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What Most Patients Don’t Know About the Residents Who Care For Them

Summary: Most hospital patients have no idea that the resident treating them could be coming to the end of a 30-hour shift. If he is exhausted, the resident’s judgment may be impaired. Yesterday, the union that represents some 13,000  residents and interns nationwide (CIRSEIU),  the American Medical Student Association (AMSA)  Public Citizen, the consumer advocacy organization based in Washington DC, as well as sleep scientists at the Harvard Medical School’s Division of Sleep, announced the results of survey published in BMC Medicine, revealing how little the public knows about residents’ hours.

Sleep deprivation is likely to lead to errors; residents themselves acknowledge that lack of sleep has caused them to make mistakes that harm, and sometimes even kill patients.  Exhaustion also affects how they feel about their patients. In 2008, the Institute of Medicine (IOM) recommended capping shifts at 16 hours, saying that longer shifts are unsafe for patients and residents themselves. The Accreditation Council on Graduate Medical Education (ACGME), the group that oversees the training of physicians in the U.S currently allows resident physicians to work for 30 consecutive hours up to twice per week.  The ACGME has been reviewing the IOM recommendations and is expected to announce its decision later this month.

The problem: residents represent cheap labor. Some say that the ACGME faces an inherent conflict of interest because its board is dominated by the trade associations for hospitals, doctors and medical schools that benefit from the residents’ long hours. Is this true?

Listen to the voices of residents and interns working in this nation’s hospitals:

“Something I have found remarkable about residency is how much it has eliminated the joy I once had for the practice of medicine. In medical school, I thought delivering a baby was incredible. Now, at 4 am, after 20 hours without rest, I find I that I have lost all sense of compassion towards my patients, just wishing they would ‘deliver the baby already,’ and I always find myself shocked the next morning at how insensitive sleep deprivation made me.

“In my exhaustion, I have forgotten to see patients that I was consulted on in the emergency room, I have confused medication orders, I have fallen asleep while standing up, and I once stuck myself with a contaminated needle on the 24th hour of my shift. I also never expected the physical toll that residency would take on me: the middle of the night nausea and chills, the post-call headaches. I don’t understand why doctors are expected to risk their health and the health of their patients in order to learn medicine.”

-Obstetrics & Gynecology resident, New York, New York

“I drive 30 minutes on a busy expressway to get home after 27-hour shifts when I may have slept anywhere between 20 minutes and 4 hours. I am embarrassed to admit that I’ve fallen asleep at the wheel and by some miracle snapped myself awake before getting into an accident. This has only happened a few times, and it has happened less as I do it more often, but it scares me because it seems totally out of my control. No matter how loud I blast the music or how far I roll the windows down, my body wants what it wants. I am embarrassed because I should know better; as a physician I understand that driving with no sleep is as bad, or worse, than driving drunk. And I am embarrassed because I’ve seen patients devastated by injuries obtained in motor vehicle accidents. I realize it is irresponsible to put myself and other drivers at risk. But time becomes so precious during residency that you’ll take risks for it.”

-Pediatrics resident, Bronx, New York

“I was covering the medicine wards as an intern when a very sick patient arrived from the nursing home around 3 in the morning. I had been up all night running around the hospital attending to the usual concerns on a busy hospital service:  admissions every few hours, elevated blood pressures, refill pain medications, follow-up on CT scans done overnight. I was mentally and physically exhausted.

“My team and I wheeled her up to the ICU. Her pulse disintegrated and we began resuscitation. It was then that my emotional exhaustion washed over me. I wished that my new patient would die. At that moment, I cared nothing for my patient, her family, her life. Her living got in the way of my sleep. She was one more name to go on my patient list, one more life to attend to, countless hours I wouldn’t spend in bed.

“Absolute exhaustion elicited by a demanding and disjointed health care system brought out a dark side of me I never want to meet again. That’s the side of a doctor no patient should have to face.”

