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.

Sunday, June 19, 2011

Emergency Room: Revolving Door or Backstop?

I received a call recently from an emergency room (ER) physician about a patient who presented there with rectal bleeding. Does this sound blogworthy? Hardly. We gastro physicians get this call routinely. Here’s the twist. The emergency room physician presented the case and recommended that the patient be discharged home. He was calling me to verify that our office would provide this patient with an office appointment in the near term, which we would. We had an actual dialogue.

This was a refreshing experience since the typical emergency room conversation of a rectal bleeder ends differently. Here’s what usually occurs. We are contacted and are notified that the patient has been admitted to the hospital and our in-patient consultative services are being requested. In other words, we are not called to discuss whether hospitalization is necessary, but are simply being informed that a decision that has already been made.

There is a tension between emergency room physicians and the rest of us over what constitutes a reasonable threshold to hospitalize a patient. I have found that many ER docs pull the hospitalization trigger a little faster than I do. What’s my explanation for this? Here are some possibilities.
  • Pressure from hospitals to fill beds
  • Pressure from admitting physicians who seek to increase their in-patient volumes
  • Belief that hospitalization markedly reduces medical malpractice risk of ER physicians
  • Desire to eliminate uncertainty that a benign complaint is masquerading as a serious condition. “It’s probably your heartburn, but let’s observe you overnight just to be sure.”
  • Pressure from patients and families to be hospitalized
  • Uncertainly that a patient will follow-up with a physician after ER discharge
  • ER physicians are making the proper judgment to admit the patient, while we specialists and primary care physicians cavalierly advise discharge.
What’s the harm of hospitalizing a patient for a day or two, ‘just to be sure’, or to expedite a medical evaluation that might take a few weeks to accomplish as an out-patient? Here are a few drawbacks to that option, and I’m sure that patients and physicians can add to the list.

  • Resource consumption
  • Risk of hospital acquired misadventures including infections, medication errors and side-effects
  • Overutilization of medical care. Hospitalized patients are routinely visited by numerous consultants who proceed to attack their organs of interest with zeal and enthusiasm
Every physician can attest to how much hospital illness is caused by hospital life and is unrelated to the original medical issue. We see this every day.

I understand the tension between the ER and the outside medical world. The ER is under a unique set of pressures and concerns, and the rest of us need to be mindful of this. Nevertheless, patients would be better served if there were more discussion and collaboration between medical colleagues to determine whether hospitalization or discharge is the preferred option. A recent study confirms that communication between ER physicians and primary care physicians needs healing.

Many patients and their families mistakenly think that hospitalization is the safer choice. Think again.

Sunday, June 12, 2011

Privatizing Social Security and Medicare: Who Can Defuse Political Dynamite?

In response to my prior post where I averred that cigarette companies were treated as scapegoats, I have had several cyber and actual conversations about personal responsibility. I believe that folks should realize the consequences and the benefits of freely made decisions. While we want American society to be compassionate, we do not want to punish success and reward failure. Our goal is to do all that we can to maximize everyone’s success. We should be ready to assist those who need and deserve our private and governmental assistance, but personal effort and responsibility are necessary elements of these interventions.

When we see patients who are in financial difficulty, my physician partners and staff will do all that we can to help them. While it is not our policy to do colonoscopies for free, we will make whatever adjustments are necessary to make sure that the patient receives colon cancer screening. However, when patients who owe us money hang up on our calls, or express their view of medical entitlement with foul language, then we forward these accounts to a collection agency.

There is also a self-interest angle to helping others. One day, we may need a boost ourselves.

In one of my post-scapegoat posts, I discussed the concept of privatizing social security, a sound proposal that was vilified and snuffed out during George W. Bush’s presidency. Antagonism against this modest proposal was seasoned with a large measure of arrogance, a splash of hubris and a dash of paternalism.

In summary, this proposal argued that if folks could manage a small portion of their social security money, which they earned themselves, that it could be a force that would reinforce and extend the program’s solvency. The political left turned white hot over the notion of the government transferring any responsibility for managing these retirement funds to the citizens who actually earned the money. Isn’t this preposterous? They predicted doomsday when our imbecilic citizenry, who were somehow smart and industrious enough to earn the money in the first place, would squander it all, vaporizing the last remaining safety net that would keep them afloat. Then, the lefties argued, the rest of us would have to rescue them at much greater expense.

Their argument is specious and transparent. Review some pesky facts below.

The plan only permitted individuals to invest 4% of their earnings privately in the first year, with modest increases permitted in subsequent years. So, even if these investment tyros lost it all, which is hard to do in any investment, it wouldn’t be a game changer.

The government was not permitting folks to invest in hedge funds, penny stocks or junk bonds. They were required to select from a list of legitimate investment vehicles.

The program was voluntary. If an individual did not have the skill or desire to make personal investment choices, he did not have to. He could continue to allow the government to manage his money.

