Do Sleepy Surgeons Have a Right To Operate? 332
Hugh Pickens writes "BusinessWeek reports that a commentary from the New England Journal of Medicine calls on doctors to disclose when they're deprived of sleep and not perform surgery unless a patient gives written consent after being informed of their surgeon's status. 'We think that institutions have a responsibility to minimize the chances that patients are going to be cared for by sleep-deprived clinicians,' writes Dr. Michael Nurok, an anesthesiologist and intensive care physician. Research suggests that sleep deprivation impairs a person's psychomotor skills — those that require coordination and precision — as much as alcohol consumption and increases the risk of complications in patients whose surgeons failed to get much shuteye."
Develop a test (Score:4, Interesting)
Why not develop a test (perhaps a video game) which a surgeon should pass before entering the surgery room?
Re:Develop a test (Score:5, Interesting)
Ten or so years ago, our trucking division experimented with such a program. It ran on a PC and had a controller with a single knob which could be rotated left or right.
You used the knob to keep the cursor in the center spot on the screen. The cursor would become more difficult to control during the test (about 30 seconds)
Drivers would sign in for the first time and establish a baseline for themselves by taking the test multiple times until the program indicated that a baseline was established. (About a dozen attempts, I think)
Once a baseline was established, a driver had to pass the test before starting his shift. If he failed, he had to see a supervisor.
I tested it on myself. After two (unmeasured) shots of vodka, I would have had to see a supervisor were I a driver.
An additional advantage was that you would also fail the test if you had the flu, were sleep-deprived or emotionally unfit to drive.
The program never went into full production at our place. Currently drivers are tested when hired and after any accident or delivery process incident.
I forget what it was called (I tried googling). I thought it was "fair". If you couldn't pass the test, you probably shouldn't drive a truck that day.
If you smoked a joint a week ago, it wouldn't affect the test but if you were up all night watching movies, you'd likely fail.
Re:Develop a test (Score:5, Interesting)
Sounds like a form of impairment testing [workrights.org], which is a pretty big win for everyone but has not been widely implemented. Employers who have used it found that it consistently reduced accidents, and employees like it since they don't have to pee in a cup--a demeaning and annoying procedure. It should also be cheaper for employers: even at a couple thousand bucks for the machine and software you used, the payoff in reduced accidents and mishaps along with not having to pay drug testing companies all the time means it'll pay for itself in a very short period of time.
It doesn't unfortunately seem like it's going to catch on anytime soon. Most companies haven't heard of it, and my guess is that most who have are waiting for it to gain a reputation before thinking about making the switch themselves.
Re:Develop a test (Score:4, Insightful)
You would think it would be a big win for everybody. You would be wrong.
It's a BIG loser for the dispatchers and salesmen. When I hired on for RTC, they gave us an indepth class on how to get more driving hours in a day. It involved sleeping and driving in four hour shifts. Now, WHY would they do this?
Because, clients would gravitate to the company that could deliver on time. There were penalties, up to and including simply refusing to accept the load, for not delivering on time. Salesmen would indiscriminately put tickets for hauls in. No consideration was taken for capacity. Dispatchers were responsible for seeing that the loads got hauled. Dispatchers could say something along the lines of, "Yeah. That's not possible. Trucks don't move that fast." Dispatchers who said something along those lines would end up asking, "You want fries with that?"
The bottom man on the pole was the driver. He got handed a ticket that said he had to haul a load 1000 miles by noon tomorrow. He could say something along the lines of "Yeah. Given our current space-time continuum and the laws of the Interstate Highway System, that is not physically possible." The next thing he would say is, "You want fries with that?"
The impairment testing would document that a driver was unfit to drive, something most drivers know already. After an accident, the first thing the insurance company would ask for is to see the results of the impairment test, and then deny the claim because the driver had been turned around with a forged log book after a 1500 mile marathon run.
Impairment testing is a win for everyone, except for the people that would be responsible for installing them.
Re:Develop a test (Score:5, Insightful)
Impairment testing is a win for everyone, except for the people that would be responsible for installing them.
Sounds like a good candidate for a law then, doesn't it?
Re:Develop a test (Score:5, Interesting)
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Just needs a different type of game. Maybe something like threading a needle (could use actual needle and thread, or a Wii or something). Or slowly guiding a point of light down a narrow twisty track with the mouse.
Re:Develop a test (Score:4, Interesting)
The problem is that most of the best surgeons are in their 40s or higher.
This is because the younger ones don't get the sheer number of cases required to be a great proceduralist. Why not? Well, it's mostly because they're required to go off shift after 24 hours, or 12 hours if they're on for a 24 hour shift the next day, etc. Who scrubs in on those cases? Well, the hospitals are hiring more physicians assistants to take up the load.