-Family physician, Los Angeles, California

“What’s it like to work 30 hours without sleep? For me, after about the 15th hour, I become unproductive, although I am still able to perform basic tasks. One area that I find as a surgeon that suffers is the ability to carry out procedural tasks to the same efficiency as when awake and fresh. Post-call, I tend to feel confused in the morning, and very ‘slow’, and I often have to ask people to repeat themselves. I generally have a headache, and my body becomes hypothermic. My eyes ache to close. Yet it is expected that you will work just as well as you did pre-call. In the past, I have made numerous errors in the operating room while post-call. I operated too slowly, and it delayed cases for the attending surgeon. Recently, while post-call, I pulled the wrong chest tube from a patient after

You’ll find these comments in a brochure titled Safe Work Hours/ Safe Patients,  produced by the union that represents some 13,000 residents and interns nationwide (CIRSEIU) and  the American Medical Student Association (AMSA). The two organizations have joined forces to alert the American public to a major cause of medical errors.

Yesterday, they, along with Public Citizen, the consumer advocacy organization based in Washington DC., as well as sleep scientists at the Harvard Medical School’s Division of Sleep, announced the results of a survey published in BMC Medicine, a peer-reviewed online medical journal, which  reveals how little the public knows about residents’ hours.

The Facts about Residents’ Shifts

“More than 100,000 resident physicians in teaching hospitals across the country are routinely scheduled to work shifts of 24-30 consecutive hours, with little or no sleep,” explains wakeupdoctor.org. “They work in operating rooms and ERs, on the wards and in the clinics. And when they are finished working, they get behind the wheel of a car and drive home. After that, they are likely to be back in the hospital for two days of “short” 8 or 12-hour shifts. Then it is another up-to 30-hour ‘on-call’ shift. This brutal schedule can continue for years.”

By contrast, under the European Working Time Directive (EWTD), their counterparts in the UK now work no more than 48 hours per week and shifts are limited to a maximum of 13 consecutive hours.

In the U.S. “one of five resident physicians admits to making a fatigue-related error that has injured a patient, and one in 20 admits to making a fatigue-related error that has resulted in the death of a patient,” observes Dr. Charles Czeisler, who specializes in sleep medicine at Harvard Medical School.

“Working for 24 hours without sleep impairs performance to a degree that is comparable to being legally drunk,” Czeisler adds. “After 24 hours sleep deprivation  affects memory consolidation, and judgment,”  Czeisler noted in a conference call yesterday morning.  Physicians become “fast and sloppy.” At that point, fatigue “degrades performance to the 15th percentile of what rested physicians” are capable of.  When it comes to performance, physicians are “used to being in the 95th percentile,” of their performance range, he adds. “That’s how they got into med school.”

Do we have unequivocal evidence that reducing work hours would reduce patient morbidity and mortality? No. As an article in the 2009 issue of the journal Sleep Clinics points out:  “An increasing body of literature reveals that physician sleep deprivation puts patients and physicians at risk” suggesting that  “rigorous control of work hours  probably reduces trainee medical errors. Research that comprehensively elucidates the effects of work hours, sleep hours, and circadian rhythms has the potential to save lives and money by directing data-driven physician work schedules.” But “the effects of these work hour and work schedule limitations on patient and physician outcomes” still need to be “rigorously followed.

Meanwhile, physicians worry about the errors that may result if residents work fewer hours and more patients are “handed off” from one resident to another. Will the second resident receive all of the information he needs? Would the patient be better off with an exhausted resident who has been checking in on him for 20 hours, rather than a fully rested doctor, who has never seen him before? These are problems that can be addressed: medical schools are already beginning to focus on teaching “the hand-off,” while developing checklists and systems to insure that better communication.

In addition, those who call for shorter hours for residents point out, there are many hand-offs in a hospital throughout the day and night: nurses hand off patients, attendings hand off patients. The answer is not to force residents to work inhuman shifts; the answer is to perfect the art of the hand-off.

