Let Me Heal: The Opportunity to Preserve Excellence in American Medicine
May 27, 2015 4:43 AM Subscribe
When I started my first year of residency in internal medicine at the Massachusetts General Hospital in 1998, there were 20 percent more patient admissions per intern in my residency program than there had been just three years earlier. The sheer number and complexity of my patients was nearly overwhelming—and I was worried that at best, they were not getting the care they had a right to expect, and at worst, that they were not safe.
To the average person, the long hours worked by residents were an obvious target for intervention, since fatigue might reasonably be considered a cause of errors.
The article makes it looks like the effect of work hours is not studied at all and that the thought that 24-hour shifts might not be a great idea is just that, an idea from an "average person" that sounds reasonable, but not based on evidence. This is not true. This has been studied. See Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance which states: As compared to when working 16-hours shifts, on-call residents have twice as many attentional failures when working overnight and commit 36% more serious medical errors. They also report making 300% more fatigue-related medical errors that lead to a patient’s death.
Of course it is idiotic indeed to reduce work hours and not hire more people to do the work.
posted by blub at 5:19 AM on May 27, 2015 [10 favorites]
The article makes it looks like the effect of work hours is not studied at all and that the thought that 24-hour shifts might not be a great idea is just that, an idea from an "average person" that sounds reasonable, but not based on evidence. This is not true. This has been studied. See Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance which states: As compared to when working 16-hours shifts, on-call residents have twice as many attentional failures when working overnight and commit 36% more serious medical errors. They also report making 300% more fatigue-related medical errors that lead to a patient’s death.
Of course it is idiotic indeed to reduce work hours and not hire more people to do the work.
posted by blub at 5:19 AM on May 27, 2015 [10 favorites]
Of course it is idiotic indeed to reduce work hours and not hire more people to do the work.
No, it's not idiotic. It's about Taylorizing the medical care production line. If the studies you cite are true, then hospital managers can run the same number of patients through without increasing the number of workers, just by fragmenting their schedules so that they don't have 24 hr shifts, all while maintaining the same level of QC. of course, fragmenting the schedule may lead to other problems but hey, as long as we are meeting the quarterly targets...
posted by ennui.bz at 5:30 AM on May 27, 2015 [2 favorites]
No, it's not idiotic. It's about Taylorizing the medical care production line. If the studies you cite are true, then hospital managers can run the same number of patients through without increasing the number of workers, just by fragmenting their schedules so that they don't have 24 hr shifts, all while maintaining the same level of QC. of course, fragmenting the schedule may lead to other problems but hey, as long as we are meeting the quarterly targets...
posted by ennui.bz at 5:30 AM on May 27, 2015 [2 favorites]
Those people who used to stay in the hospital 16 days and now stay 5 days? Everyone is just as sick as before (perhaps more so, with comorbidities like obesity, diabetes, and related conditions piling on to whatever other condition landed the patient in the hospital), but now we send them home when they're just starting to get better. Which means it used to be maybe 33% of our patients who were super sick and 66% who were on the mend, and now everyone who's in the hospital is super sick. Having 100% of your case load be the difficult cases means the work is more demanding, even if the ratios of caregivers to patients had stayed the same. And instead there are more patients per provider, not fewer.
To make things worse, nurse-patient ratios have been changing similarly. Nurses are often the next line of defense against medical errors, especially when residents are overworked and less experienced than the nursing staff. If your nurses are also frantically busy, then maybe nobody mentions to the doctor, "Hey, he's been reporting X symptom" or "Did you notice Y lab value?" and important, potentially life-threatening things get missed.
posted by vytae at 5:53 AM on May 27, 2015 [7 favorites]
To make things worse, nurse-patient ratios have been changing similarly. Nurses are often the next line of defense against medical errors, especially when residents are overworked and less experienced than the nursing staff. If your nurses are also frantically busy, then maybe nobody mentions to the doctor, "Hey, he's been reporting X symptom" or "Did you notice Y lab value?" and important, potentially life-threatening things get missed.
posted by vytae at 5:53 AM on May 27, 2015 [7 favorites]
I'll be starting residency in about a month so this has been on my mind since I want to avoid harming people. The big argument about hours at this point is while individual errors due to fatigue has dropped, there are more errors due to incorrect hand-off of patient care. Most residents I have talked to said it really depends on program whether the work hour restrictions affects patient care. If the program is really good about enforcing and teaching good handoff procedures( see IPASS) The work hour restriction is a plus. Generally with the work hour restrictions most programs implement a night float system where people work 1 to 2 weeks night shifts to cover the floor during the intern year and a rotating call schedule once a person is a senior resident.
