Sleep-Deprived Doctors

August 16, 2011 11:31 PM

The Phantom Menace of Sleep Deprived Doctors: Young doctors are no longer working long, stupor-inducing hours. So why aren’t hospitals any safer?
posted by homunculus (72 comments total)

Because they are still working the same number of hours. This rule change is not being enforced at all.

Resident: "Hey Attending, I just hit my hour limit for X period."

Attending: "You know that if you tell me that, I have to send you home right?"

So next time the resident doesn't say anything. The culture of medicine has not caught up with this policy yet. Another issue is getting the required number of surgeries if you are a surgery resident. Surgery residents don't want to go home, because they might miss a surgery needed to fill up their report card.
posted by Drama Penguin at 11:45 PM on August 16, 2011 [14 favorites]

And the article says as much: There are several possible explanations for the failure of the nationwide 80-hour rule to reduce medical harms. In 2008, the journal Pediatrics reported that two-thirds of residents regularly broke the rule, suggesting that poor enforcement, perhaps related to ingrained norms, had undercut the reform.
posted by Gyan at 11:57 PM on August 16, 2011 [1 favorite]

I have to wonder how many people are put off being doctors by residency. I mean, you spend years of the best part of your life completely exhausted and miserable, and if you screw up because of that you might kill an innocent person. Oh, and there's really no good reason for it aside from tradition and cheap labor. It's as if auto mechanics had to arbitrarily do an Ironman while carrying a baby before they started out in their career.
posted by Mitrovarr at 12:00 AM on August 17, 2011 [43 favorites]

Next week in the New York Times:

The Attack of the Clones: Generically engineered supersoldiers on the battlefield.
posted by 2bucksplus at 12:05 AM on August 17, 2011 [7 favorites]

Oh, and this would be easy to fix - make it so that any resident who's worked over 50 hrs/week is legally considered to be slightly drunk (BAC of .08), and anyone who's worked over 80 hrs/week is considered to be very drunk (BAC of .16). The effects are similar enough for it to be reasonable. If the hospital recorded any hours worked over these values they'd be on the hook for any mistakes that were made, since they're be admitting they knew they had unsafe workers and didn't do anything about it.
posted by Mitrovarr at 12:32 AM on August 17, 2011 [14 favorites]

There are several possible explanations for the failure of the nationwide 80-hour rule to reduce medical harms. In 2008, the journal Pediatrics reported that two-thirds of residents regularly broke the rule

The book Sleep Thieves covered this several years ago. Even following the guidelines, it's still not enough sleep, and the guidelines still allow marathon shifts.
posted by benzenedream at 1:08 AM on August 17, 2011 [2 favorites]

I assume hospitals have enough electronic access controls on doors, cabinets, and computers that systematic auditing of work hours would be trivial to implement.
posted by ryanrs at 1:12 AM on August 17, 2011 [1 favorite]

I mean, you spend years of the best part of your life completely exhausted and miserable, and if you screw up because of that you might kill an innocent person.

When my ex-wife went through her residency at Grady Memorial Hospital in Atlanta, it was a grind house. As I remember it, she used to clock up 50 hours in three days. She was certainly exhausted, but hardly miserable.

In one way, residency can be seen as an accelerated period of necessary training. After four years of medical school most graduates are utterly unprepared to take responsibility for patients and to manage patient care. That's what internship/residency is for. You need ten thousand hours of hands-on training before you can fly on your own in any speciality. The faster you rack up those hours, the faster you can "begin" your career.

Long shifts also are supported by the argument of continuous patient care: it helps to see what happens every hour of the 48 hours after you admit a patient from the ER. It also generally helps the ER patient to have one doctor responsible for the first 48 hours.

Residency also puts you under tremendous personal stress which is itself very useful in learning how to be a doctor. If you cannot handle stress, if you cannot learn how to work under literally life and death stress, you can't really be a surgeon can you?

Dealing with patients (who are actually fellow human beings held at arms length) is an emotional as much as technical skill and residency stretches the bounds of both.

Also finally, at least so far as Grady Memorial Hospital was concerned and as a practical matter in most hospitals not to be overlooked, residents provide the basic health care for thousands of poor people who have nowhere else to turn. Cut back on the hours residents are required to work and you cut back on the availability of medical care for many inner city residents.
posted by three blind mice at 1:25 AM on August 17, 2011 [8 favorites]

Residency also puts you under tremendous personal stress which is itself very useful in learning how to be a doctor. If you cannot handle stress, if you cannot learn how to work under literally life and death stress, you can't really be a surgeon can you?

What does this have to do with sleep deprivation? I mean, stress hormone levels are all out of whack in sleep deprived individuals, but I don't see how fucking with someone's cortisol levels amounts to training.

Generally, to train people to function in high-stress situations, you drill repeatedly, developing muscle memory and reflexive responses. Sleep deprivation is bad for memory formation, too, so it seems ill-advised to deprive someone in a repetitive-drilling type training situation of sleep.
posted by mr_roboto at 1:59 AM on August 17, 2011 [23 favorites]

I can say that I didn't go to medical school because of the residency hours, and only because of the residency hours. So it's anecdata, but, you know, there's one. I've worked in a bunch of related fields instead.

I think this is really misleading. All it really says is, "Doctors are sleeping better, but hospitals still have stupid old practices that assume they're never going to leave and therefore they never have to tell someone else what's going on. As a result, with residents occasionally *going home*, now we've got all these problems with them not knowing how to do hand-over, and nobody else knowing how to teach them."

And then a few people use that to justify why they're cranky that the new generation is limited to "only" 24-hour shifts (WTF) and such. No. You're just managing your hospital in a sucky way. How do you think they manage it with nurses? Get the information out of the provider's head and into the records system. Record everything. Don't leave it up to someone to remember after a 24-hour shift to tell the next guy something that happened 20 hours ago. Get them to make a record of it at the time, every time. Make it easy enough that they'll do it. Don't make a tired resident's brain act like a filing cabinet when it's supposed to be a finely-honed treatment machine. Granted, the nurses have enough trouble, when it's paper. (I don't blame them, I can't even read my own handwriting half the time.)