Morever, no one is suggesting that a resident cannot stay longer, on occasion, to watch over a patient. But  the resident who is supposed to pick up his shift should also be there, taking charge of the case, while consulting with the tired physician who knows the patient better.

The Doctor Patient Relationship

Finally, as the testimony from the brochure illustrates, what is certain is that exhaustion has an effect on the physician patient relationship. The National Summit on Medical Errors and Patient Safety Research reports: “Many studies have found that fatigue has deleterious effects on moods and attitude. After one night’s sleep loss, mood disturbance increases, anxiety increases and motivation declines. Hostility and anger also rise with sleep loss and are more prevalent in residents at midyear compared to the beginning of residency training.

“As fatigue and exhaustion mounts, physicians begin developing resentment toward patients. Patients also begin to resent the arrogant attitudes that develop in physicians.” Dr. Timothy McCall writes:  “Too few residents emerge from training thankful for the opportunity to practice in a fascinating and intellectually challenging field. Instead, many believe that the world owes them something for what they have been through.”

The ACGME Is Now Considering an IOM Study on Hours

In 2008, The Institute of Medicine (IOM), the non-profit that provides advice on national health issues, recommended further limits including capping continuous shifts at 16 hours. The IOM concluded that longer shifts are unsafe both for patients and for resident physicians themselves.

The Accreditation Council on Graduate Medical Education (ACGME), the group that oversees the training of physicians in the U.S., has yet to implement the IOM recommendations. The ACGME currently allows resident physicians to work for 30 consecutive hours and allows such extended shifts to occur up to twice per week.

In fact, many residents work longer. The Journal of the American Medical Association reports that when residents were promised confidentially 84% admitted violating the 30 hour shifts or the 80 hours a week.    (The fact that residents often don’t comply with the rules complicates tracking the effect of shortened hours.)

The JAMA study notes that at many hospitals, senior physicians disapprove of shift limits, ignoring medical evidence about the effects of fatigue. This, I’m afraid, is another example of older physicians letting custom trump evidence-based medicine.

ACGME has been reviewing the IOM recommendations for limiting resident physician work hours for the past 18 months and is expected to announce its decision later this month.

Getting Patients Involved

Hospital patients have no idea that the residents caring for them are working marathon shifts. This is why (  CIR/SIU) and Public Citizen,  decided to commission a survey, asking Americans how long they think  residents work, and how long they think they should work . The 18 minute telephone survey was conducted by Lake Research Partners, a professional polling company based in Washington and Berkeley, and is discussed here

It turns out that the majority of the 1200 respondents believed that residents work 12.9 hour shifts and 58.3 hour work-weeks. Meanwhile, most felt that these residents should be working shifts that last no longer than 10.5 hours, and that the maximum work week should be 50 hours. When they were told that residents now work 30-hour shifts and 80 hour work-weeks, they were shocked. Eighty-one percent believed that patients should be informed if a treating resident physician has been working for more than 24 hours; 80 percent said they would then want a different doctor.

“The American public realizes that the 19th century practice of scheduling resident physicians to work marathon 24-hour shifts is unsafe for patients,” said Harvard’s Czeisler, who is a senior author of the study.  “The 108,000 resident physicians in the U.S. provide much of the direct medical care in our nation’s teaching hospitals, where more than half of all hospitalized patients in the U.S. receive their care. Implementation of a 16-hour work-hour limit for resident physicians, as recommended by the IOM, is long overdue.”

In part 2 of this post, I’ll consider the $64 billion dollar question: can hospitals afford to cut residents’ hours? Residents, after all, represent cheap labor. On the other hand, can we afford to let them continue to work dead on their feet, raising the odds that patients will be injured?

Should someone other than the ACGME be making the decision?

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much, an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author of the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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19 replies »

  1. Whoever is going to pay you that salary, assuming it’s not the Government, is not less likely to be money and productivity driven than the most profiteering doctor. Actually, while most physicians are very much in this for bigger reasons than money, most physician employers, including non profits are bound to consider money first.