The programs that have been most negatively impacted are various surgical specialties since they have to divide a lot of time between the hospital floors and the operating room so more surgical graduates are opting to do fellowships to increase the amount of training time. Some programs try to remedy this by hiring mid-levels to handle the increase amount of documenting requirements that come with every law that's passed.
posted by roguewraith at 5:55 AM on May 27, 2015 [3 favorites]
The programs that have been most negatively impacted are various surgical specialties since they have to divide a lot of time between the hospital floors and the operating room so more surgical graduates are opting to do fellowships to increase the amount of training time. Some programs try to remedy this by hiring mid-levels to handle the increase amount of documenting requirements that come with every law that's passed.
posted by roguewraith at 5:55 AM on May 27, 2015 [3 favorites]
What I don't understand is how this article talks about the changeover from fee-for-service to prospective payment, and how it started the whole slide of do-more-with-fewer-resources in hospitals. It seems like our country is still trying to figure out how to get rid of fee-for-service, still blaming it for skyrocketing medical expenses, so obviously it's not completely gone. But we've also got plenty of evidence already that prospective payment (you get $X to treat a diagnosis of Y, regardless of what it actually costs you) is not working either.
posted by vytae at 5:56 AM on May 27, 2015
posted by vytae at 5:56 AM on May 27, 2015
I trained surgical specialty residency at a major medical center and finished up a few years ago. Our workload was overwhelming and there just wasn't time to care for patients if we didn't fudge our work hours. I often worked 100-110 hour weeks my first two years because if I wasn't there when I was supposed to be, no one else would be there.
Our program, which took 3 residents a year for a total of 15 at a time, has petitioned the GME for another residency spot for a decade now and it has routinely been denied. At my program, the problem wasn't a cultural one. It wasn't "you have to live at the hospital because that's how we did it!" It's just that there was too much work for the number of workers!
posted by robstercraw at 6:59 AM on May 27, 2015 [3 favorites]
Our program, which took 3 residents a year for a total of 15 at a time, has petitioned the GME for another residency spot for a decade now and it has routinely been denied. At my program, the problem wasn't a cultural one. It wasn't "you have to live at the hospital because that's how we did it!" It's just that there was too much work for the number of workers!
posted by robstercraw at 6:59 AM on May 27, 2015 [3 favorites]
I trained surgical specialty residency at a major medical center and finished up a few years ago. Our workload was overwhelming and there just wasn't time to care for patients if we didn't fudge our work hours. I often worked 100-110 hour weeks my first two years because if I wasn't there when I was supposed to be, no one else would be there.
Our program, which took 3 residents a year for a total of 15 at a time, has petitioned the GME for another residency spot for a decade now and it has routinely been denied. At my program, the problem wasn't a cultural one. It wasn't "you have to live at the hospital because that's how we did it!" It's just that there was too much work for the number of workers!
Robstercraw, your observations about medicine have consistently been my favorite this last day and thanks for that. I just finished my M3 surgical rotation at a major Chicago hospital (Lutheran General) and that jives exactly with my experience. The surgical interns were the rockstars because there was just nobody else there for the amount of work they did, managing patients both in the OR and the general floor. You guys are nuts, in a good way.
posted by kurosawa's pal at 7:21 AM on May 27, 2015 [3 favorites]
Our program, which took 3 residents a year for a total of 15 at a time, has petitioned the GME for another residency spot for a decade now and it has routinely been denied. At my program, the problem wasn't a cultural one. It wasn't "you have to live at the hospital because that's how we did it!" It's just that there was too much work for the number of workers!
Robstercraw, your observations about medicine have consistently been my favorite this last day and thanks for that. I just finished my M3 surgical rotation at a major Chicago hospital (Lutheran General) and that jives exactly with my experience. The surgical interns were the rockstars because there was just nobody else there for the amount of work they did, managing patients both in the OR and the general floor. You guys are nuts, in a good way.
posted by kurosawa's pal at 7:21 AM on May 27, 2015 [3 favorites]
It seems like our country is still trying to figure out how to get rid of fee-for-service, still blaming it for skyrocketing medical expenses, so obviously it's not completely gone. But we've also got plenty of evidence already that prospective payment (you get $X to treat a diagnosis of Y, regardless of what it actually costs you) is not working either.
Well, fee-for-service and prospective payments aren't mutually exclusive. They way that Medicare and some other payors reimburse for outpatient care is both prospective and fee-for-service. It's fee-for-service in that, for every distinct service performed, there's a separate fee paid (subject to some reduction when related services are performed in the same encounter), and they're prospective in that the fee schedule reimbursed for any particular service is determined in advance, by the payor, without reference to the dollar amount being charged by the provider.
