Sunday, June 26, 2011

Do Overworked Medical Interns Cause Medical Errors? Let’s Sleep on It.

As of this writing, 5 air traffic controllers have been found asleep at the switch. By the time this piece is posted, several others may have joined the slumber party. Keep in mind, there’s a lot more snoozing in the towers than we’re aware of. We don’t know the denominator here. Our wise reactive government has recently issued orders that airport control towers must not be manned by only one individual. Somehow, prior to NappingGate, our bloated and inefficient government that is riddled with redundancy thought that one sole guy watching the radar at night was sufficient.
There are some jobs where nodding off poses no risk. Let me test my readers’ acumen on this issue. Which of the following professions would not be at risk if an unscheduled siesta occurred?

  • A race car driver
  • A congressman
  • A circus clown (not to be confused with above listing)
  • A lawyer (not to be confused with the above listing)
  • A school bus driver
Let’s face it. Some folks on the job simply can’t safely snore their way through it. We don’t want New York City taxi drivers to fall asleep while they are swerving through midtown. We don’t want a navy pilot who is racing through the sky to catch some ZZZs. And, we don’t want a surgeon to have to be nudged into consciousness while he is performing some task within an abdomen.

We don’t know yet the reasons why folks are sleeping in the air traffic control towers. Maybe it’s the soft music they play. Perhaps, the sounds of incoming aircraft have a hypnotic effect. Or, maybe they’re just tired.

Indeed, the issue of control tower fatigue has been raised, among other potential explanations. It may be that their assigned work schedules are too demanding, and there are not sufficient work breaks. We’ll find out. Most of us who enjoying the luxury and comfort of air travel (turn on guffaw track now) are hoping that the air traffic controller who is guiding our plane to the runway is reasonably alert. However, I shouldn’t assume this. Choose from the following 2 statements.

I prefer that my air traffic controller be alert and well rested.

I prefer that my air traffic controller be in the 36th hour of his shift, with only a few pockets of interrupted sleep. I feel safe knowing that this battle hardened professional is prepared for any adversity. I don’t want some softie managing the radar. I want a tough guy who will do his job regardless of how fatigued and stuporous he is.

I’m afraid that many readers are now stuck, as they are agonizing over the above choice. If after 15 minutes, you still cannot choose an answer, then move on. You will have time later to return to this question.

The issue of fatigue is now recognized to be an important issue in the training of medical interns and residents. I remember when the tragic Libby Zion case in New York City occurred in 1984, which we all hoped would lead to reform in medical education. It is amazing how entrenched the medical education system is, and how difficult it is to modify it. New rules were issued to allow interns and residents more sleep and some mandatory time off, but there were exceptions and loopholes that are still used today. This was not simply an effort to introduce humanity into medical training. Relieving overworked medical interns and residents was designed to reduce medical errors and reduce medical malpractice.  Even if I can't prove it, I maintain that a rested medical intern is more likely to avoid medical errors.

Why do so many still want medical interns and residents to work when they are exhausted? Is it for cheap labor for hospitals? Is it to test their mettle for when they become real doctors? Is it really so interns don’t ‘sign off’ at 5 pm and miss the natural history of their patients’ diseases? Are program directors trying to minimize patient ‘hand offs’ by having medical housestaff work extended hours? Or, do some senior physician educators advocate arduous work schedules because they endured it in their time?

All of the above reasons, and others I may have overlooked, can be refuted with sensible reforms, and everybody knows it. Sure, practicing doctors have to be sharp in the middle of the night, and we are. But, most nights we sleep comfortably at home. I don’t think the fatigue and ongoing sleep deprivation I suffered as a medical resident was necessary preparation for the nocturnal care that I am called to render now, from time to time.

I know that many physicians have strong opinions that oppose mine. I hope that they and others will express themselves here. I would like to close this post with the irrefutable evidence that supports my argument, but I feel myself starting to nod off. No worries. When a blogger bugs out for a few minutes, no one gets hurt.