This is what the director of surgery at a major New York City teaching hospital told me earlier today.
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Re:Develop a test (Score:5, Informative)
Please don't diss NHS doctors. Having been in exactly that position, a junior doctor too tired to do a proper job, I can tell you that the major reason the NHS is in such a world of pain originates from the top down, not the rank and file.
The NHS has for some time been dependent on the goodwill and vocational motivation of it's healthcare professionals, because they sure as hell ain't motivated by the working conditions, pay, and benefits.
The real problems in the NHS stem from multiple sources, including the increasing cost of healthcare consumables (increasingly expensive technology and pharmaceuticals), the costs of revolting profiteering (aka the "Private Finance Initiative"), targets set by politicians, an excess of managers, a decrease of basic common sense and an increase of feelings of entitlement amongst the UK population (I've seen people turn up in A&E (ER) depts for things as basic as a cold or a knee graze).
Yet despite all this, we still achieve better health outcomes than the USA despite spending a quarter per-capita what they do on healthcare. Does this mean we are more than four times as competent?
The story itself is from the New England Journal of Medicine - so has originated from doctors themselves, trying to improve the care that patients receive by fighting against the market forces that increasingly try to reduce medical professionals to the same depth as any other druge worker stuck in a poverty trap.
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Being indirectly involved with a Canadian health region and its workers I can say that the first three paragraphs of your post describes the situation here also. Not only for doctors but also for nurses. I'm curious if you see the same situation you describe applied to the nursing staff also.
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Part of the problem with the NHS is that too much of it is privately run. Now, while that all sounds like a big happy capitalist love-in, the difficulties start when money begins to get tight. Oh, we're not showing enough growth this year? Well, lay off a few doctors and a few dozen nurses. The rest can pick up the slack. Wait, we're spending *how* much on cleaning? Oh, I'm sure the wards are just fine as they are, let's not pay for such an expensive cleaning company.
Even at that the NHS manages to do
This is just another waiver (Score:5, Insightful)
Re:This is just another waiver (Score:5, Informative)
I agree. If the surgeon's abilities are impaired for lack of sleep, he shouldn't operate, and it's the responsibility of the surgeon and the hospital to enforce that rule.
They can't dump the responsibility on the patient, especially by shoving an informed consent form under his hand in the 15 minutes before surgery. The patient isn't qualified to evaluate that risk.
This wasn't a BusinessWeek article, btw. It was a HealthDay rewrite of a New England Journal of Medicine article http://www.nejm.org/doi/full/10.1056/NEJMp1007901 [nejm.org] [free]. The NEJM article more clearly made the important point that hospitals shouldn't get into these situations in the first place by letting surgeons schedule elective surgery after a night of being on call. Here's the hypothetical case from the original article:
A surgeon on overnight call responds to an 11 p.m. call from the hospital, where a patient has presented with an acute abdomen. After working up the patient for several hours, the surgeon decides to call in an anesthesiologist and perform a bowel resection. By the time the procedure is completed and the operative note has been dictated, it is time for morning rounds. The surgeon has not slept all night and is scheduled to perform an elective colostomy at 9 a.m. Does the surgeon have an obligation to disclose to the patient the lack of sleep during the past 24 hours and obtain new informed consent? Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon? Should the hospital have allowed the surgeon to schedule an elective procedure following a night he was scheduled to be on call? Should it allow a surgeon to perform elective surgery after having been awake for more than 24 hours? What potential unintended consequences of disclosing a clinician's sleep deprivation should be considered?
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Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon?
Both of these are problematic - in first case because the patient has scheduled a work vacation for the surgery and in the second case, because the primary surgeon is familar with the case and has spent time doing pre-operative planning. You don't just throw in another surgeon at the last minute unless it's an emergency.
The correct answer, as mentioned previously, is to consider on-call time as util
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Truck drivers have more sensible rules.
But a doctor can usually only kill one person at a time. Depending on the cargo, a truck driver can take out a pretty large area.
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There are also a lot more truck drivers than surgeons. The payoff for beneficial rules comes a lot faster when amortized over a larger population.
Re:This is just another waiver (Score:5, Informative)
The way to reduce call is to increase the number of people in your group. Larger group = less frequent call. HOWEVER, larger group = larger number of patients admitted to multiple hospitals to care for overnight, and less familiarity with those patients. If you're in a 3-man group, and you're on call every third night, you'll get to know your partners' sicker patients better. If it's a 10-man group? You'll rarely see the same patient twice, and there will be a lot more of them. In the 3-man group, you'll have a manageable list of patients, and given the number of things that happen in an average night, you'll probably get a bit of rest. The bigger the list of patients, though, the more likely you are to get called about something during the middle of the night. Maybe the primary surgeon forgot to write an order for Tylenol for the patient; maybe the patient is constipated and wants something for it (an astonishingly common complaint); maybe they want a sleeping pill. Doesn't matter; you've got to take a call and deal with it.