  2. Funny how this has been the system for many years without any great disasters.

  3. Uh, I thought Maggie was actually talking about reducing the “slave labor in training.”
    I got a lot of respect for you old-timers, man – my father, his father, etc…they’re all docs too. And also exhausted. But man, in all their warnings, misgivings, and advice, they were never as nonsensical as you just were.

  4. First, Dr Motew’s last comment started out great and then crashed and burned with his salary comment at the end, which at least Ms G-A came in to close the save with her very nicely stated comment (I must say!). Then, we as readers were saved the endless reply by Ms Mahar to just confuse and abuse.
    But, Dr Motew is so right, I am glad he said this: “you are seriously out of touch with the clincal practice of medicine”. Duh! This blogger isn’t even a practitioner of any kind. And she writes these exhaustive posts that claim she knows what is better for us as doctors.
    Shameful. Not of her, as she will not learn, at least yet. Again, of the owners of this site to allow this ongoing ranting disguised as thoughtful and insightful recommendations to just further destroy what little integrity and ability we have left as doctors.
    And, the focus on putting all in electronic records. Wonder what that will accomplish in the end. Do all the authors at this site get rose colored glasses when they agree to write here?

  5. “I am absolutely in favor of salaried positions and work hours…”
    I am not.
    Whoever is going to pay you that salary, assuming it’s not the Government, is not less likely to be money and “productivity” driven than the most profiteering doctor. Actually, while most physicians are very much in this for bigger reasons than money, most physician employers, including “non-profits” are bound to consider money first.
    I don’t understand why we are in such a big rush to destroy whatever is left of the positive aspects of being a physician, positive for patients that is. Medicine has a long history and rich heritage and it has never been based on profit. In recent times some docs have strayed and have turned into entrepreneurs, so instead of curbing the trend, we are proposing to turn the entire field of medicine into enterprises, not necessarily run by docs. Maybe run by MBAs, with employed physicians working 9 to 5 and having to show contributions to the company bottom line in order to get a raise.
    How is this going to solve anything?
    And why should we accept that if you go to the hospital, you will have to be attended by an unknown doctor? There are still PCPs who manage their own hospitalized patients and I suggest that we make it so they can all do that. If the time is short and the patients are many, let those hospitalists go practice Family Medicine. The sum total of time spent will be equal, but the quality and continuity will be better.

  6. Ms. Mahar,
    I greatly appreciate your attempt to understand the current health care realm, but without any intended disrespect, you are seriously out-of-touch with the clinical practice of medicine, despite what “a doctor told you”. Very few surgeons (and physicians for that matter) are fool enough to work this hard for ‘money’, financially, emotionally and lifestyle-wise it makes no sense.
    I invite you and other policy-based individuals to spend a week with me and learn something. You will notice that my level of hard work and long nights and hours relate primarily to the one or two (usually Medicare or self-pay) ruptured aneurysms or limb salvage patients which I HAVE to (and gladly do) take care of for very little money (total payment about $1000 at best for 90 days of work)…doesn’t even cover my malpractice during that time. I could always do ‘volume-based’ easier procedures for ‘money’, but not only would I be miserable, but access to my services for those who really need it would be severely limited.
    I do not feel pressure at all to ‘do more surgeries’, I do what I have to in order to take care of the patients swamping my office, so offering me a strict salary would be welcomed..it would make my decision very easy..I will work as hard as I possibly can to the level of the salary that I feel is supported, and woe to the patient sitting in the waiting room when my shift is over. Offer me too little, and I will pursue a different pathway.
    I am absolutely in favor of salaried positions and work hours, just be sure to make them commensurate with the true level of training, hours, risk, stress and skill.

