Sunday, 6 January 2013
Doctors of the old school tend to be rather proud of how hard they worked when they were young, and to attribute their current enormous technical competence as well as the magnificence of their character to the long hours that they then endured. They were not much fun at the time, perhaps, but it made them what they are.
I remember those long hours well, and how at the end of a forty-eight hour shift my head felt as if it contained nothing but lead shot, as if it might just fall off my body. Leaving the hospital was like leaving prison after a long sentence; the starving man dreams of food, but the sleepless man dreams of bed.
It has long been suspected that such exhaustion cannot be good for patients; no one in his right mind would wish to be flown by a pilot who had gone two days without sleep, for example. Why should doctors be immune from the normal effects of fatigue on performance?
A study in a recent edition of the Journal of the American Medical Association attempted to demonstrate the effects of a protected sleep period on interns and residents when they were obliged to work shifts longer than 30 hours. On some such shifts they were given five hours, between 12:30 am and 5.30 am, when they could not be interrupted except by the direst emergency, and when they were given the opportunity to sleep. This might not be what most mothers would call a good night’s sleep, but it was better than what was normally available to such interns and residents.
The subjects of the experiments acted as their own controls: half the time they had protected sleep periods, and half the time they hadn’t. Unsurprisingly, they got more sleep (about an hour more per night) when they were given such a protected period rather than when they were not. They were more alert, both subjectively and objectively, when they had slept 3 hours a night instead of only 2. Three hours is hardly enough to make one feel fully rested, but slugabeds know that even a quarter of an hour of extra sleep can seem the most luxurious thing in the world.
The authors were unable to demonstrate any superiority of actual performance by the better-rested doctors, as measured by the crude outcome of patient deaths. This was not surprising because their sample size was too small; the experiment would have to be repeated on a larger scale to prove what seems intuitively obvious: that exhausted doctors – or perhaps I should say more exhausted doctors – are more inclined to make medical mistakes than less exhausted doctors.
Strangely enough, another study of a similar kind has shown that while protected sleep lessens the fatigue of young doctors, it increases their level of anxiety. The authors of that study hypothesized that the extra sleep merely compressed the amount of work they had to do, which remained the same, into fewer hours, thus increasing their anxiety. And when anxiety increases beyond a certain beneficial level, it tends to depress performance just like fatigue.
Perhaps young doctors are also so used to hearing how hard their elders and betters worked when they were their age that they feel slightly ashamed of their protected sleep periods, unluxurious as they might seem to the great majority of the population, as being indicative of a lack of commitment and stamina, what was known in my childhood as moral fiber. All I can say is that I would certainly not have wanted to be treated by me at the end of one of my forty-eight hour shifts.
First published in PJ Media.
Posted on 01/06/2013 6:33 AM by Theodore Dalrymple
6 Jan 2013
It sounds like the sleepless regimen is a sort of macho initiation rite where a young doctor proves his mettle, worthy to be inducted into the medical fraternity. But medecine is about caring for the health of patients, not catering to the ego of doctors. These are real people's lives at stake, not some college fraternity house torturing freshmen.
The government needs to crack down on these self-indulgent and dangerous practices.
6 Jan 2013
I believe that there are EU Guidelines governing how many hours junior doctors can work nowadays. The difficulty nowadays is getting into a hospital in the first place.
8 Jan 2013
As noted in Wikipedia:
"New York State Department of Health Code, Section 405, also known as the Libby Zion law, is a regulation that limits the amount of resident physicians' work in New York State hospitals to roughly 80 hours per week. The law was named after Libby Zion who died at the age of 18 under the care of what her father believed to be overworked resident physicians and intern physicians. In July 2003 the Accreditation Council for Graduate Medical Education (ACGME) adopted similar regulations for all accredited medical training institutions in the United States.Although regulatory and civil proceedings found conflicting evidence about Zion's death, today her death is widely believed to have been caused by serotonin syndrome from the drug interaction between the phenelzine she was taking prior to her hospital visit, and the Demerol administered by a resident physician. The lawsuits and regulatory investigations following her death, and their implications for working conditions and supervision of interns and residents were highly publicized in both lay media and medical journals."
I haven't the foggiest if the People's Republic of China, once known for its "barefoot doctors" and notorious "Cultural Revolution" (a madness finally brought under control with widespread application of Mao inhibitors) has been the scene of similar abuses and purported cures of the circadian rhythm. In Cuba physicians often supplement their meager income by driving taxis. Cuba is also an example of Michael Moore's Law, to wit, visiting bloated, fat-cat anti-capitalists receive a level of care far beyond that of ordinary citizens/slaves and the state's claims with respect to infant mortality, longevity and literacy are unaccepted uncritically by the Western MSM.
The two residents involved in the Libby Zion tragedy escaped all of the criminal and some of the civil penalties largely because of testimony by other physicians that they themselves were unaware of the potential for a deadly serontonin syndrome resulting from the interaction between MAO inhibitors such as Phenylzine and agents such as Demerol. Looking on the bright side, the publicity given the trial served to educate many physicians regarding such interactions. And with respect to regulations limiting the hours worked by residents, as they don't quite say, "Bad cases sometimes make for good laws." And as for what doctors call "good cases," -trust me; you don't want to be one of those either. It should also be noted that in spite of the drawbacks of EHR (electronic health records), they often include an automated check for drug interactions with the entry of a prescription.
The good doctor Dalrymple neglected to mention that, at least in what might be a bygone era in the US, many residents worked extra hours for extra pay during their free nights away from an often brutal call schedule [mea culpa -R.]. Perhaps a few of the Gentle Geriatric Readers will recall my harrowing documentary, Ill Met By Moonlighter.
Smiting Jerry Hip & Thigh,
Patrick "Paddy" Leigh Femur
Tags: A prudent resident, given a patient with a guarded prognosis, soon learns to defensively "hang crepe," Crete, kidnapping but no hanging of General Kreipe. Put de lime in de coconut, but don't put de Phenylzine wit' de Demerol an' drink 'em bot' together, http://en.wikipedia.org/wiki/Ill_Met_by_Moonlight