someone else might be able to catch it. Much of the wait and drag of a hospital can involve running these types of checks. Yes it can get bogged down in bureaucracy, but I would rather have accuracy than speed when it comes to my health. 

Which is why I simply did not understand the hue and cry raised about lowering the number of hours that residents can work. Exhausted students that work 30+ hour shifts, go home to study more, and then must return to the hospital for more work simply makes no sense to me whatsoever if a patient's life is on the line.

Put simply, safety is put into jeopardy. I don't really see that as being an option, really.

Arguments against cutting back hours and shifts are kind of ridiculous, in my opinion. The one good argument against cutting hours was made by Orac a few weeks back, and it is somewhat compelling. We'll visit it by and by.

A residency is a paid apprenticeship. A resident gets paid very low wages for a lot of work, but it is expected because the resident is learning their profession and their craft. An attending doctor oversees their work and makes sure that they are learning what they need to learn, but in a lot of ways they are basically practicing medicine.

Because the resident is working for very low pay, certainly less than she can command as a full doctor, she pumps a lot of free work into the hospital. More patients can be seen quicker because there is a larger staff of doctors that can cover the demand, and thus the hospital brings in more revenue. The hospital benefits from this, much like when you volunteer somewhere. You are performing a service for free because it helps the organization you are working for, and you personally are possibly learning or devoted to a cause. The teaching hospitals objected to the proposed changes because it would cost them revenue.

My question to them is this: if it meant fewer mistakes, fewer lawsuits, and lower malpractice insurance, wouldn't you do it? I'd love to see numbers where the cost/benefit analysis was done, with an estimation of how much the hospital can save in lawsuits and/or eating the costs associated with mistakes, vs. how much revenue is lost from either requiring more residents to cover the lost shifts or not having that many residents.

The next objection was safety. I worked veterinary emergency for years, and I know what happens when shifts change. You hand patients off to the next oncoming shift. In many cases, to promote safety and make sure that things go well, you have the shifts overlap significantly (by perhaps 2 hours) to make sure that nothing comes up. The oncoming shift reads the chart thoroughly to make sure that they understand the case and ask questions to make sure that they get it.

The process takes perhaps 20 minutes TOPS. WHY is this so difficult for human doctors to do? What, precisely, is wrong with handing patients off to another doctor?

There was all of this noise made about "continuity of care" nonsense that really irked me. I've sen it done. It isn't that hard. Why is this kind of continuity so flippin' important that it was raised as a major safety objection? If there is something here that I've missed, please let me know, because I frankly don't get it.

Dr. Wachter's article above made some good points, which kind of coincide with Orac's argument. One is the idea that even though a shift is technically over and the resident is free to go, that the resident might need to stay for whatever reason. I do get this. I've done it myself, because I had a project or issue in the back of my mind that I had to handle before I left, and explaining it might be too complicated or take too long. This I do understand.

The other is the "swinging door" mentality, that the resident might be too eager to leave or know that the shift is over and that things might get dropped just because the resident knows they have to go. Appropriate care to detail and discussions with the attending or oncoming attending physician, in conjunction with staying to make certain that cases are being handled adequately or to handle the case yourself, can probably settle this issue. Knowing the kind of sacrifice, hard work, and discipline involved in getting into and graduating from medical school, I think that this concern really doesn't give residents enough credit for being mature adults. Communication is the key when it comes to patient care, and not being communicative enough with your team will raise all kinds of problems, not just this one.

And we come, finally, to Orac's objection, the one that I think carries the most water. There is a massive amount of information necessary to becoming a doctor, and a good one at that. Book learning can only take you so far, which is why there are residencies and internships. Residencies can be anywhere from 2-5 years long, because there is so much to learn. Orac's problem with decreasing shifts is that there is less actual time to learn what you must in order to pass the boards and be a fully accredited and independent doctor.

I understand and agree with this point of view: there is a huge amount of material to learn, and less and less time in which to learn it. There will be a critical point, with short shifts and a very long residency, past which students will be unwilling to devote their education to a particular discipline simply because of the time involved.  I also think, however, that there are ways to increase the efficiency of a program so that you can indeed learn more effectively. Due to the shift restrictions, this conversation about restructuring the residency programs offered at teaching hospitals is already happening. I think that that is a great idea, because learning medicine is like trying to hit a moving target: it is constantly changing and updating itself.

There are good objections to changing the shift requirements and allowances for residents, but I honestly think that the most important ones are being lost in the shuffle. In addition, creative solutions to solving the aforementioned objections are also being lost because of a seemingly stubborn adherence to a fixed curriculum.

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