  7. Stephen –
    Thanks for youre reply.
    I have been told that attending surgeons often work very long hours. I asked why, and a doctor told me “money.” If you’re paid fee for service, the more surgeries you do, the more he make. He felt strongly that attendings–particularly surgeons– should have a cap on their hours too. Most patients have no idea . . .
    As we move away from fee for service, the pressure to do more surgeries should subside. I’m assuming surgical hospitalists are on salary . . . If, ideally they woudl spend more time talking to patients, sharing decision-making with them, giving them the videos, the pamphlets and time to aborb the infromation, and wind up doing fewewr surgeries. (When fully informed about risks and benetifts at last 20% of patients decide against elective surgery. This isn’t passive informed consent–they’re making an informed choice.
    I understand what you mean by a committed ongoing relationship with the patient. And I agree that trust leads to better outcomes. But more and more I think “trust” between doctor and patient depends on the doctor acknowledging the uncertainties of medicine. And encouraging the patiient to be very open about his hopes and fears–what risks he is and isn’t willing to take.
    NOt long ago, an woman in her 70s said to me: “What happened to The Doctor?” You had one doctor you relied on. He knew everything.”
    Of course today no one doctor can know everything. Ideally, patients would have a medical home, and someone who knows them and their imedical history well. Even so, when they are in a hospital, a hospitalist will be overseeing the case. The hospitalist doesn’t know the patient–and should consult by phone with the patient’s doctor, make sure he has all records, etc.
    But the hospitalist knows how to make the hospital work to the patient’s benefit– who to call to get the lab work, etc. He also is there for 10 or 12 hour shifts (my ideal), so he is much more likely to be there in an emergency. No one can be there 24 hours, so there will always be hand-offs.
    Medicine is changing, which is hard for everyone.

  8. No, Ms Mahar, I am an example of someone who is prime for the challenge to take on the fraudulant commentators like you who think that repeating the lies and misperceptions of someone who does not work as a health care provider will convince the ignorant and easily mislead to buy the failed message this legislation is trying to sell.
    And you do not like respondents like me who just call it as it is. I do not see my replies as paranoia, but just pissed so many of my colleagues once again sold out, as they did when managed care back in the late 1980’s started to significantly destroy health care with their equally unqualified intrusions as non providers.
    So, the fools and naive hopefuls can buy your failed rhetoric that is written by misleading legislators. In the end, the truth will play out, I expect you will have cashed in and basically disappeared from the landscape of failed health care interventions to be that we as realistic providers saw coming now, and once again human nature will look for easy targets for blame when the consequences play out.
    And the idiots I unfortunately have to call colleagues are too busy painting those bulls eyes on the backs of their white coats while agreeing with this legislative onslaught. Residents are just the recent example of failing to accept the realities of what is expected of accepting an MD degree after their names, and they foolishly listen to those outside the profession for direction. They recklessly think that it should be easy to become a doctor. And you want to reinforce that message. Those who do deserve you as a mentor and advisor. Hey doctors in training, careful what you wish for, slave labor in training will prepare you for slave labor by government! Don’t believe me, hey, I just did the exact same thing you are doing just 20 years ago, but you all just continue listening to politicians, out of touch former colleagues in isolated ivory towers, and people figuring out how to cash in on the profit machine that medicine still seems to churn out. Call this paranoia, I don’t care. You are the ones starting on the path. Just pay attention who screams the loudest for you to march aimlessly forward, and seem to sound distant as you near the cliff. They are behind you, but it is not just figuratively, but literally.
    By the way, Ms Mahar, if the truth does catch up with you in 2014 or beyond, how will you twist what is written here now? Being a ploy of government, will they protect you then as they seem to do now?
    Nice attempt at another shot at me though. I am aware of the defenses of those who are out to manipulate and deceive. You do well at validating them.

  9. Maggie,
    Appreciate your points, but a few issues for clarification.
    When looking at hospitalists and primary care, true the 16 hour day is uncommon, however it is quite common for specialists particularly surgeons and cardiologists to maintain long shifts, long weeks and frequent long on-call nights. While this is not ‘justification’, it is reality. The creation of a surgical hospitalists is emerging, and I would suspect will likely improve quality.
    My comment regarding ‘ownership’ of your patient refers to the formation of a professional relationship whereby one develops a deep responsibility for the care and outcome of each patient, as if they are your family for example. This sense of committed responsibility I believe is significantly lessened by hand-offs and shift work. I also believe this relationship improves individual outcomes, tired or not. The question of whether this ‘counters’ the benefits of shorter days etc. is a good one, but as you stated, I don’t see the RCT to look at this either!