This is basically what EMR got invented for. What future is this we're living in, where we have people using little touch screen computers everywhere to download Angry Birds over nearly ubiquitous wifi, and yet we're still having medical errors because vital information is stored on unreadable paper or even-less-readable gray matter?
posted by gracedissolved at 2:01 AM on August 17, 2011 [30 favorites]

You know you all act as "Doctors" in one capacity or another to your family, friends, and peers. So let's all not "boo-hoo" when one can put in a certain amount of work to be deemed "Doctors" by the whole of society. IT'S HARD WORK.
posted by coolxcool=rad at 2:05 AM on August 17, 2011

The problem with your argument, Three Blind Mice, is that you can pretty much turn every aspect of it around if that's what suits you.

The faster you rack up those hours, the faster you can "begin" your career. - and the less effective your training is, having dealt with fewer patients and situations than if it were more spaced out. This is borne out by:

the argument of continuous patient care - which (aside from the fact it is merely asserted here) surely is an argument for better communication between doctors, not less doctors doing the work.

Residency also puts you under tremendous personal stress which is itself very useful in learning how to be a doctor. - The pressure of long hours is not the only stress to which doctors are exposed. You might as well argue that the best way to train tennis champions is to expose them to 50 hours over three days. After all, they are exposed to very stressful situations. It also means that our doctors will be selected from a very limited range of personality types, something which may well lead to worse care.

Dealing with patients (who are actually fellow human beings held at arms length) is an emotional as much as technical skill and residency stretches the bounds of both. - Again, it's pretty obvious that one can test skill and resilience in circumstances that don't involve insanely long hours.

residents provide the basic health care for thousands of poor people who have nowhere else to turn - You could easily turn this on its head. "The poor make excellent lab-rats on which to train exhausted doctors, at an acceptable rate of attrition caused by negligence induced by exhaustion".

I'm not saying that your arguments are without any validity, but I'm not sure that they add up to a strong enough case for inducing an inherently dangerous state of affairs in hospitals by having such a significant proportion of staff exhausted.
posted by howfar at 2:08 AM on August 17, 2011 [7 favorites]

I know residents. Current residents. The rule, while not perfectly enforced, is still adhered to more often than not.

The problem is that sleep deprivation was never the biggest source of medical error. A source, certainly, but not the big one.

The article mentions this.
posted by valkyryn at 2:15 AM on August 17, 2011 [1 favorite]

You mean it's not all like on "Scrubs"?!
posted by chavenet at 2:48 AM on August 17, 2011 [1 favorite]

An 80 hour limit? We have so many acres of research suggesting that productivity in less complex/stressful fields (like programming) tops out around 50 hours/week, and it's considered progress to limit doctors to "only" 80?

No wonder they aren't seeing an improvement.
posted by rodgerd at 2:55 AM on August 17, 2011 [12 favorites]

Yet another thing that George Lucas has destroyed. I just don't get that man's obsession with having young kids doctors as comic relief.
posted by Foci for Analysis at 3:24 AM on August 17, 2011

Drivers may drive up to 11 hours in the 14-hour on-duty window after they come on duty following 10 or more consecutive hours off duty.

The prohibition on driving after being on duty 60 hours in 7 consecutive days, or 70 hours in 8 consecutive days, remains the same, but drivers can "restart" the 7/8 day period anytime a driver has 34 consecutive hours off duty.

But doctors can still work 16 hour days and 80 hour weeks? You're kidding.. right?
posted by Ahab at 4:08 AM on August 17, 2011 [2 favorites]

One of the residency administrators sent this article around the email loop. The old-school types, who all think the Institutes of Medicine and ACGME are full of coddling commies, took great delight.

This reaction has been so maddening to me, I haven't been able to rationally digest the contents and implications yet.

Residency is necessary. Murderous hours are not. Whatever staying up 36 hours was supposed to be, it wasn't an educational experience. It was able practice in avoiding work. If the work was at all reasonably close to starting or quitting time, you could make it seem like it was the previous or next guy's job. If there was an ER guy waffling on whether to formally consult you, you'd convince him the patient was fine and/or faking. Solutions to patient issues in the middle of the night are literally a band-aid on the problem.

One grows to hate his patients at around 03:00am. That was an educational experience. Never mind "go the fuck to sleep."

In contradistinction to another commenter's wife, I felt both tired and miserable during most of my residency. The part of residency where I didn't feel tired and miserable was the part where I wasn't on-call, where I worked only 40-50 hours per week. As they say, "your experience may differ."

If I had to do the whole thing over, I wouldn't. Medicine isn't so lucrative. I know it's just a few years before a full career. One plows through because you're pot-committed. They don't even allow you an automatic deferral on your student debt while you're in residency anymore. Every year, you have to prove "economic hardship," as if it were easy for anyone making $45k to make a $1500-2000 payment each month on top of rent, food, and car. During those months when you're on call a lot, working erratic hours, those bills and forms and whatnot will probably be ignored or forgotten unless you've got an SO. Residents primarily have other residents as friends because those are the only people they interact with besides patients.

I did my internship at a place that was pioneering max-16-hour shifts for all its residents. Our handoffs were excellent by discipline and experience. Then I went to my residency, where they did traditional 30-hour calls. That morning after my first call, I had a microsleep while driving down the highway. No crash, no injury, but I had to pull off and try to nap (which I couldn't, because I was so jittery and disturbed). When I brought this up recently to a group of recent residency graduates, more than half had a story about car damage or near-misses involving sleeplessness.

So my main reaction is: if hospitals are just as safe with residents working fewer hours, and (although I don't think this is touched on) board passing rates haven't changed, then what is the usefulness of an overworked residentariat anyway? Seems like it was superfluous. Then it's not the phantom menace of sleep-deprived doctors, it's the bogey of the underworked house officer.
posted by adoarns at 4:16 AM on August 17, 2011 [23 favorites]

Ultimately, though, the jury believed that Libby Zion had used cocaine and should have told doctors about it. At the same time, the jury faulted Drs. Sherman, Stone and Weinstein for prescribing Demerol. In addition, Weinstein, who was responsible for 40 other patients that night, was found negligent on two more counts: for not prescribing cold soaks in timely fashion when Libby's fever rose dangerously, and for not returning to Libby's bedside when called by a concerned nurse.