Furthermore, surgeries are scheduled by days of the week - you will have (e.g.) one room on Mondays, two rooms on Tuesdays, and one room on Friday afternoons. Regardless of what night you're on call, that's when you can operate. Since surgeons only make money when they operate, there is an enormous incentive not to miss an operative day. Since the hospital only makes money from ORs that are in use, if you don't use your operative time you'll lose it. Cancelling a day of surgeries has enormous costs - you already have a nurse anesthetist, a scrub tech, a circulating nurse, and housekeeping personnel scheduled to work there. Do you send them home early, effectively docking their pay for something that isn't their fault? Or do you pay them to do nothing?
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I agree. Being a resident I have some additional points to add on to your arguments. It may seem simple to reduce work hours, but it's over-simplified solution to a very complex problem.
Resident physicians are physicians who have finished medical school. They have a MD behind their name but are still in training. Say that hospital A has a training program for doctors. In order for the community to recognize the doctors graduating from hospital A's program is competent, hospital A must get approval from
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They can't dump the responsibility on the patient, especially by shoving an informed consent form under his hand in the 15 minutes before surgery.
Oh yes they can (legally speaking), and as long as it's profitable for them to do so they're going to do exactly that. That's the problem with a health care system driven by the profit motive - actually caring for patients well is highly unprofitable.
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And now us doctors will have another reason to be afraid of lawsuits: "Your honor, evidence shows that the defendant was awake for 16 hours straight and did not inform the patient. Thus, he should be found guilty of malpractice!"
Of course we shouldn't have tired doctors (nurses, technician, etc.) working and treating patients, but as long as the system demands it (because of shortage of staff [and money, of course]), you can't put the blame on doctors and open up another avenue for lawsuits.
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If we can quantify standards for sleep deprivation, and if someone such as the AMA comes out with standards, then you need not worry. Find that magic number, which may need to be low to accommodate varying age groups and personal abilities, and then you have a golden standard. If a
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In general, I agree with you. One important difference needs to be pointed out: In order to prevent drunk driving, we are measuring a substance (alcohol) that has some (albit, not perfect) corrolation with drunkness.
We have no way to measure sleepiness. Some people need just 6 hours of sleep to be wide awake. Me? I can manage with 6, but 8 is ideal for me. Also, if I had a few tiring days, even 8 isn't enough, and I may crush and need 10 hours. The same is true if I drank the night before.
I think you catch
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Without any standard, you are at the mercy of the judge or (more likely) jury. A standard, even an imperfect one, is better than nothing: especially given that the court must take the physician at his word regarding quantity of sleep. The only evidence would be time worked in a medical facility. So this would definitely be in favor of a surgeon who could say "sure I worked 16 hours straight but I went home and slept nine hours and woke up refreshed." In reality, he could have gone home and watched DVDs all
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It'd be nice to see a cure for the requirement of sleep in human beings. This is a bad flaw. Not to mention it cuts back on my WoW time.
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If they allowed/required docs to get 8 hours of sleep a night they'd not only be doing the patients a favor but they'd be doing the doctors a favor. It isn't good for their health either. They require truckers to get some sleep, I'd think that a person performing surgery is at least as important.
My brother is a doctor and sister a head nurse and from what I hear there is no good reason beyond macho tradition for doctors to work without sleep for so long.
Well, of course, it should be the other way around (Score:2)
Doctors should get a good night of sleep before a surgery, and it should be their responsibility.
Of course, the hospital should take care of not overworking him.
an institutional illness (Score:5, Interesting)
Part of the problem is the medical profession's method of "training" physicians by putting them through an extended period of hazing: working around the clock, being awakened at random intervals, etc. Many of the ones who get through it develop the delusion from it that they can do the work properly under any conditions, especially sleep deprivation. It's a badge of honor for them, and they will engage in all sorts of denial and rationalization to keep at it.
Re:an institutional illness (Score:5, Informative)
I can assure you that most doctors I know, me included, know that the long hours endager our patients. We do not take pride in taking someone to the OR at 4AM while barely being able to tie our shoelaces correctly. It is not pride, but necessity.