  10. Stephen, Adult DayCare and George G, Exhausted MD, Holt Sucks, Elaine, Propensity
    Stephen– When I ask “Do we have unequivocal evidence” the key word is “unequivocal.” It’s hard to provide air-tight evidence that, overall, morbidities would fall if residents worked shorter shifts. (Can you imagine setting up a randomized controlled experiment with half of the patients treated by rested residents and half treated by residents at the tail-end of a long shift–just to see what would happen?)
    But we do have hard evidence of individual cases where exhausted residents killed patients. Did they make a mistake because they were exhausted or did they make a mistake because they were lazy, not as bright as the average resident, distracted because they had a fight with their wife on the phone . . . It’s hard to prove.
    Nevertheless many residents report that exhaustion was the cause–and they don’t see this as an excuse. AS you know, any physician who harms a patient is horrified. Residents feel that they Should have been able to stay alert–they blame themselves.
    Yet we have sleep studies providing clear medical evidence that when working these long hours, residents are impaired. It isn’t really their fault.
    We also know that a fair number of residents have fallen asleep at the wheel after a long shift. Some have killed themselves. Some have killed other people
    In one case, a resident in Chicago was trying to drive home when he fell asleep and hit another car. The driver was a brilliant, beautiful young woman. She survived but with brain damage that left her about as functional as a 3-year-old.
    The resident was sued. CIR (the union) tried to help him, arguing that the hospital that insisted that he work the long shift should share responsiblity. But the judge ruled that while he agreed, the law in Illinois
    said that the resident is a student, not an employee, and thus the hospital is not responsible for his actions.
    CIR is suggesting that if hospitals demand that residents work these very long shifts, they should provide transportation home– much as many companies provide transportation (a car service) if you work past 9 p.m. Form a public health point of view, this certainly makes sense. But it still doesn’t protect the patients in the hospital.
    As for docs in private practice in the real world–I don’t know any whose office are open 16 hours a day.
    Of course docs do receive phone calls at night–but they’re not seeing patients for 16 hours straight.
    And if a patient winds up in the hospital, hospitalists oversee his care (while also consulting with the patient’s doctor by phone.)
    More importantly, the days of the lone-wolf solo practitioner who “owns” his patients are ending. 21st century medicine has become a team sport. No one can know everything they need to know, even in their own specialty. This is one reason why outcomes tend to be better at Accountable Care Organizations and other multi-specialty centers where docs collaborate–and work sane hours. A new generation of doctors tends to prefer working in this environment.
    When it comes to needing to work long shifts, surgeons who do very long surgeries are the exception. They can’t really “hand off” the patient in the middle of the surgery. So I can see why they need to participate in long surgeries while training–though ideally they will be training on virtual patients, not flesh & blood patients. And in real life, I assume that when a surgeon is involved in a 12-hour surgery, he is assisted by other surgeons who can back him up if he is exhausted. . .
    The public poll that CIR did shows that when patients find out the hours that residents are working they definitely would prefer to be “handed off” to another physician.
    George G & Adult Daycare– Thank you!
    Exhausted M.D.– I guess you serve as evidence of what happens to a person who is deprived of sleep over many years. Paranoia sets in.
    I like doctors. I have friends who are doctors. Many read my blog.
    Here, you seem to miss my point– I am defending young doctors-in-training, and suggesting that hospitals abuse them by using them as cheap labor. As residents and doctors responding to this post on my blog (HealthBeat) have pointed out, residents often spend quite a bit of time doing things that non-doctors could do–if the hospital was willing to pay for more clerks, etc. Many of these tasks have nothing to do with their medical education.
    Rose– Your story about a resident breaking down is not as uncommon as people may think . . . Of course, it’s not common, but the stress combined with exhaustion takes a toll on mind as well as body.