The idiotic residency hours limitation was borne out of the inevitable death of a coddled rich-kid junkie whose journalist daddy was in denial about why his daughter died. Cold soaks and hand-holding won't bring anyone back from a fatal cocaine overdose, sorry.

It was an ill-conceived idea and I'm glad programs are waking up to the fact that it doesn't make a difference.
posted by Renoroc at 4:36 AM on August 17, 2011 [3 favorites]

According to the article here, written by a doctor (and not a jury of laypeople), she died from serotonin syndrome.

They didin't know that she was ODing on cocaine anyway, so the lack of treatment was not attributable to the abhorrent "LOL junkie whatevs" attitude that you're displaying here.
posted by the young rope-rider at 4:50 AM on August 17, 2011 [5 favorites]

Saying something is the "Phantom Menace" of something is pretty harsh criticism. I'd only reserve that label and title for the absolute worst of things in life - like Hitler or Gwyneth Paltrow's blog. Just saying, you can't throw these words around...there's power behind them.
posted by Fizz at 4:53 AM on August 17, 2011 [1 favorite]

Just saying, you can't throw these words around...there's power behind them.

I guess, but the prime examplar of said power was also kind of a whiny little bitch.
posted by valkyryn at 5:15 AM on August 17, 2011

Didn't the article say basically the opposite? That mistakes are happening because of inadequate supervision and controls, and not because of sleep deprivation?
posted by gjc at 5:39 AM on August 17, 2011

I have to wonder how many people are put off being doctors by residency. I mean, you spend years of the best part of your life completely exhausted and miserable, ...

Well, they have TONS of potential romantic partners falling at their feet. They can date and marry whomever the heck they want. Ego is a powerful thing.
posted by Melismata at 5:39 AM on August 17, 2011

@young-rope rider: Serotonin syndrome is a potentially life-threatening adverse drug reaction that may occur following therapeutic drug use, inadvertent interactions between drugs, overdose of particular drugs, or the recreational use of certain drugs.

She had serotonin syndrome due to cocaine intoxication. She died of cocaine abuse, not due to medical error. The elevated temperature (103F) she presented with is often seen in acute overdoses.

The more you know....[cue star]
posted by Renoroc at 5:41 AM on August 17, 2011 [1 favorite]

Did they mention any other big causes of medical errors? Like, for example, sociopathic janitors posing as doctors?
posted by indubitable at 5:43 AM on August 17, 2011 [2 favorites]

The places that have tried really hard at getting work hours right (eg Mayo) seem to have done a good job focusing on handoffs and documentation, which should have been happening anyway. I've heard really positive things about their system from residents and fellows. They've also acknowledged that three things didn't change 1) the amount of patient care required 2) the amount of money you get 3) the number of residents you have. As a result, you have to change a little how your non-teaching service works. On the other hand, Mayo has really smart people and lots of money to work with; they had a low error rate anyway.
posted by a robot made out of meat at 5:50 AM on August 17, 2011 [3 favorites]

You know you all act as "Doctors" in one capacity or another to your family, friends, and peers. So let's all not "boo-hoo" when one can put in a certain amount of work to be deemed "Doctors" by the whole of society. IT'S HARD WORK.

I "honestly" don't "understand" a word of this comment.
posted by (Arsenio) Hall and (Warren) Oates at 6:03 AM on August 17, 2011 [10 favorites]

She had serotonin syndrome due to cocaine intoxication. She died of cocaine abuse, not due to medical error. The elevated temperature (103F) she presented with is often seen in acute overdoses.

Renorac, even the People article you quoted says that the jury "faulted Drs. Sherman, Stone and Weinstein for prescribing Demerol. " plus the two other mistakes that you already mentioned.

What you're doing is basically excusing multiple medical errors based on the fact that you don't like the victim. That's pretty shitty and completely orthogonal to the point at hand, which is that sleepy doctors--like sleepy people everywhere--make more mistakes. That's not the only reason that they make mistakes, but that doesn't make it okay.
posted by the young rope-rider at 6:05 AM on August 17, 2011

(Sorry for misspelling your name)
posted by the young rope-rider at 6:06 AM on August 17, 2011

Interesting article; it seems that people are still focusing on the work hour issue at the expense of other problems brought up in the article. The fragmentation of medical care is a big problem (and one that socialized medicine would go a long way toward solving). Adequate supervision of residents is another; although resident work hours are limited (and despite what others have said in this thread in my experience they are taken seriously by teaching hospitals) the attending physicians supervising them have no such protections. In many cases the attendings are working harder to take up the slack left by residents being limited by work hour restrictions (in our OR today we have had to make adjustments because the resident on call worked late last night and is unavailable today). Also, those protections vanish as soon as the resident finishes their training, and there are certainly doctors in private practice who work long hours, sometimes for the additional income, sometimes because there is no one to cover for them. In fact, this is one of the difficulties in recruiting physicians to rural, underserved areas; they will be practicing alone which basically means they are on call 24/7/365 unless they hire a locum tenens to cover for them while they take vacation (which isn't cheap).

Electronic medical records have been touted as a solution, but in many instances they are cumbersome to use and cause more problems than they solve. When one childrens hospital adopted EMRs several years ago, death rates in the ICU and ER went up. It turns out that in an emergency situaion, having to turn your attention from the patient to enter information in a computer delayed adminstration of vital drugs long enough to make a negative impact. We are attempting to go paperless at our hospital, but there are a number of hurdles, not least the fact that the software is expensive and hard to maintain and it requires literally tens of thousands of computers be made available to everyone involved in patient care, all at a time when the state and federal government are cutting funds for Medicare, Medicaid, and medical education in the name of cutting deficits without raising taxes.

The fact is medical errors come from a variety of sources. Although a lot of attention has been paid to resident work hours, most people in this country get their care in the private sector where there is much less regulation. There are a lot of potential solutions out there, but it would require major reform of the way health care is delivered in this country, and we have seen how well that goes.
posted by TedW at 6:19 AM on August 17, 2011 [5 favorites]

She had serotonin syndrome due to cocaine intoxication. She died of cocaine abuse, not due to medical error.