The present situation is that doctors need to work a lot. Why? Lack of personnal, lack of money lack of resources (Actually, it can all be summed up in: Lack of money). The reason is not important. The bottom line is that a doctor needs to operate a patient. Ideally, he should be wide awake. Unfortuntly, sometimes this is not the situation, even for elective surgeries.
We shouldn't point the blame at the doctors, but at the system.
Yes, it's nice to tell horror stories of what I have to do in the middle of the night after 20 hours of working without a minute of sleep. But every doctor I know will have the situation changed to 8 hour shift at the first chance possible.
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The health care system in the USA gets a larger share of the richest economy in the world than any other health system anywhere. If the problem is lack of money, I must ask...where is the money going, then?
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Mostly? New technologies and medications, they are the biggest drivers of increased healthcare spending.
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The health care system in the USA gets a larger share of the richest economy in the world than any other health system anywhere. If the problem is lack of money, I must ask...where is the money going, then?
The health care expenditures of the US increase on a yearly basis, and average physician salaries decrease on a yearly basis.
On the other hand, hospitals are happy to hire new nurse managers, paperwork associates, EHR czars.
Oh, and not to mention the lawyers. Always need more lawyers....
Re:an institutional illness (Score:4, Informative)
First of all, I was talking about the medical system. I order to have doctors working shorter hours, you need to have more doctors -> more money.
Secondly, in the US doctors might make a lot of money, but in Israel (where I am from) and many other countries, the doctors' salary isn't so lucrative. I am not saying I am starving, but considering how much I work, it's pretty disgracing. If I wanted to have a good salary, I would have gone to IT (yes, you read that right).
I will make good money, but only 15 years from now, when/if I have a private clinic, otherwise my salary will be above-average but I will not be making as much as you might guess.
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... Secondly, in the US doctors might make a lot of money, but in Israel (where I am from) and many other countries, the doctors' salary isn't so lucrative...
Funny story (IMHO) - in 1983 there was a doctors' strike in Israel complaining of the low wages - in U.S. currency they were $3600 for an intern and $6000 for an experienced doctor a year. That's right, that's what they were being paid - a specialist with 20 years experience was paid $6000 a year. But here in the U.S. the news media consistently reported the salaries precipitating the strike as $36,000 and $60,000 a year! News editors in the U.S. apparently could not believe the actual low salaries and mult
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Part of the problem is the medical profession's method of "training" physicians by putting them through an extended period of hazing: working around the clock, being awakened at random intervals, etc. Many of the ones who get through it develop the delusion from it that they can do the work properly under any conditions, especially sleep deprivation. It's a badge of honor for them, and they will engage in all sorts of denial and rationalization to keep at it.
Respectfully disagree. I'm a resident in a surgical subspecialty, a subspecialty I chose in no small part because there aren't nearly as many surgical emergencies compared to general surgery. That being said, residents don't go through "hazing" as much as "trial by fire." For instance-- awakened at random intervals. It's not as though residents got woken up for the fun of it (well... depending on the nurse.). It's because there's an issue for a patient that needs attention-- be it a new consult in the ER, a
Re:Well, of course, it should be the other way aro (Score:4, Insightful)
NO (Score:4, Informative)
Would Patient Consent Work? (Score:2)
I like the idea of patient consent, but it wouldn't always be possible. I just got into a motorcycle a few months ago and had surgeries, chest tubes, intubations, and couldn't even breathe on my own for a bit. I wouldn't have been able to consent to any of this, but it was necessary to keep me alive.
I work a night shift in a hospital. If you've never worked one before, know that some nights you will be absolutely exhausted. I'm sure most night-shifters have fallen asleep at work before, if not on a regular
Re:Would Patient Consent Work? (Score:4, Funny)
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I was in no condition to be consenting to anything. Fortunately, the stay was covered, which was lucky because my insurance company only covers one of the local hospitals for things which aren't trauma care or preapproval.
Re:Would Patient Consent Work? (Score:4, Insightful)
As an Aussie who enjoys cheap and effective universal health care, I cannot for the life of me understand why Americans are not outraged by that sort of bullshit.
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I'm pretty sure prisoners in America get better healthcare than the average american. ^_^.
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I work a night shift in a hospital. If you've never worked one before, know that some nights you will be absolutely exhausted. I'm sure most night-shifters have fallen asleep at work before, if not on a regular basis. Doctors are not above this. Our hospitalists have on-call rooms to sleep in every night. If you code in a hospital overnight, chances aren't bad that one of the doctors that shows up was woken up by your code seconds before he showed up in your room.
My point is, hospitals are open 24/7. There is a night shift. Those people are usually tired. Also, emergencies happen 24/7. Sometimes patients can't consent to anything.