    Elaine– I agree: attending physicians should not be working these long hours either. As you get older it’s that much harder to function with too little sleep. (I know.)
    But part of the problem is that we have too many patients in our hospitals who don’t need to be there.
    Some are undergoing unnecessary angioplasties, back surgery, etc. (See all of the studies in peer-reviewed medical journals regarding surgeries that provide no benefit to patients.) Some are undergoing elective surgery without full appreciation of the risks as well as benefits. (When patients go through a “shared-decisoin-making” process and really understand risks, benefits and odds, reserarch shows that at least 20% decide not to have the surgery.
    Then there are the patients who show up at the ER with a problem that isn’t really an emergency . . .but someone makes the decision to admit them, “just to be safe,” or because the hospital administration has been making it known that they need more admissions. (A doctor recently told me that the CFO at his hospital told docs at a staff meeting: “IF each of you could just admit one more Medicare patient each month, we’d be making money.)
    Then there are the preventable re-admissions.
    And the patients who wind up spending more days in the hospital because they acquired an infection or fell victim to a medical error.
    I’m hopeful that under Medicare reform, successful pilot projects that focus on patient safety will begin to be implemented nationwide. Surgical checklists, a campaign that focuses on hand-washing,analysis of errors which reveals what about the system needs to be fixed . . This will shorten hospital stays.
    Medicare also is going to stop paying for an excessive number of preventable re-admissions. Already, the hospitalist association is working on procedures –both when a patient is admitted and when he is discharged–aimed at reducing re-admissions.
    I’m also hopeful that Medicare will begin to pay doctors for the time it takes to “share decision-making” with patients who are considering elective surgery. And I think it’s likely that Medicare will pay more for palliative care. Too many patients die in ICUs or hospital beds who, if given a choice, might well have chosen getting palliative care or hospice care in their homes. No one ever told them what their options were. No one wanted to talk to them about dying. Palliative care specialists are trained to do this.
    And I know that Medicare will be rewarding more efficient hospitals that avoid unnecessary tests and procedures. . .With more publicity in the media, patients also may begin asking more questions about angioplasties, back surgery, treatments for prostate cancer that carry the risk of life-changing side effects.. . vs. “watchful waiting.”
    Finally, the reform legislation provides funding to double the capacity of community clinics. Patients will need to learn to go to those clinics (that will be open “after hours”) rather than to ERs. This will reduce unnecessary hospital admissions (not to mention relieving crowding at ERs.) With more clinics available, ER nurses and docs can direct non-emergencies to these clinics. People with a sore throat don’t belong in an ER–even if it’s strep. A clinic can diagnose and treat strep throat, an ear-ache, etc.
    What I’m suggesting is that there should be fewer patients in our hospitals. Those who need to be there would get better care, and nurses and docs will find working conditions much improved.
    Especially in poor neighborhoods understaffed hospitals where residents work long hours–often unsupervised– should be replaced with clinics that can serve as medical homes for patients. If a patient needs to be hospitalized, he may have to be transported out of his neighborhood, but if that means he winds up at a fully staffed private hospital with more resources in an more affluent part of town, he’ll be better off.
    Finally the legislation provides loan-forgiveness and scholarships for nursing students as well as higher pay for teachers in nursing schools. They should increase the supply of RNs and NPs who will help staff those clinics.
    Propensity– Agreed. Though I’m hopeful that new improved open-source VistA software may turn out to be the answer. Unlike proprietary software, users can refine it. And its software that was created “by doctors for doctors.” It is, as Margalit suggests, “clunky,” but its being refined by the VA so that it can “talk” to other systems. And there is a company (run by the doctor who overhauled the VA in the 1990s) that provides excellent support. See my post on the VA and Memorial Day on this blog.