25 comments:

A. Bailey said...

Nice post. I can find no fault in it.

I'm wondering how the dynamics of "morning report" have changed, or if there is morning report at all in the sense of what it used to be 30 years ago.

Back in the day, we'd have 6-7 after hour admissions and would get, at most, one hour of sleep. Our data base consisted of a Washington Manual of Therapeutics and one three year old copy of Harrisons that was always hiding under a desk or something. The attendings, well-rested from a good night's sleep, would pick the most obscure or complex case and rake the house-staff over the coals for not knowing the world literature on the subject.

Now the house staff has full computer access, and can learn a lot of information on their IPhones from UpToDate in about ten minutes. If the attendings walk in cold and aren't current with the literature, I can see how the tables would be turned very quickly.

Which means that they would do away with morning report, I would guess, and use some other means to humiliate the house officers.

Michael Kirsch, M.D. said...

@AB, agree with all that you said. We have the same memories of 50 Ways to Humiliate the Housestaff. Regarding your comment: Nice post. I can find no fault in it, perhaps you could make this your default comment on future posts? Other readers may with to adopt also.

Toni Brayer, MD said...

Nice post, I find no fault in it.

I believe the new regs allow shifts to 24 hours, work weeks of 80 hours and first year resident shifts up to 16 hours with mandatory 8 hours off. That hardly sounds like easy street and that is still a lot of sleepy young doctors. The FAA doesn't permit pilots to fly more than 34 hours a week and they have automatic pilot systems!

I remember actually falling asleep as an intern with my pen sliding across the page as my head and hand collapsed forward. That can't be good for patient care. I was also cranky alot and would groan and complain at the idea of a new admission. I thought of the patients as my enemy.

The people who are against the new regs are either old and of the "we suffered so should they and it never hurt me" mentality, or they are panicked at how they can staff hospitals with cheap labor with the new regs.

I also think arduous training is what makes so many physicians feel entitled once they make it in through. Just because we can survive...doesn't mean we should.

A. Bailey said...

It's a great line, one with which I find no fault. I stole it from a movie but I can't for the life of me remember which. Maybe Jane Eyre or Pride and Prejudice.

Would you consider making one of your next posts about this question?: A nurse is able to deliver optimal care when her back is to the patient so she is able to make her timely computer data entries. Yay or nay?

Michael Kirsch, M.D. said...

First of all, you didn't steal the line, you are merely borrowing it. Your visual of the nurse entering data on the computer while the patient is gasping for breath or seizing is great. You should be a blogger even though you would be a fierce competitor.

Mark Faasse, MD said...

at the end of the day, experience is what makes a doctor good. fewer hours of training = less experience, unless we can find a way to creatively increase the "impact factor" of the hours that trainees have left; I don't really hear anyone talking about this, though. as a result of duty hour restrictions, residents are "softer" and less accountable than ever before.

Michael Kirsch, M.D. said...

Mark, might it be possible that more humane training might result in more humane practitioners? Why is 'softer' inferior? Thanks for your comment.

Mark Faasse, MD said...

By "softer," I mean less demanding of themselves, less committed to going the extra mile, sticking around for the extra case, etc. Many residents (and medical students) today seem to always have an eye on the clock - and that's a bad thing for current and future patients.

One reason medicine used to command societal respect was because of recognition for the rigors of training. Obviously, medicine no longer commands the societal respect it once did, for many reasons, but the cultural changes occurring in medicine because of duty hour regulations will serve to erode it even further.

Michael Kirsch, M.D. said...

Thanks, Mark. Agree with you that there are many reasons why physicians today are a different than our predecessors. Yeah, many might be 'watching the clock', but many outsiders are now 'clocking' us. When you're treated like an employee, guess what?

medaholic said...