Funny, all the source I can find said it was the combination of phenelzine and demerol that killed her, and that the tests for cocaine were faulty, and the more comprehensive follow up tests performed by the ME after her death showed no traces of cocaine. It is very clearly accepted in the medical world that cocaine played no part in the death of Libby Zion.

It's sad, and sadly common, that the moment an illegal drug was mentioned, you immediately convinced her and sentenced her to death.
posted by eriko at 6:23 AM on August 17, 2011 [10 favorites]

Also: most people in the country aren't treated by residents anyway, so even if sleep-deprivation in residents was a major cause of medical error, it would only affect a fraction of patients.
posted by valkyryn at 6:31 AM on August 17, 2011

We're #1!
posted by schmod at 6:37 AM on August 17, 2011 [1 favorite]

not least the fact that the software is expensive and hard to maintain and it requires literally tens of thousands of computers be made available to everyone involved in patient care, all at a time when the state and federal government are cutting funds for Medicare, Medicaid, and medical education in the name of cutting deficits without raising taxes.

To be fair, there is some federal money available under the HITECH act as increased Medicare and Medicaid reimbursement for achieving meaningful use of EMRs, just not enough to cover the actual implementation costs. And of course in 2015 that carrot turns into a stick in the form of reduced reimbursement for not implementing.

In any case, I tend to agree that EMRs are not the silver bullet they're sometimes portrayed as: the technology is at least another decade away from reaching maturity, hospitals tend to be terrible at managing complex IT implementations, and there's not many other areas where poor user interface design can actually kill somebody.
posted by strangely stunted trees at 6:45 AM on August 17, 2011 [1 favorite]

if sleep-deprivation in residents was a major cause of medical error, it would only affect a fraction of patients.

Well that's fine then. Particularly as they're disproportionately likely to be poor!

But seriously, valkyryn, is your argument that the benefits of the residency system outweigh its costs? We're going to need a bit more data and a little less anecdote before we can settle that one, surely? Medicine is the only field which regards such long hours as a necessity for training (as opposed to the exploitation of young professionals which occurs in most fields). Extraordinary claims are typically seen as requiring extraordinary proofs. If you're going to persuade people that such long hours are fine, you're probably going to need more than assertion.
posted by howfar at 6:52 AM on August 17, 2011 [1 favorite]

At my institution, work hour restrictions are pretty well enforced, and from the attending physician's perspective (mine), sometimes maddeningly so. Enforced by both admin and of course the residents themselves. It's a pretty regular occurrence that we'll have some critically ill patient we've been working on all night and then 7 am rolls around and suddenly the resident who knows this case is abruptly off and the care is passed to someone just coming on, who is in a conference room hearing about 20 other patients for the first time. You can imagine, as the article alludes to, the kind of lapses that occur during this hand off -- it usually takes about 4 hours for the new person to put out the emergency fires on the other guys and getting up to speed on the critical one. Last week, I was the ward attending (we do one week at a time), and I had this one guy who was basically trying hard to die in the ICU all week, and he was cared for by seven different residents, each in 12 hour blocks. What actually happened is that I took care of him all week myself, and the residents missed out on the learning and experience of an evolving critical illness.

The point about EMRs fixing this hand off problem is a bit simplistic. What's happening now is that everything *is* being documented and users of EMRs are lost in a sea of information. I look at screens full of numbers with dozens of exclamation points, pop up warnings that I have to click to ignore so I can get to what I really want to look at. Medical information is complex and so far (I've been involved in EMR implementation and have looked at and worked with dozens of EMRs), there just isn't a system that organizes and prioritizes information better than a human brain.

That's not to say that I oppose work hour restrictions. The data about judgement errors and sleep deprivation is compelling and irrefutable. But until EMRs are really perfected, until we train enough physicians to cover the real work load, and until we come up with uniform comprehensive access to health care, there is a huge amount of mental and emotional stamina in being a physician. We might want our doctors to be clear headed, well rested, and relaxed (Christ how I would like to be these things!) but a lot of things need to happen before we get to this point without causing more medical errors. I'm glad for work hour restrictions because I don't think anything would change if we continued to place the inadequacies of the system on the backs of overworked doctors who trained in these insane systems and expect future generations to do the same. But this is a sea change in health care and the rest of the system hasn't really finished adapting yet.

I still worry that my residents aren't getting enough real experience before they graduate, but like information systems, and hand offs, this is something that needs to be worked out, and we don't know what the end result will look like.
posted by Slarty Bartfast at 7:05 AM on August 17, 2011 [20 favorites]

Airline pilots have it so easy: "Current FAA regulations for domestic flights generally limit pilots to eight hours of flight time during a 24-hour period."
posted by mrhappy at 7:53 AM on August 17, 2011

What does this have to do with sleep deprivation?

Doctors have to do stuff post-residency in the middle of the night on very little sleep, so you have to get used to doing that sooner or later. If you've only ever practiced medicine when you're well rested, that's the only time when your medical decisions will be reliable. And since you can't rely on that during your career, you might as well get used to it.

I have to wonder how many people are put off being doctors by residency. I mean, you spend years of the best part of your life completely exhausted and miserable

Meh. I have known a lot of young people in my day, and I can't say I've been particularly impressed with what they did with all of the "extra" hours they had available because they weren't medical residents. I mean, does anyone really say, "I would become a doctor, but residency would really cut in to my opportunity to go to shows, attend happy hour after work, and catch up on my knitting"? I kind of understand if someone wanted to get married and have children at a young age being put off by residency, and I kind of understand why someone wouldn't want to go into a really hours-heavy specialty, but other than that?
posted by deanc at 8:38 AM on August 17, 2011

But until EMRs are really perfected, until we train enough physicians to cover the real work load, and until we come up with uniform comprehensive access to health care, there is a huge amount of mental and emotional stamina in being a physician.

Since there's actual doctors in this discussion, what is the story behind the "doctor shortage"? I've seen lots of people comment that it's a deliberate decision by "the medical establishment" (whoever that is) in order to keep doctors rarer and therefore more valuable. I've seen others say that Those Kids Today just aren't interested in working hard, and so on.

