October 27, 2004

YOU'RE GETTING SLEEEEEEPY: A new study shows that tired interns are making mistakes.

D'uh! I have no patience with the way hospitals work their interns and residents. I've never heard a good explanation for why we want our junior medicos, who provide a lot of our front-line care, in a state of perpetual exhaustion; most revolve around the utterly unconvincing idea that they somehow need to learn to work under pressure, as if they were all going to be disaster-relief doctors. After a few weeks, older doctors assure me, they learn how to cope.

Hogwash. I've worked those kinds of ours as a technology consultant many times, and while you do get better at coping with exhaustion, there are limits. And I don't care who you are or how many times you've done it before, when you've been up for 36 hours: you. are. stupid. Your reaction times slow waaaay down (or speed up disastrously, as you short circuit past critical steps), you're over-emotional, and you're prone to cut corners as your body and brain cry out desperately, desperately for sleep.

Sure, I've done it. But at the end of the day, I was working on a box of bolts. It would be a VERY BAD THING if one of my clients, say, couldn't trade on Monday morning -- but they'd all still be breathing when they came in on Tuesday. Also, I rarely had to make split-second, irreversible decisions about caring for my boxes; they were unlikely to flatline while I took a few minutes to think things over.

The system endangers patients. I recall when a friend of mine, an intern, had to go to work despite the fact that he was suffering from terrible influenza. Why? He had to make his hours. How ridiculous is it to have a system that puts sick doctors out on the floor where they can infect patients? And what kind of decisions do you think a flu-ridden intern makes?

Even worse than that, the doctors know it endangers patients--they don't want themselves, or their families, in the care of residents. Some of that is because we all naturally want the most experienced doctor for our families, of course. But some of it is because they know that exhausted doctors make for bad care.

(Why can't they just let them work shorter hours? Say it with me, folks: the reason is green, and it folds. Fewer hours for residents mean more hours for attending physicians, who, unlike residents, would have to be paid for it.)

UPDATE: a fellow alum of the University of Chicago Business school emails

I'm in healthcare, have been for 13 years or so, and know a thing or two about overworked interns. The ACGME, who accredits most residencies, has put new guidelines in place that essentially prohibit working more than 80 hours. This may sound little better than "slaves may only be whipped 20 times per day," but it's a start. Many of our hospital clients have been busily hiring more physician faculty and mid-level providers to make up the difference. The downside here, the point you almost seem to be getting to, is that this is awfully expensive, especially at a time when hospitals are being forced by the government to implement scores of new regulations, and forced by private payors and employers to implement lots of good, expensive, ideas like hiring full-time intensivists and converting to electronic medical records. I am fortunate enough to have access to good, expensive health insurance. But anything that raises costs will have the effect of pushing healthcare further out of the reach of tens of millions of Americans. Is a sleepy intern better than no intern? You decide--but let's not be so na´ve as to pretend there is no trade-off.


Just saw your post on sleepy interns & the 80-hour limit. I'm not sure where
your friend is writing from, but NY state has had the 80-hour limit in place
since the 1980s (the Bell Commission recommended it after the 1984 death of
Libby Zion) and it's generally regarded as a bad joke amongst doctors. A
massively disproportionate number of my friends are doctors who are doing or
have recently completed their internships, and the 80-hour-limit is widely
regarded as being flouted more often & more flagrantly than the Giuliani
crackdown on jaywalking. (I believe that hospitals would rather pay the
fines for violating the rules than hire more personnel - an eloquent
statement of the inadequacy of the NY sanctions, the expense of hiring more
personnel, or both.)

ANOTHER UPDATE: Jonathan Wilde at Catallarchy has a long, thoughtful piece on the problem.

Unfortunately, none of these explanations stack up against the one that makes the most sense, and the one that Megan mentions. As usual, when in doubt, look at the incentives. The number of practicing physicians in this country is not determined by the market like the number of practicing engineers, architects, or plumbers. Rather, it is strictly limited by law. Who has the incentive to limit the number of practicing physicians? Currently practicing physicians who do not want to face competition. Yet, the work still has to get done. Rather than work harder themselves to make up for the paucity of workers, they shift the burden to residents. Why do the residents have an incentive to put up with difficult working conditions? Because once they finish residency, they will be the ones enjoying monopoly privilege while future residents suffer in their stead. They have an incentive to choose delayed gratification.

But in the end, patients do suffer as a result as these studies and others in the past have shown.