Imagine this: A patient shows up at 2am with an injury that would kill the patient before the morning shift came in. All the surgeons are asleep. You'd have to wake up an entire surgical team. All of them will be tired when they come in.
All that is true. Doctors often have to perform emergency surgery after inadequate sleep. But the point of the NEJM article http://www.nejm.org/doi/full/10.1056/NEJMp1007901 [nejm.org] was that doctors shouldn't schedule elective surgery the day after they're on call. Some hospitals already have that policy. They argue that if they don't adopt that policy, they should at least inform the patient. I think it was more of a way to embarrass doctors and hospitals into adopting the policy rather than a serious solution to
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My point is, hospitals are open 24/7.
There are several 24/7 stores where I live. Somehow these stores manage to operate without sleep-depriving their employees. Just sayin'
But hey, go ahead and flame me for not having respect for medical traditions when those traditions are counterproductive.
That's just how it is.
It doesn't have to be. Although the solution I'm implying by comparing a hospital to a 24-hour store would probably bring down doctors' wages, so I'm fully expecting that it'll never happen.
Trust a doctor (Score:5, Insightful)
Asking me to sign a waiver should a surgeon about to cut me open be tired seems only like a CYA policy. I can't make an informed decision, and I am most likely in distress and need of the surgery and saying no would delay it.
I am already putting a huge amount of trust in his abilities, and that includes him being able to decide if he skilled and in shape to do the operation or not. If I can't trust my doctor to make that decision I can't trust him to operate at me anyway. Therefor this seems completely pointless.
I
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You know how you can be feeling fine, running on adrenaline long after you should have got some sleep? Thinking "This is great, I'm the king of the world"? Then it suddenly hits you and you're ready to collapse.
Now, how do you feel about your surgeon hitting that wall when he's up to his elbows in your guts?
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Asking me to sign a waiver should a surgeon about to cut me open be tired seems only like a CYA policy. I can't make an informed decision, and I am most likely in distress and need of the surgery and saying no would delay it.
Exactly. I don't think the authors were seriously concerned about the patient consent problem. They wanted to change the scheduling policy.
I think they just wanted to drop a hot potato into the laps of doctors and hospitals that do perform elective surgery after a night on call: "If you insist on doing this, then you have to inform the patient."
What doctor or hospital is going to give a patient an informed consent form that says, "My abilities may be impaired because I didn't sleep last night"?
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I think the point is that doctors are being pressured by management into working excessive hours that negatively impact patient care.
By making the patient aware of their tiredness, they are living up to their ethical responsibilities. By making the patient responsible for the choice, they are avoiding the pressure that would otherwise be deployed by their management, because they cannot operate on the patient without informed consent. If management pressures them to stop informing patients of their exhausti
this is just dumb (Score:5, Insightful)
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People, in general, do not have the knowledge necessary to figure out the difference between a surgeon that's competent and safe and one that just presents well. Likewise, the anesthesiologist is every bit as important and one really doesn't have any good way of knowing if they're up to it.
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one really doesn't have any good way of knowing if they're up to it.
Although a few turkeys make it through now and again, certification by the American Board of Anesthesiology is a pretty good starting point. Approximately 10% of graduates of American medical schools fail the written exam the first time, and about 30% of American medical school graduates fail the oral exam the first time. It was definitely one of the most stressful hours of my life...
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It's a concern, although, the vast majority of anesthesiologists aren't doing that. They do have one of the highest rates of substance abuse of any profession.
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The rate of abuse is primarily an issue of access: we hold the keys to the candy store. If you were a high-functioning individual who liked using drugs, what would you choose? Pediatrics, where you get all t
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The whole point about establishing procedures like "At least 8 hours between shifts" is because nobody - not even a surgeon - is immune to making silly mistakes, particularly when tired.
Even with all the disclaimers in the world, deaths don't reflect well on hospitals.
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On the other hand, your taxi driver isn't taking regular shots of vodka as part of his job. Sleep deprivation is considered routine for hospital doctors.
Proper rest (Score:4, Interesting)
You know, in a country where even truck drivers have regulations requiring proper rest, you'd think there'd be some sort of standard for medical practitioners of any kind. Of course, if any politician ever tries it those AMA campaign donations will dry up like the Gobi Desert.
Re:Proper rest (Score:5, Interesting)
I get some great reactions from medical folks when I mention that the Air Force generally enforces a 12-hour shift limit for aircraft maintainers, even in wartime. Tired people fuck up, and anyone who pretends otherwise is full of shit.
The medical world should borrow two things from military aircraft maintenance. Limit shifts to 12 hours except in emergencies where manning is insufficient, and CHECKLISTS.