I know that on the nursing end, my mother in law, who is a nurse, has told me it's hard to train enough nurses because of a teacher shortage; once someone is a nurse the relative low wages of teaching nursing don't appeal next to professional nursing, thus less teachers, smaller schools, and eventually, fewer nurses.
posted by emjaybee at 8:41 AM on August 17, 2011

The idiotic residency hours limitation was borne out of the inevitable death of a coddled rich-kid junkie whose journalist daddy was in denial about why his daughter died. Cold soaks and hand-holding won't bring anyone back from a fatal cocaine overdose, sorry.

It was an ill-conceived idea and I'm glad programs are waking up to the fact that it doesn't make a difference.

Are you seriously suggesting that a single anecdotal case was the entire basis for the idea that sleep deprivation results in undesirable performance impacts? You must know that's ridiculous, and that there are mountains of data to support that conclusion.
posted by odinsdream at 8:52 AM on August 17, 2011

deanc: Meh. I have known a lot of young people in my day, and I can't say I've been particularly impressed with what they did with all of the "extra" hours they had available because they weren't medical residents. I mean, does anyone really say, "I would become a doctor, but residency would really cut in to my opportunity to go to shows, attend happy hour after work, and catch up on my knitting"? I kind of understand if someone wanted to get married and have children at a young age being put off by residency, and I kind of understand why someone wouldn't want to go into a really hours-heavy specialty, but other than that?

So basically what you are saying is that you cannot understand why anyone would want to have anything in their life aside from work? Since apparently nothing of value or interest exists anywhere else in the world...
posted by Mitrovarr at 8:52 AM on August 17, 2011 [10 favorites]

There are 168 hours in a week. Why are these "doctors" wasting half of that? We should be doubling their work hours! Or don't they care about their patients?
posted by blue_beetle at 9:10 AM on August 17, 2011

It was an ill-conceived idea and I'm glad programs are waking up to the fact that it doesn't make a difference.
posted by Renoroc at 4:36 AM on August 17 [1 favorite +] [!]

Reverse masking won't help... of COURSE a coroner is all about more medical mistakes that lead to extra dead bodies! It's good for your business!
posted by FatherDagon at 9:12 AM on August 17, 2011 [3 favorites]

In general: ask your residency director, today, for the scientific studies demonstrating the old residency training program to be effective.

This isn't a joke: you'd think that if a training program was going to ask for 120/hr weeks, they'd be doing so because of something like:
- (a) they'd previously tried 80/hr weeks
- (b) but their trainees weren't passing objective competency tests
- (c) so they went to 120/hr weeks and their trainees' scores on those competency tests improved

...but they can't, b/c there are no such studies (and rarely such objective competency tests, either).

Which, again, is the point: if your physician suggested a treatment as medically necessary, you'd expect them to have some objective evidence they could point to for why they had that opinion; when it comes to residency programs that standard goes out the window and it's all gut feelings, tradition, and operational requirements of the program (eg: how much labor it needs from its residents).

If there's a scientific case for the 120 hour week then surely someone would've made that case by now?
posted by hoople at 9:13 AM on August 17, 2011 [3 favorites]

deanc gives a nice example of an empirical-looking claim that could stand actual investigation.

Specifically: "If you've only ever practiced medicine when you're well rested, that's the only time when your medical decisions will be reliable."

It sounds plausible, but is it true? We need not sit around flapping our gums at each other for a question like this.

Has anyone done the studies to actually check that fact?

EG: Train group A and group B on some elaborate task. Group A only trains when rested. Group B is trained after being kept up for 24 hours. Give them a month or so's rest, then keep group A and group B up 24 hours and measure their performance on the task.

Does B *actually* do better than A?

If so, how much better?

How few sleep-deprived practice sessions can B get away with while still doing materially better than A?

Is this effect skill-specific -- Group B would have to do sleep-deprived practice sessions for each specific skill -- or is it a general skill such that Group B need only get used to operating when sleep-deprived for the benefit to accrue across-the-board?

Unlike studies of residency-training programs I'm sure studies of this sort have been done (by the military, if no one else); this isn't to pick on deanc specifically but to show that these kinds of questions *can* be empirically investigated, and presumably *should* be investigated when setting policy.
posted by hoople at 9:16 AM on August 17, 2011 [1 favorite]

I suppose you could rephrase the headline as: "Hospitals Just As Safe With Residents Working Fewer Hours" (thx adoarns) and end up telling a different story.
posted by epersonae at 9:17 AM on August 17, 2011

hoople: Neurocognitive Consequences of Sleep Deprivation (PDF) - looks like a summary of lots of other research. (155 footnotes!)

recent experiments reveal that following days of chronic sleep restriction, significant daytime cognitive dysfunction accumulates to levels comparable to that found after severe acute total sleep deprivation. Executive performance functions subserved by the prefrontal cortex in concert with the anterior cingulate and posterior parietal systems seem particularly vulnerable to sleep loss. Following wakefulness in excess of 16 hours, deficits in attention and executive function tasks are demonstrable through well-validated testing protocols.

(IANAScientist, just googled "chronic sleep deprivation research.)
posted by epersonae at 9:25 AM on August 17, 2011

"Did they mention any other big causes of medical errors? Like, for example, sociopathic janitors posing as doctors?"

Hospital PA voice, "Will the REAL Doctor Pederman please report to Neurosurgery . . . IMMEDIATELY!"

ht - Firesign Theatre
posted by Standeck at 9:30 AM on August 17, 2011

epersonae: what you quoted doesn't address the question I was getting at.

What you quoted says in a nutshell: "If you have an acute shortage of sleep (eg: say up 24 hours straight) your cognitive performance suffers; likewise, if you have a cumulative shortage of sleep (eg: sleep 3 hours/night for several days in a row) your cognitive performance will suffer."