  11. What may be worse than extended hours for residents is the harsh reality they will face in a busy private practice without residents where they may be required to cover their patients for extended hours and are woefully unprepared to do so.
    Please recognize the key sentence from Maggie’s post:
    “Do we have unequivocal evidence that reducing work hours would reduce patient morbidity and mortality? No”
    So do we just make evidence-based decisions when it is convenient?
    I agree that I am more cranky, bitter etc. after a long call night, but the rigorous training with long hours that I endured has provided the knowledge of my limitations and taught me when to ask for support or to “sleep it off”.
    The unreasonable expectations of physicians entering the real world may likely cause workforce issues as they seek unrealistic positions and work hours. We are seeing this in our recruitment for surgical positions right now.
    I do agree that shift works make some sense, however the patients must accept that they are going to be evaluated, operated-on and followed by different physicians. The most harmful aspect of this is the loss of ‘ownership’ and responsibility for the patient, which to me is a driving force for quality, attentiveness and caring.

  12. I certaly agree – I find that lack of sleep in my business causes a huge impact on my productivity and if I don’t get enough sleep, I make errors. Can’t even imagine the impace to hundreds of interns without sleep. Greta post and lots to think about.

  13. Maybe no one else has the guts to go out on a limb and make the accusation, but I will, because the documentation at this site certainly supports the following until something else follows of credibility and irrefutability: this woman is out to demonize and vilify physicians, and I for one will not just sit here and read these weekly attacks without a rebuttal.
    Ok, oh brillant and accurate poster Ms Mahar, so you want to change the call system for residents, but as you allude to in this post, what about the attendings who also have call demands and don’t have unions or employers to answer to? How do doctors who live in the real world, not the one I can’t account for that you live in, learn how to adapt and cope with the call demands this culture expects, and I feel equally acts entitled to regarding 24 hour health care needs?
    Have you ever been on call as a health care provider, Ma’am? It isn’t the same as being on call as a tow truck operator, or plumber, or hospital administrator. You get woken up after 11PM to make decisions that could dramatically impact on people’s lives, literally, and there ain’t anyone else to just simply switch it over to when you are having a tiring day. So, this is what training is about, not just the ins and outs of medical care of didactics, but the physicality of being a doctor, one who is on the front lines of providing care. But, again, from someone who isn’t doing this kind of work, it is easy to be critical and offer quick fix solutions that haven’t come to fruition before you and other meddling non providers want to dump on us to adapt and apply, eh?
    I read this site less now not only because the postings are just reinforcing the silicon solutions of internet and computer applications, but these lame and falsely leading provider criticisms that don’t really offer solutions, just bashing and inconsistent critiques.
    Well, as I read elsewhere earlier today, I think the letters to the editor at USAToday who ran an article earlier this week about this matter of residency call hours, when the new 30 million people who access health care because of this wonderful legislation half assed thought out by, again, non provider legislators, this will create less demand and relax providers further?!
    You don’t think out this crap when you champion for your party line, do you, Ms Mahar!!!???

  14. People used to think I was joking when I’d say I chose nursing school over medical school because I knew I’d kill someone when I was sleepy. I never was.
    I know myself well enough to know how utterly useless I am when tired. And I experienced it while working 16 hour shifts in the ED at the beginning of my career.
    While working in that same ED, I witnessed one of the surgical residents have a psychotic break and be admitted to our mental health unit after working about 60 hours straight.
    Please, can any doc, or doctor’s organization out there defend these practices? I think not.

  15. Maggie,
    Thanks for this post on an important subject. I agree completely that residents’ doctors should be limited and admire the European model with 13 hour shifts and 48 hour work-weeks that allow residents’ time for sleep, family, exercise and maybe even some reading.
    The emerging problem is this: as the laws here (in the U.S.) restrict work hours of residents (and fellows, who are considered as such, at least in New York), attending physicians need cover more and more inpatient work. That creates sleep/stress issues for older doctors, whose responsibilities and hours are for the most part unrestricted.

  16. Cheap, tired residents combined with attendings who abdicate their accountability using user unfriendly flawed HIT equipment is not a good recipe for safe and effective medical care.

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