The big push now is moving reimbursement to a pay-for-performance model, where reimbursement amounts get partially determined by health outcomes for the population being treated by the provider. Which is one of those things that sounds good at first blush, but I think is vulnerable to a lot of the same problems with No Child Left Behind-type education reforms have had in terms of gaming of metrics and inputs outside the providers' control.
I would also say that the push towards shorter hospital stays as part of prospective diagnosis-based reimbursement for inpatient stays is not inherently harmful - it's a huge unnecessary expense to hospitalize somebody when they don't need to be in-house, and presents risks to the patient in terms of things like hospital-acquired infections. The problem with the implementation has been that hospital staffing in general, and of residencies in particular, has not shifted to reflect the higher acuity and faster turnover in the population of admitted patients.
posted by strangely stunted trees at 8:25 AM on May 27, 2015 [4 favorites]
Well, fee-for-service and prospective payments aren't mutually exclusive. They way that Medicare and some other payors reimburse for outpatient care is both prospective and fee-for-service. It's fee-for-service in that, for every distinct service performed, there's a separate fee paid (subject to some reduction when related services are performed in the same encounter), and they're prospective in that the fee schedule reimbursed for any particular service is determined in advance, by the payor, without reference to the dollar amount being charged by the provider.
The big push now is moving reimbursement to a pay-for-performance model, where reimbursement amounts get partially determined by health outcomes for the population being treated by the provider. Which is one of those things that sounds good at first blush, but I think is vulnerable to a lot of the same problems with No Child Left Behind-type education reforms have had in terms of gaming of metrics and inputs outside the providers' control.
I would also say that the push towards shorter hospital stays as part of prospective diagnosis-based reimbursement for inpatient stays is not inherently harmful - it's a huge unnecessary expense to hospitalize somebody when they don't need to be in-house, and presents risks to the patient in terms of things like hospital-acquired infections. The problem with the implementation has been that hospital staffing in general, and of residencies in particular, has not shifted to reflect the higher acuity and faster turnover in the population of admitted patients.
posted by strangely stunted trees at 8:25 AM on May 27, 2015 [4 favorites]
What I don't understand is how this article talks about the changeover from fee-for-service to prospective payment, and how it started the whole slide of do-more-with-fewer-resources in hospitals. It seems like our country is still trying to figure out how to get rid of fee-for-service, still blaming it for skyrocketing medical expenses, so obviously it's not completely gone. But we've also got plenty of evidence already that prospective payment (you get $X to treat a diagnosis of Y, regardless of what it actually costs you) is not working either.
This is why people who are all about "if only we had single payer..." are substituted one hard problem for another. It would be really difficult to restructure the US health care industry just by changing the way things are paid for. That the system imposes "efficiencies" on primary care while giving the surplus to pharmaceuticals and other profit centers isn't strictly a pricing problem...
posted by ennui.bz at 8:34 AM on May 27, 2015
This is why people who are all about "if only we had single payer..." are substituted one hard problem for another. It would be really difficult to restructure the US health care industry just by changing the way things are paid for. That the system imposes "efficiencies" on primary care while giving the surplus to pharmaceuticals and other profit centers isn't strictly a pricing problem...
posted by ennui.bz at 8:34 AM on May 27, 2015
You know, the way the UK dealt with this back in the 1990s was via regulation and reforming our national contract (after years of ineffectual "guidance"). So under the New Deal, if you worked over 65hrs a week your pay immediately doubled, as did that of everyone else on your rota. That provided a MASSIVE incentive for trusts to employ more doctors and keep us under the limit. EWTD limited that still further to a mean of under 48hrs. We achieve that - my current rota averages 46.5hrs a week, including prospective cover. It can be done, given sufficient motivation.
And frankly "ooh we can't work shifts because we're really rubbish at handover" is no excuse at all given the plethora of medical handover tools out there. If your departmental handover isn't up to scratch, improve it.
posted by tinkletown at 3:30 PM on May 27, 2015 [3 favorites]
And frankly "ooh we can't work shifts because we're really rubbish at handover" is no excuse at all given the plethora of medical handover tools out there. If your departmental handover isn't up to scratch, improve it.
posted by tinkletown at 3:30 PM on May 27, 2015 [3 favorites]
Of possible interest to some: Neurosurgeon Henry Marsh's recent book Do No Harm is a great read and he is a damn fine writer. He also gives a great interview as he did yesterday on Fresh Air. The precision with which he speaks fascinates me even as the subject matter disturbs me.
posted by bz at 4:00 PM on May 27, 2015
posted by bz at 4:00 PM on May 27, 2015
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posted by ArbitraryAndCapricious at 5:18 AM on May 27, 2015