That's not what deanc is claiming and not what I'm questioning.

deanc's claim is: yes, your cognitive performance will suffer if you have sleep deprivation. However, if you have enough experience operating under sleep deprivation then you will be able to perform *better* when you're sleep deprived than if you had no such prior experience. Moreover, deanc also claims that without that practice -- the prior experience operating under sleep deprivation -- then the "baseline" level of performance under sleep deprivation will be inadequate.

It's that second point -- that experience operating under sleep deprivation results in future better performance when sleep deprived -- that I'm questioning.

It's intuitively appealing -- and quite possibly actually true! -- but if it's going to be the basis for why residents work a certain number of hours / a certain number of night shifts / why patients should be treated by such residents, then it'd be nice to see some empirical evidence justifying the claim.
posted by hoople at 9:35 AM on August 17, 2011

Unlike studies of residency-training programs I'm sure studies of this sort have been done (by the military, if no one else); this isn't to pick on deanc specifically but to show that these kinds of questions *can* be empirically investigated, and presumably *should* be investigated when setting policy.

I'm not taking it personally, that's actually a good question. One of the problems in the field of medicine is that there are actually a lot of ideas and practices that everyone "knows" is true but haven't actually been rigorously evaluated.

At issue is the fact that in a doctor's career, there will be plenty of times a doctor will be called upon to perform under sleep-deprivation conditions, so the idea is that they have to be trained to operate under such conditions. Rigorous empirical study could reveal that this intuition is wrong, but that's the operating assumption, for now.
posted by deanc at 9:38 AM on August 17, 2011

Mitrovarr writes "this would be easy to fix - make it so that any resident who's worked over 50 hrs/week is legally considered to be slightly drunk (BAC of .08), and anyone who's worked over 80 hrs/week is considered to be very drunk (BAC of .16). The effects are similar enough for it to be reasonable. If the hospital recorded any hours worked over these values they'd be on the hook for any mistakes that were made, since they're be admitting they knew they had unsafe workers and didn't do anything about it."

There is no need to make the equivalencies. It is well known how to enforce work hour limitation even in a hostile environment because we enforce work hours on commercial drivers. Log books would make it very hard for residents to cheat on their hours. Especially considering it would be easy to require resident logbooks to be counter signed where as that is difficult for many drivers. And then apply the same penalties. Suspension of your drivers/doctors licence is a compelling motivator to not skirt the system.

three blind mice writes "Also finally, at least so far as Grady Memorial Hospital was concerned and as a practical matter in most hospitals not to be overlooked, residents provide the basic health care for thousands of poor people who have nowhere else to turn. Cut back on the hours residents are required to work and you cut back on the availability of medical care for many inner city residents."

This doesn't follow. If doctors are required to perform a set number of hours as residents and then you enforce rules that effectively force them to take 20% longer to get those hours then sure you'll reduce the number of hours any particular resident works but you'll also have a greater number of residents in your pool. IE: you can have two people working 12 hours a day or three working eight.

deanc writes "I mean, does anyone really say, 'I would become a doctor, but residency would really cut in to my opportunity to go to shows, attend happy hour after work, and catch up on my knitting'? "

Lots of people make this kind of decision, its the age old live to work or work to live philosophy divide. Personally I'm amazed anyone wants to work that hard. Also knitting can be productive work as much as doctoring.

deanc writes "At issue is the fact that in a doctor's career, there will be plenty of times a doctor will be called upon to perform under sleep-deprivation conditions,"

Not snarking but is that true for even the majority of doctors? I can see that a subset of doctors (EG: ER, rural sole practictioners, GYNs, some surgeons) would regularly be called on to perform while sleep deprived however why for example would doctors in family practice or assorted specialists ever have to work while sleep deprived?
posted by Mitheral at 9:47 AM on August 17, 2011

At issue is the fact that in a doctor's career, there will be plenty of times a doctor will be called upon to perform under sleep-deprivation conditions

Doesn't this suggest, again, that we don't have enough doctors to cover the work?
posted by Mister Fabulous at 9:55 AM on August 17, 2011

deanc: I'd rephrase what you wrote here as "In a doctor's career there will be times that a doctor will be called upon to operate under sleep-deprivation conditions. Doctors would like to be able to perform well under such conditions. Medical training programs have their residents operate under sleep-deprivation conditions in the belief that this will make those residents perform better under similar conditions in the future."

It's plausible, but a lot of things are plausible, not all of them are true, and those that can be nailed down empirically ought to be nailed down empirically. In medicine there's a standard of evidence required to show efficacy of medical treatments, but the "standard of evidence" used to demonstrate the efficacy of approaches to medical training is nowhere near as rigorous.
posted by hoople at 9:55 AM on August 17, 2011

It's that second point -- that experience operating under sleep deprivation results in future better performance when sleep deprived -- that I'm questioning. - Gotcha, my bad. (But it was interesting to read, as someone who is usually (much less!) chronically sleep deprived.)
posted by epersonae at 9:58 AM on August 17, 2011

Not snarking but is that true for even the majority of doctors? I can see that a subset of doctors (EG: ER, rural sole practictioners, GYNs, some surgeons) would regularly be called on to perform while sleep deprived however why for example would doctors in family practice or assorted specialists ever have to work while sleep deprived?

I don't know what percentage, but a lot of physicians have to perform while sleep-deprived at some time. Interestingly, one of the exceptions is usually ER doctors, where the nature of the work lends itself to shifts. Family doctors often deliver babies and so are subject to the same middle of the night deliveries as obstetricians (perhaps even more since they tend to do fewer c-sections). Specialists are particularly prone to middle of the night phone calls; if you are the urologist on call and you have had a full day of surgery and clinic, you will still have to come in when that patient with a testicular torsion or kidney stone with obstructing hydronephrosis shows up in the ER. Depending on how flexible your practice is, you may still have a full day the next day and if you try to reschedule some patients it may be weeks before they can be seen which may send them to another practice (costing you money) or lead them to lower patient satisfaction scores (which will get you on the administration's shit list). Even radiation oncologists (who used to get done by early afternoon even as residents when I was in training) can get called in in the middle of the night for emergencies such as a newly diagnosed tumor causing paralysis or obstructing the trachea.