Pilots, who are at least as studly and narcissistic as physicians, KNOW ignoring checklists is a great way to fuck shit up. That's why it is PUNISHED.
They also know, even with training, that no one can remember every detail of every complex task they have to perform. From maintainers to aircrew to the folks in the control tower, checklists are considered orders to be obeyed.
Physicians have little time to see each patient, so they have to match symptoms with their concept of a "template" for a particular malady. Checklists are ideal for this sort of thing.
As to the civilian custom of working interns to exhaustion, that's just stupid. The military can train enough folks for wars, the civilian side of the house should "militarize" medical care (including quality control and open chain of command for complaints) and get shit done.
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Re:Proper rest (Score:4, Insightful)
3 cheers for checklists! My sister is studying nursing right now. Those checklists are life-savers.
I also have friends who are or recently have been medical residents. That kind of pressure, with shifts that last well over 12 hours, is quite simply an abusive labor practice.
Re:Proper rest (Score:5, Insightful)
The military has a culture that's designed to take ego out of the decision processes. Perhaps imperfect, but the danger is recognized and dealt with. Now, try working at a hospital...
Actually, it would be interesting to compare military hospitals with civilian and see how they rate on important measures.
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Actually, it would be interesting to compare military hospitals with civilian and see how they rate on important measures.
Having worked quite a bit in both, I'll say that I think military hospitals are ahead by almost any measure you care to name.
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Pilots, who are at least as studly and narcissistic as physicians
I don't think you understand the size of most doctors' egos. It took me a while to understand that they literally think they're gods.
They also know, even with training, that no one can remember every detail of every complex task they have to perform.
Doctors haven't figured that out yet. I don't think they ever will because they believe themselves to be infallible and also because most people believe doctors to be infallible.
It's fun when I have to research a call or two (I work at an answering service) because a doctor is throwing a temper tantrum and I catch her in a lie (or two or three). But, for some reason, that
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The medical world should borrow two things from military aircraft maintenance... CHECKLISTS.
Pilots, who are at least as studly and narcissistic as physicians, KNOW ignoring checklists is a great way to fuck shit up. That's why it is PUNISHED.
As to the civilian custom of working interns to exhaustion, that's just stupid. The military can train enough folks for wars, the civilian side of the house should "militarize" medical care (including quality control and open chain of command for complaints) and get shit done.
Checklists for surgeons are a silly idea. Why? You know an aircraft's blueprints. You know that the aircraft has been through a rigorous certification procedure whereby each and every maintenance technique has been methodically tested and examined.
My patient? I don't know how my patient is built. I don't know how he or she will react to this medication or this surgical procedure. I don't know for a fact their anatomy. That nerve I see, is it a vital cranial nerve or an anatomical variant of a meaningless
Re:Proper rest (Score:5, Informative)
Proper checklists aren't constraints, they are reminders of proper procedures. There is even a saying in aircraft safety, "add but don't take away".
Pilots can fly highly complex combat missions and adapt to changes on-the-fly, yet basic procedure checklists reinforce memory. The pilot doesn't always read the checklist verbatim while doing a task, but does have it available to supplement his skill.
Have some Atul Gawande:
http://www.npr.org/templates/story/story.php?storyId=122226184 [npr.org]
""We brought a two-minute checklist into operating rooms in eight hospitals," Gawande says. "I worked with a team of folks that included Boeing to show us how they do it, and we just made sure that the checklist had some basic things: Make sure that blood is available, antibiotics are there."
How did it work?
"We get better results," he says. "Massively better results.
"We caught basic mistakes and some of that stupid stuff," Gawande reports. But the study returned some surprising results: "We also found that good teamwork required certain things that we missed very frequently."
Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.
"Making sure everybody knew each other's name produced what they called an activation phenomenon," Gawande explains. "The person, having gotten a chance to voice their name, let speak in the room -- were much more likely to speak up later if they saw a problem."
Re:Doctors/Nurses do not get speeding tickets (Score:5, Interesting)
This is simply not true.
If you are legitimately speeding (safely) to perform an urgent operation, the police may escort you to the hospital, enter with you, verify you are about to do an operation, then leave you without a ticket (it happened to several of my colleagues, usually late at night.)
Just being pulled over and showing your hospital badge / white coat is not going to help you 99+% of the time. *Especially* if you were driving in a dangerous fashion. One of my friends has a funny story on how he tried it after being pulled over, and his ID says:
".... ..., MD
DERMATOLOGY"
The police officer laughed and gave him the maximum fine.
article's title (Score:3, Insightful)
"Doctors Urged to Admit Fatigue Before Performing Surgery"
I wish we had something similar in my previous company.
