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."
NO (Score:4, Informative)
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.
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?
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.
Re:this is just dumb (Score:2, Informative)
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.
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.
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.
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.
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.
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?
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:This is just another waiver (Score:3, Informative)
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 the ACGME(Accreditation Council for Graduate Medical Education).
The ACGME evaluates the program intermitently to assure the program's training fits the acceptable standards. Say the Residency program has 5 residents per year.
Right now the ACGME has a limit that no resident physician can work over 100 hours per week.(Let me point out that is actually 2.5 full time jobs). Say the ACGME drops that to 80 hours per week. Now suddenly you need more residents. If all 5 residents work 20% less, they will need at least 2 more residents per year to make the schedule happen. If the program have 20 residents, they'll need 6-7 more residents to make it happen. The ACGME however, might not approve of this. All hospitals have a patient load. If your residents are barely getting enough experience, diluting the load by adding more residents might put the training program below standard. Thus the ACGME can deny your request for additional personnel.
So the ACGME is forcing hospital A to reduce work hours, yet at the same time refuse to approve more residents. What do you do? Hire some physician assistants? Their average salary is more than 150% of an average resident, and they work far less hours. As a hospital/group who is trying to make profit, it would be less than ideal. Like the "don't ask don't tell system" it's easier if they just didn't report the work hour violations.
So if the problem is sleep, if you set thinigs up so residents work only 12 hour shifts instead of a 24 hour shift(call) then it would be okay right? No so. Continuity of care is not as good. A nurse sign out to the next nurse when their shift is done, but they have upwards of 6-8 patients on the floor. When a physician sign out to his/her relief, you are talking about any where from 10-50 patients. The more hand offs = more room for error, so you are trading exhaustion for hand off errors. Plus you have to now staff nights, which increases the number of staff needed. Previously when one person is staffing you now require 2 to provide 24 hour coverage.
The ACGME is making work hours more strict, but is the hours the surgical resident working really going down? Are they going to scrub out of a 12 hour case early so they can go home? no. Are they going to come in late and miss the next day's cases? no. Are they willing to lengthen their training from 5 years to 8 years because of a reducting of work hours and cases? hell no. Are they going to report their own program, have it shut down and end up having to look for new place to train? Again no. So most of the time they just don't report it when they work over their limits.
The institution try to fix the problems on the surface. The real problem lies in the cost of hiring medical personnel, the large debt from medical education, and the sharp difference in wages between a resident physician and an attending physician. Medical care when treated as a business is going to be squeezed for profit like any other business. Work hours is one of the scenarios where patient care and profit clash.