I mentioned above that most physicians are not covered by work hour restrictions, but also significant is the fact that nurses are also not covered and are also in a position to make serious errors. Many nurses work more than one job and/or pick up extra shifts to cover for personnel shortages, increased patient load, or whatever. Since they are paid by the hour and extra shifts are paid as overtime, there is a big financial incentive for them to work more hours. When I was an intern one of the nurses at our hospital was killed in a car wreck on the way home after working back to back shifts at two different hospitals.

Since there's actual doctors in this discussion, what is the story behind the "doctor shortage"?

To some extent there is not some much a shortage as there is a maldistribution, both in terms of relatively few medical students choosing primary care specialties (for reasons both good and bad and which is a big area for discussion in and of itself) and in terms of geographic distribution, with most residents coming out of training preferring to stay in major urban centers (once again for a variety of reasons).

As far as the powers that be intentionally limiting the supply of doctors, there is some truth to that idea. Training programs are accredited by the ACGME (the same folks behind the work hour restrictions) in conjunction with the relevant specialty boards. There is certainly some pressure from the specialty organization to not accredit too many programs so as to reduce the supply of new doctors coming out to compete with established physicians. But a bigger issue is that incensing the size of a program or starting a new one is not easy. First someone has to pay for the salaries of all those residents. Then the ACGME looks at the educational component of the program, the training and experience of the faculty running the program, and the number and type of patients the program treats (so that the resident will have a lot of experience in the appropriate areas when they finish). By comparison the pressure to limit competition is relatively minimal.
posted by TedW at 10:28 AM on August 17, 2011 [2 favorites]

however why for example would doctors in family practice or assorted specialists ever have to work while sleep deprived?

Big city doctor, family medicine here. Happens on a weekly basis in fact. Granted, I work for uninsured patients and do obstetrics and inpatient medicine, with a 2 year old at home to boot. But 12 hour days seeing patients every 15 minutes on <6>As an aside, all of the studies cited when debating work hour restrictions deal with cognitive performance testing under sleep deprived conditions -- answers on a written test, reflex times, etc. -- there is a great qualitative difference between these tests and taking care of actual patient, when adrenalin runs, you have worried family members standing around, or maybe you personally dislike the person whose life you are charged with, or maybe you're worried about being sued if you make a mistake. The point is, applying evidence to the debate is very difficult. Someone would have to set up residency training programs wtih similar doctors, similar patients, similar hospitals, and have a way to measure quality of outcome long term. In the current climate, this isn't going to happen, so we are acting with "best available evidence", clinical experience, expert opinion, and financial realities.
posted by Slarty Bartfast at 10:34 AM on August 17, 2011

The point about EMRs fixing this hand off problem is a bit simplistic. What's happening now is that everything *is* being documented and users of EMRs are lost in a sea of information...there just isn't a system that organizes and prioritizes information better than a human brain.

I agree completely. As a chief resident in a surgical specialty, I cover 5 hospitals when I'm on call. Some of them use EMRs and some of them use paper charts. I vastly prefer the paper because you can actually read what another physician thought was pertienet information, rather than having to sort through page after page of check boxes and fill-in-the-blanks that are only there to maximize billing.
posted by robstercraw at 10:34 AM on August 17, 2011

(pertinent, dangit.)
posted by robstercraw at 10:36 AM on August 17, 2011

wow did my last comment ever get borked...

I was going to say that in normal practice for me, I don't even need to be called in the middle of the night to make a decision of importance in sleep deprived conditions. I draw on my experience and training to supress that inner voice that says "I don't care about this person, all I want to do is go back to sleep/pee/eat/spend time with my family." But I am a product of the old work hours and I think future generations of doctors will simply refuse/or be unable to work under these conditions. Overall, this is a good thing for doctors, and probably in the long run, a good thing for patients, once we figure out to distribute the resources to effectively cover everyone.

/must remember to close tags
posted by Slarty Bartfast at 10:41 AM on August 17, 2011

Slarty Bartfast: perhaps, but again (I am too lazy) but similar objections would apply to military decision-making and I would be *shocked* if they're not making evidence-based decisions on similar topics, and would be even more *shocked* if they don't have a pile of research that'd be more of an apples-to-apples comparison than you're admitting here.

I'm really not taking a stance on whether or not the "training under sleep deprivation material improves future performance under sleep deprivation" question; I'm just pointing out it's easier to apply evidence than you're making it out to be, and if evidence isn't supplied it's hard to justify policy permitting those types of hours.

Which is really what the Libby Zion situation was about: when push came to shove the explanations for the 120+ hour weeks were found wanting, and in the absence of a good justification it'd be hard under the precautionary principle to justify allowing the practice to continue.
posted by hoople at 11:08 AM on August 17, 2011 [1 favorite]

At issue is the fact that in a doctor's career, there will be plenty of times a doctor will be called upon to perform under sleep-deprivation conditions, so the idea is that they have to be trained to operate under such conditions. Rigorous empirical study could reveal that this intuition is wrong, but that's the operating assumption, for now.At issue is the fact that in a doctor's career, there will be plenty of times a doctor will be called upon to perform under sleep-deprivation conditions, so the idea is that they have to be trained to operate under such conditions. Rigorous empirical study could reveal that this intuition is wrong, but that's the operating assumption, for now.

A number of doctors contributing to this thread seem to be confusing sleep deprivation with being awakened in the middle of the night to deal with a crisis.

These are very different things.
posted by jamjam at 11:35 AM on August 17, 2011 [1 favorite]

A number of doctors contributing to this thread seem to be confusing sleep deprivation with being awakened in the middle of the night to deal with a crisis.

These are very different things.