"Developers Urged to Admit Fatigue Before Fixing Bugs"
hospital covering ass (Score:2)
This is the same policy used in the US military. You're supposed to get people involved if you're too tired to do your job. This responsibility should be completely on the shoulders of the doctor to speak up. I think it's likely that some doctors have used a "sleep deprivation" excuse when being reviewed for a botched procedure. This seems like some bean counters are pushing for a way to reduce the hospital's liability in those matters.
Tougher question than it seems (Score:2)
At first, you think it's obvious that people who are responsible for other peoples' lives should be required to be 100% alert.
However, the problem with that is that this by necessity means that you will need more doctors to man places up, thus increasing costs (not to mention that I don't think that there are that many superflous doctors just ready to jump in).
And here's the thing, in most cases, doctors do get to work reasonable hours, the times they don't get to is related to when there is a current crisi
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Here's a crazy idea. (Score:5, Informative)
How about ensuring doctors work humane shifts as opposed to trying to squeeze every penny out of the system?
This is not just a problem with the US btw. I've spoken to doctors from lots of different countries, including Sweden, the US and England.
In general they are overworked, get little time to recover between shifts, and are expected to work overtime as part of the job description.
That's not going to be good for either doctor or patient.
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I don't see it getting truly better without a great deal of pain for everyone. First thing is that we've got to get enough doctors to treat every patient without doctors having to stand crazy shifts.
But how do we do that? We sure don't want to dumb-down med school so that more people can pass and get their MD.
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we've got to get enough doctors to treat every patient without doctors having to stand crazy shifts.
You know why the AMA won't ever do that, right? It would drive wages down for doctors, and we can't have that.
We sure don't want to dumb-down med school so that more people can pass and get their MD.
That's not what the problem is. No one's flunking out of med school. The AMA won't let med schools take in more students.
Most people assume that doctors are thoroughly educated, dedicated, and intelligent individuals. Go work at an answering service for a year or two and you'll find out something else.
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Another issue is that residency training (which is basically where doctors learn to take care of people) is funded for the most part via Medicaire. Without that money (which is substantial) hospitals cannot afford to train doctors. So even if there were sufficient medical students in the system, under current licensing laws (which require at least 1 year of post-graduate residency training) the bottleneck would be on residency positions and funding.
Re:Here's a crazy idea. (Score:5, Informative)
There are several things that need to be done. They're mostly interdependent, so in no particular order:
1) stop the hazing culture in medicine
2) striate the practices. The concept of an Uber-doctor is antiquated. (LPN's and PA's are starting to help here). Cooperating teams is the smarter approach.
3) decrease doctors' hours
4) decrease doctors' salaries
5) get the government out of licensing doctors and medical schools (the chronic shortage is purposeful)
6) get the AMA out of dictating government policy for licensing doctors and medical schools (the chronic shortage is purposeful)
7) destroy the third-party payer system
8) get the States out of regulating insurance
9) privatize medical charities (the Shriners are a great example)
The current system is not designed to produce the best patient care, and that's all that needs to be said. In most industries we praise the "customer first" approach, even for ultimately stupid and inconsequential stuff. We know by experience that if the customer is placed first that the rest of the business succeeds, but somehow fear that approach when it comes to one of the most essential industries.
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1) stop the hazing culture in medicine
Mod parent up. I've listened to some doctors who would put Gny. Sgt. Hartman to shame. It's disgusting, childish, and completely unprofessional. Sure, we all think it's cute when Dr. House says something surly, but the reality of the situation is that the culture in medicine needs to change.
4) decrease doctors' salaries
You're playing with fire, sir, to suggest such a thing, but I wholeheartedly agree. The inflated wages of the US doctor are a sign our system is broken, not a sign that our doctors are somehow better than other docto
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For someone that is pushing a very libertarian philosophy that sounds like some pretty strict regulation.
Like I said, interdependent. If there are more doctors, fewer responsibilities for doctors, and they work fewer hours, their salaries will go down. Supply and demand are sufficient forces here.
I don't know about you but I don't want someone slicing me open and operating on me based on a piece of paper from a degree mill.
Why would you go to a doctor that had a degree from a paper mill? There are alread
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Re:Economics vs Health (Score:5, Informative)
This is a common misconception but is not true. Which imaging modality to use depends on the clinical scenario. MRIs have the downside of taking a long time, requiring the patient to be relatively still during this time, and being in an enclosed space (which some patients refuse to go into - hence the development of "open" MRI patients). And yes, they are expensive. CTs in contrast (pardon the pun) are quick, much cheaper, and do an excellent job of visualizing things like blood which is important in stroke management, trauma, etc...In the acute setting, your patient might die in the MRI machine while a CT scan would give you all the information you need in a much timelier fashion.