I'm a medical student from Canada, so my perspective might be a bit different but here goes

1) More hours worked generally = more experience. I think it's necessary for students/interns/residents to accumulate enough clinical experience that they can be competent with their work.
2) how can you fit enough hours in a week? if we were to work normal hours, training may have to be extended a few years, which is less than ideal
3) on the topic of sleepy interns - i know at our institution we did not implement a strict 12 or 16 hour rule, as this would actually cause residents to end up working more. there would be no protected post-call days, and what might end up happening is people will be placed doing shift work, possible 5-6 days in a row, without ever breaking any of the rules

Michael Kirsch, M.D. said...

Appreciate comment from our neighbor from the north. Good points. I still maintain we need a better balance between a humane experience and sufficient clinical experience, eh?

Nicholas Fogelson, MD said...

Michael - I see the argument you are making, but my feeling is that the quality of medical education for our residents has dramatically worsened since the institution of the 80 hour work week. I was actually a 3rd year resident when it went into effect, and because of the mechanics of my program it didn't really affect me (3rd and 4th years didn't work more than 80 anyway). I saw, however, an immediate negative impact on the training of our interns.

They just weren't gaining the skills that we did in the time that we did. At six months into internship, they didn't have the breadth of knowledge and capability that we had after just two months of working 100+ hour weeks. I really don't think people catch up either.

The shift mentality of a limited hour work week led to a sharp decrease in accountability, and transfer of routine authority to the attendings that used to be taken (competently) by the chiefs.

An unlimited hour workweek defined ones job completely differently. The job was to take care of one's patients, and to a lesser extent to help your colleagues with theirs. One went home when the work was done. Efficiency was greatly rewarded, as it gone you home sooner. The job now is quite different - its to come to work and put in the hours and then leave. Responsibility is not personal, but shared. Some might say that is better, but personally I don't think so. It leads to too many mistakes and lack of in depth consideration of diagnoses and treatment plans.

Internship was demanding, but it was a great year. It consumed my life, but in my opinion that's what residency is supposed to do. People have shifted to a belief that residency is supposed to be just a slice of one's life, which I think is ultimately to the detriment of our educational system. By having such an intense first few years, the more senior residents have an easier time of it and start having a bit more life - because the lower levels have the talent and skill to really run things. Now each year is more or less like the last, with somewhat more authority and technical difficulty along the way.

I was very tired during intership. I was emotionally effected. I was pissed off a lot, and occasionally depressed. I did fall asleep unintentionally a few times. But honestly I don't think I made any mistakes because of it. I might have tried to a few times, but better rested colleagues or nurses were there to catch me. That's the system we were under, and it worked well.

I know it will never go back, but honestly I wish it would.

Nicholas Fogelson, MD said...

And I really wish people would stop using these Air Traffic Controller or pilot metaphors. ATC is very different skill set as being a physician. ATC is looking at a screen and juggling many inputs and outputs with very precise timing required. Intellectually I just don't think medicine is like that.

I don't know why people don't use a military metaphor. We absolutely punish Navy SEALS in training. We don this not only to train them but more importantly to get them to learn how much greater their capabilities are than they thought. Our special forces would not be what they were if we didn't do that. I truly believe that the same goes for docs.

Nicholas Fogelson, MD said...

Mark makes a great point about societal respect.

Our previous model required that physicians view themselves as doctors 24 hours a day 7 days a week, with no change of identity when outside of the hospital. That level of dedication and sacrifice garnered a great deal of societal respect.

Now physicians are taught that once they go home they aren't doctors anymore, and that their responsibility ends when their call coverage come on. Its not surprising that society doesn't think as highly of that.

Michael Kirsch, M.D. said...

On a slight tangent, a new idea on how medical schools should screen applicants. http://nyti.ms/qSBpY8

Michael Kirsch, M.D. said...