The program was so modest and so reasonable, that it seems that it would be difficult to attack it. Why, then, did it provoke such ire and vitriol from the left?

These guys were scared. They weren’t frightened that folks would lose money and be vulnerable during their retirement years. They weren’t spooked that it would jeopardize the social security system’s financial stability. They were terrified that the privatization program would actually work. They couldn’t tolerate any fissure in their edifice that stood for total government control of other people’s money and personal decisions. If this initial privatization effort succeeded, they knew that the public, now empowered, would demand greater control of their own money.

To those who believe that the government knows best how to invest my social security retirement money, then why shouldn’t it control all of my investment income? Should I be trusted to invest money that will one day be used to pay tuition for my kids? Indeed, anti-privatizers could argue that all of our money should be turned over to the government, so they can wisely manage it and then disburse it as it sees fit.

Alice Rivlin, a Democratic economist and Paul Ryan, a Republican congressman, who many hope will become a GOP presidential candidate, advised consideration of privatizing the Medicare program. Of course, this idea is political dynamite, but their proposal from two thoughtful public servants on opposite sides of the aisle shows that this strategy deserves air time and public discussion.

Privatization should not be a private matter. Let’s bring it out into the public square.

Sunday, June 5, 2011

The Future of Medicine: Do Pre-med Students Have a Clue?

At this writing, I am in Atlanta visiting our daughter at Emory University. This may be the only college campus in the nation where you can’t buy Pepsi. Coke is King here. If you don’t know this, do some due diligence before you or someone you love interviews here.

I remember a few decades interviewing at the medical school here. There are only 2 medical school interviews that I recall after all these years. At N.Y.U. School of Medicine, the canny interviewer asked me what the death rate of Americans is. I correctly responded, “100%”. I suppose that untangling enigmatic questions was an N.Y.U. admission requirement, since they did accept me, and I did attend. The other medical school interview I still recall was at Emory, although it’s not the questions I remember. Their unique interview format made the experience memorable. Three medical school applicants were interviewed simultaneously as we faced a bank of questioners. This was reminiscent of the ancient and popular TV show, The Dating Game, where 3 bachelors or bachelorettes heard their competitors’ responses and often had to respond to the same questions.

Emory University still has a strong pre-med focus in their undergraduate community, as do many other colleges. Do these idealistic kids have a clue about what post-med life will be like on the other side of the wall? Have they been reading newspapers (or iPads) about the convulsions the medical profession is experiencing, or have they been immersed in memorizing arcane facts about anatomy and pharmacology? Will they find medicine to be a satisfying career? What are their expectations?

In many ways, it will be easier for these new physicians than it has been for their ossified, older colleagues. You can’t miss what you never had. Their reality will be that they will be controlled by the government and insurance companies, if the latter still exist. They won’t be frustrated over loss of autonomy that they never had. They will regard absurd medical quality programs, such as pay-for-performance, to be necessary and integral components of quality medical care. They will routinely submit patient outcome data to payers who will link these outcomes to their reimbursement. These new doctors, who didn’t witness the evolution of these accountability initiatives, won’t recognize the gaping flaws and hidden agendas in these programs. They will likely be employed, and won’t harbor resentment and regrets of having been forced to leave private practice. There won’t be medical guidelines to consult designed by academics, but there will be medical mandates that will require compliance. Those who dare to deviate will have to submit volumes of documentation to justify thinking outside the mandate.

They will enter a profession very different from the one we did. They will be conscientious practitioners, but they won’t have the unbridled dedication to the profession that defined physicians for generations. They will value their lifestyles and their leisure time with friends and families. They will have more of a shift work mentality, which is natural for employees who don’t feel ownership of the operation. Increasingly, medicine will be practiced remotely from the patient, with telemedicine and robotics.

Of course, many of these changes will offer amazing medical benefits to patients. But, there will be a cost. Many of these advances will change what has been the core element of medical care – the doctor-patient relationship. This new paradigm is a difficult concept for many of us to accept, but it may not translate into inferior care. In many cases, medicine will be practiced without putting a reassuring hand or stethoscope onto the patient. Relationships will become more clinical and less personal, particularly as medical advice is offered from physicians in remote locations, who may not have met the patient. A skin rash in Cleveland may be evaluated by a dermatologist in New York City. An abdominal tumor in Topeka might be removed surgically by remote control by a surgeon in Chicago.

I think that physicians of the next generation can still find great fulfillment and reward in their work. Their satisfaction, however, will have to be linked to their expectations, which are quite different from those of their predecessors. There is another side of the equation that I have bypassed here, but is worthy of comment. The expectations of the public – our patients – will have to change also. The new rules of the game will challenge healers and those who come seeking their assistance. Will patients who have yesterday’s expectations be satisfied with tomorrow’s doctors?

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