Just like truck drivers? (Score:2)
I don't know how it's there in US, but here in Europe professions such as long-haul truck and tourist bus drivers are regulated so that they are not allowed to drive for, say, 36 hours w/o sleep, and it's enforced by monitoring their shift schedules.
Patient 'consent' wouldn't be a solution, but hospitals definitely could enforce rules that no surgeon can get a shift for more than x consecutive hours without having a break in between that would allow for proper full night sleep.
Some doctors in my hospital do cancel elective sur (Score:5, Interesting)
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I am an anesthesiologist. When I am on overnight call I am always off the next day. Our group of Anesthesiologist strongly believes this is the right thing to do. On overnight call I don't come in until 3pm because 24 hours it too tiring. The motto of the American Society of Anesthesiologists is "Vigilance" You can not be vigilant if you are sleep deprived.
On several occasions I have seen heart surgeons who are up at night with emergencies call off scheduled, elective cases in the morning. Perhaps we just have a good bunch of surgeons here, but all of the OR team (nurses, perfusionists, Anesthesiologists...) think it is the right thing to do.
Respectfully... the reason why anesthesiologists need stricter work hours, "breaks" during their cases, etc., is because their job is so f'ing boring that even the well-rested often fall asleep at their anesthesia consoles.
=)
test (Score:2)
How is this even a question? (Score:2)
Informed consent? (Score:3)
I wonder if informed consent is possible just before surgery. Even if the patient is alert, (and often elective surgery involves giving a sedative before surgery) can he observe the doctor long enough to decide he is sleep deprived? How much before surgery can informed consent be made? If the time delay is sufficiently long, the doctor might cross the line of being sleep deprived but the patient saw him an hour before surgery and decided he was not sleep deprived? Also, some surgeries are long affairs, the surgeon might cross the line sometime during surgery. I think informed consent in this case is worthless. It's just like the driver that had been drinking and starts driving just before he gets drunk. He wasn't drunk when he started driving but he soon will be.
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Things that can be done to correct the disaster that is U.S. heath care:
3)Eliminate Malpractice lawyers / insurance.
These three things would restore market forces to the medical industry.
So you think that the problems with the U.S. health care system would be corrected if we eliminated the right of patients to sue when they were needlessly crippled by an incompetent doctor.
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Medical malpractice costs aren't really a serious problem, they're just a hot-button issue for (mostly) conservatives.
Malpractice premiums are about 2% of health care costs. Insurance company administrative costs and profits are 15-20%.
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Health Care is perhaps the one area where I'm not particularly thrilled with "market forces" taking over. That, and I think world would have been generally far better off had AT&T not been broken up, but that's not really relevant.
Market forces are responsible for cheap chinese crap of low quality, where warranties are a joke because you know they're just long enough to last until they know the product is going to crap out from normal usage, forcing you to buy a new one. I don't want the crappy, Chine
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It sounds like your doctor was a great doctor. I don't knock that. It also sounds like market forces are askew if your doctor was cheaper than your Mother's. You should give out your doctor's name here so other people can go to him, and he could charge more.
As for your contention that the AMA is a certifying agency that ensures doctors are qualified, I could point out numerous counter examples, where the AMA has hurt patients. We all want the best qualified doctors. However, I would rather have an exce
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"I'd hazard a guess this is far more costly than most hospitals could afford or would want to cut into profits."
That's the place for rules to take away discretion. If they lack the manning, consolidate surgeries and staff local clinics with the physicians assistants and enough other techs to get those who actually need emergency surgery to a proper facility. Military medical care in the field relies on transport to get this done.
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It's not true that in some areas they might not be able to get another surgeon. Around here anybody living in the Pacific Northwest in that kind of bad shape ends up at Harborview anyways. That sort of care isn't generally provided elsewhere, making it rather a moot point.
OTOH operating when you're tired is just as dangerous as tryin
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Analogy fail.
They had ample manning and plenty of civilian auxiliaries to supplement them. Their manning was not artificially held down, and they have goverment support.
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I, as a doctor, have the right to operate people, as part of my license, under the condition that I have been given informed consent.
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It's not a silly question. Surgeons do in fact have a special right to operate that isn't available to ordinary people. If you perform elective surgery and make mistakes such as they are killed you would not be able to rely on them having given consent in order to escape liability for manslaughter. A surgeon would be able to and any liability would sound only in negligence. The question here is whether there should be an additional requirement that the surgeon be in a fit state to perform the surgery before