Not when you have a full days work before and after and said crisis keeps you awake from 10 pm until 2 am; it is very easy to go 36 hours with only 3 or 4 hours sleep in such a circumstance, which by most definitions is sleep deprivation.
posted by TedW at 12:13 PM on August 17, 2011 [2 favorites]

Because I might have to drive my wife to the ER for her allergies in the middle of the night after a hard day, I practice driving around while sleep-deprived. If you see me at 4AM during my "practice runs", wave! The more time I log while sleep-deprived, the better prepared I will be to drive to the hospital. See you on the road!
posted by benzenedream at 1:08 PM on August 17, 2011 [2 favorites]

Also, this article from Walter Reed Army Institute is interesting, although it doesn't address the "sleep deprivation conditioning" question:

"At the time we conducted our study, FDC teams were able to process two fire missions concurrently. In our study, FDC teams from the 82nd Airborne division were tested during simulated continuous combat operations lasting 36 hours. Throughout the 36 hours, their ability to accurately derive range, bearing, elevation, and charge was unimpaired. However, after circa 24 hours they stopped keeping up their situation map and stopped computing their pre-planned targets immediately upon receipt. They lost situational awareness; they lost their grasp of their place in the operation. They no longer knew where they were relative to friendly and enemy units. They no longer knew what they were firing at. Early in the simulation, when we called for simulated fire on a hospital, etc., the team would check the situation map, appreciate the nature of the target, and refuse the request. Later on in the simulation, without a current situation map, they would fire without hesitation regardless of the nature of the target. Early in the simulation, when we called in two concurrent fire missions and for fire on a pre-planned target, they would, having already plotted and derived information for the pre-planned target, fire upon all three quickly and accurately. Later on in the simulation, when we called in, simultaneously, two concurrent fire missions and called for fire on a pre-planned target, the team, having neglected to plot and derive information for the pre-planned target, would try to plot and derive information for three targets concurrently using the two charts (three missions and two charts and chart operators). In this effort they typically became disorganized and confused. The targets, if fired upon at all, were fired upon only after long delays."
posted by benzenedream at 1:11 PM on August 17, 2011

I applaud limiting residents' hours, but I can't imagine we're going to reduce medical errors significantly as long as docs are expected to care for so many damned patients an hour.
posted by serazin at 1:38 PM on August 17, 2011 [1 favorite]

Because I might have to drive my wife to the ER for her allergies in the middle of the night...

I have had to perform this calculus before; your wife is in a massive asthma attack at 1 am and her toy spirometer is on the borderline between yellow and red. Do you want to wake your daughter while you go to the ER? Do you call a friend or relative to watch your sleeping child while you take your spouse to the ER? Do you call an ambulance? It becomes even more complicated if you have to worry about the cost of each option; the one time we did call an ambulance was a few hundred dollars out of pocket despite having not only top of the line health insurance but an employer that writes off most out of pocket costs as long as you use them for health care. Can you get out of work the next day? Will your child's school accept this as an approved excuse? Will your employer penalize you for taking time off to deal with the situation?

I'll do my best to look out for you if you look out for me.
posted by TedW at 5:23 PM on August 17, 2011 [1 favorite]

Is it really possible to be trained to work well while sleep-deprived, such that you don't lose effectiveness/don't make more errors? I would love to see some proof of what seems a fairly extraordinary claim.

And yes, if it's simply impossible for so many doctors ever to get enough sleep, we need more doctors/a better-organized system. Certainly in unusual circumstances (earthquake, airplane crash, pandemic) you'd expect that, but why is it so routine, especially with so much at stake?

I find it interesting but strange that so many doctors defend this setup as something that can't be changed, as just part of medical care (as opposed to docs who see no way to fight it because the causes are so complicated/large).

And it also makes me wonder if it's not just trackable medical errors, but lost opportunities. How many patients with subtle signs of a disease that will kill them because it wasn't caught get missed by an overworked/overtired doctor? How many near-misses get caught by other doctors, nurses, or the patients themselves noticing something is wrong? How would we even know?
posted by emjaybee at 5:59 PM on August 17, 2011

I find it interesting but strange that so many doctors defend this setup as something that can't be changed, as just part of medical care (as opposed to docs who see no way to fight it because the causes are so complicated/large).

I don't think you're talking about the MeFite doctors here, but I just wanted to make the point that of the four of us that commented in this thread, only one (who lists his profession as "researcher") was even slightly defending the old work requirements. At least where I work, I think the general consensus is that work hour restrictions are a necessary change, for many reasons, but that the number of medical mistakes *directly* attributable to resident fatigue alone is overstated, a theory supported by this article. I think about medical errors all the time and am frankly dumbfounded by the complexity and variety of contributing factors. Medicine is currently where the airline industry was in the 1950s when it comes to safety, which is pretty humbling, but we are gradually moving toward a culture of airing out mistakes in the spirit of understanding their causes and fixing them. Cutting back on work hours is just a small part of this. I could go on at length about the dozens of other contributors.

That is not to say you won't hear doctors grumble about these young kids today. I mean, my god, I *never* would have called my attending at 2 AM because I made it through a year of internship without learning to write orders for IV fluids and fuck, if I had, I would have looked it up in a book myself (yeah, we had *books* back then and we carried 'em around in the overstuffed pockets of our white coats) before I risked getting chewed out by my attending. Shit was just so much harder for me what with the sleeplessness and the snow and the bare feet and the war rationing. These upstarts don't know how good they got it. Ok Bartfast, just be a professional, turn on the light and call him back: "Oh no, don't apologize, you should call me with any question you're not sure about....ok, IV resuscitation is really important, here's a little calculation I use..."
posted by Slarty Bartfast at 9:17 PM on August 17, 2011 [4 favorites]

I don't think you're talking about the MeFite doctors here, but I just wanted to make the point that of the four of us that commented in this thread, only one (who lists his profession as "researcher") was even slightly defending the old work requirements.

If you're referring to me, IANAD, nor was I claiming to be one!
posted by deanc at 4:48 AM on August 18, 2011

That's weird, you play one so convincingly on TV.
posted by Slarty Bartfast at 1:11 PM on August 18, 2011 [1 favorite]

But seriously, valkyryn, is your argument that the benefits of the residency system outweigh its costs?

No, my argument is that the idea that sleep deprivation in residents accounted for any significant percentage of medical error was never all that sensible. A majority of the patients in the country are never treated by residents, so the suggestion that we could eliminate a majority of medical errors by targeting residency programs always struck me as a little weird. It's like saying that we can fix the budget deficit by eliminating pork barrel spending. Sure, that's probably something that needs to go, but the real problems lie elsewhere.
posted by valkyryn at 6:04 AM on August 22, 2011