Nick, I want to thank you for your typical thoughtful comments. I follow your points, but am uncertain if they represent the best that we can do in training new physicians. Just because this is the way it was always done, does not mean it is optimal, particularly during changing times. To expect unbridled dedication of physicians as health care 'reform' lumbers onward, is not realistic. The new and improved medical profession will not attract the type of physician that you describe in your comments. To paraphrase you, medicine is now a part of new physicians' lives, not their lives. I think that there were many reasons that interns and residents worked 100+ hours per wk that have nothing to do with their education. Finally, I respectfully suggest that the analogy between exhausted medical trainees and air traffic controllers is valid.

Once again, I appreciate your thoughts.

Mark Faasse, MD said...

Don't you think there is validity in the SEAL analogy, Michael?

Michael Kirsch, M.D. said...

Mark, regarding your proposed Navy SEAL analogy, what are you getting at here?

Mark Faasse, MD said...

I was referring to Nick's comment (7/10, 8:56p) suggesting that medical training might be more properly analogous to that of Navy SEAL's than air traffic controllers. Air traffic controllers work in a highly controlled environment, on shifts that are easily defined. Most physicians don't work this way - we work until the job is done, and some of us have to be ready to save lives at all hours of the night after having just been awakened. Isn't this more like the work of a SEAL than of an air traffic controller? And if so, shouldn't our training reflect this? Nobody is advocating "more humane" training for the SEAL's. Certain skills can only be acquired through physically/mentally exhausting training.

Anonymous said...

As a current resident, I honestly think that many of the things done under the guise of "resident education" are nothing more than hazing and taking advantage of cheap/forced labor. Is being a doctor really similar to being a navy seal? I guess a lot of people out there think so, because sometimes I feel that going to the hospital is like going to war! Clearly, a substantial portion of medicine is learned by experience. But when the workload is so much that it gets in the way of teaching, didactics and thinking about what you're actually doing, it's of questionable benefit. There were times in my intern year when we had so many patients to round on that there was no time for any meaningful discussion. We were basically paper pushers and note writing machines.

Not to mention the chronic sleep deprivation that most residents have. How much do you think someone is really learning on their 30th hour of being awake? Study after study shows the negative effects of sleep deprivation on mental processing and motor skills. This is even with skills that have already been acquired. But even ignoring those factors, wouldn't it be better to test your skills against sleep deprivation AFTER you've already mastered the skills? Imagine if driver's education consisted of being forced to stay up for 24 hours before being allowed to get on the road.

Medical education in its current state is outdated, inefficient and is in dire need of a more direct/practical approach. I whole heartedly agree that experience is the key, but it needs to be acquired over time GRADUALLY. Less time should be spent memorizing arcane basic science factoids (I had memorized the citric acid cycle 4x in my pre-med and medical career and I've needed it a total of zero times clinically).

Michael Kirsch, M.D. said...

Thanks, Mark. I follow your point but would quite equate physicians' training needs with those of Navy SEALS. These guys, I imagine, need to be 'on the edge' at all times. Fortunately, not quite for most of us physicians. Appreciate comment.

Anonymous said...

Can't say I agree with the navy seals analogy. How long does the average navy seal career last? If physician training needs to be that rigorous in order to prepare for such a stressful career, then maybe we should limit doctors' career to 10-15 years.

Michael Kirsch, M.D. said...

To the anonymous and tired medical resident, thanks for your comments. Despite your ongoing fatigue, they were cogent and on point. I hope you'll return to this blog again and offer your views.

Nicholas Fogelson, MD said...

Docs are SEALs intelectually, not physically. SEALS could probably go as long as docs if it weren't for the physical demands of the job. And the bullets.

tired medical resident said...

people underestimate the physical rigors of residency and practicing medicine. my surgery resident colleagues routinely go through months where they work 30 hours on, 24 hours off or the typical night float schedule where you work 5pm-8am exclusively. neither schedule is amenable to a healthy lifestyle and after a few years you start to see the physical effects.

i'll tell you something that doctors DO have in common with navy SEALS; both have very high divorce rates. not to mention that substance abuse and depression in the medical field are among the highest in any career.

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