The Sleep-Deprived Doctor Saving Your Life
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.
*****
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Previously from Dr. Dalrymple at PJ Lifestyle:
I’m appalled by many aspects of modern medical practice, starting with those long intern shifts, basically a medieval hazing process of huge negative value.
The long hours are not a rite of passage. They allow the novice physician to follow a patient’s course from presentation through resolution. This exposure is an essential part of training and is diminished at the patient’s peril. Perhaps the answer is to lengthen Internships/Residencies.
This stupidity was operative when I was a medical resident 30 years ago. 100 hour work weeks don’t make doctors smart, they make us dumb.
After we graduate, MDs go to informal “Journal Club” meetings where take turns reviewing the latest scientific articles in the medical literature. I remember going to JCs and being surprised how poor a grasp of basic medicine board certified, American trained internists had.
Medicine requires a strong background of reading and study, and people on their feet 100 hours a week don’t read and study.
Hogwash.
There’s really nothing more that can be said to such idiocy.
Well said, Martel. In the case of surgeons, what matters is the number of surgical cases you perform and the number of sick patients you take care of. Lower case numbers per year = additional years to accrue the case numbers needed for competency. Simple math. People who cannot grasp this fact are essentially disqualified from the discussion.
Previously submitted but not in the system. My apologies if both comments show up.
A great topic, worthy of open discussion amongst health care providers.
My two cents as a recent hospital patient (last 3 months): The hospital ..
- had the nurses and techs doing super long shifts too. Everyone looked tired and stressed, but doctors most of all.
- had established protocols for all treatments but they were not flexible.
- only had protocols for single diagnoses cases. If there were complications, as in my case, no one seemed to know what to do.
- used a teaming concept with many doctors on each case. Unfortunately there appeared to be little communication between team members resulting in a lot of conflicting orders. Also the team had literally no communication with the patient’s primary care and specialist doctors.
- used a computer system called EPIC. No treatments, no drugs, nothing occurred unless the computer said to do it. The EPIC system reminded me of HAL in the movie 2001, a Space Odyessy. I had the following recurring dream about EPIC as HAL in the creepy movie voice:
me: Hello HAL, do you read me HAL?
HAL: I read you Dave.
me: I need my medicines now HAL.
HAL: I’m afraid I can’t do that Dave.
me: What’s the problem HAL?
HAL: I think you know what the problem is as well as I do, Dave.
me: I don’t know what you’re talking about HAL.
HAL: Obamacare is too important for me to allow you to jeopardize it Dave.
me: HAL give me my meds!
HAL: Dave, this conversation can serve no purpose anymore. Goodbye.
- was undergoing construction to change out all patient rooms to singles to comply with HIPPA. Basically they were worried about being sued for HIPPA violations if the patient in the bed next to you overheard the doctors talking to you about your case. So much for keeping health care costs down.
- put everything in the computer, which is a boon to better treatment but also gives government more control over you. In the hands of a tyrannical government (oxymoron?) your health care record can be used to deny you almost anything, guns, driving, etc., without appeal.
Back to the long shifts by doctors at hospitals, what’s jeopardized is the ability to think clearly or creatively. If all one is doing is following a cookbook of clinical diagnoses and applying the pre-approved treatment, ok. But if more is needed, watch out.
PS – When doctors do get to sleep, what do they dream about? I hope it’s not HAL/EPIC.
Sleep deprivation does nothing to improve a person’s disposition.
It may explain, in part, the callous behavior of too many doctors, nurses, and other hospital employees toward their patients.
I was once called to start an IV on a woman enduring her nth round of chemo for ovarian cancer. It was the middle of the night, I was a sleep-deprived third-year resident and I remember actively, viscerally hating the patient for getting me up (again), having tiny little chemo-scarred veins, having cancer, refusing comfort care only, etc. etc. etc. It was the low point of my career. I caught myself halfway through the middle of this encounter and did a mental “What the f*** is YOUR problem- she’s the one who’s dying!” I doubt the patient noticed anything except a quiet resident who maybe got a little more friendly.
It was a turning point for me. I’m glad it happened so early in my career. When I had to retire early a few years ago due to health problems, the head of the ER department sought me out to say how much they were going to miss me. “You were always so gracious when we called you in in the middle of the night.” Little did he know it was just penance for all the times I was an ass.
I was a surgical resident before the 80-hour work week requirements kicked in (i.e., before 2003), and am no stranger to every-other-night call. This would mean showing up at the hospital at 5 a.m. one day and usually not leaving until the next day at 7 p.m. or so. That is about 38 hours, roughly. Never heard of a “48-hour shift”, and frankly doubt they existed. BTW, when you are in your twenties, after about a month of “every-others”, your body and mind adapt. If not, we don’t want you as a surgeon. Or didn’t… now we let weaker souls do it. And quality suffers. I say this as a residency program director.
Why? Do many surgeries last 38 hours?
No, nobody in their right mind would do surgery for 38 hours. Surgeries that could potentially take that long are usually staged: broken into reasonable 8-12 hour chunks that can be concluded over a period of weeks or months. A surgical resident is usually taking care of an entire service of inpatients when they are on call.
Actually, the worst call I endured was in private practice. That was the start of the Friday night-to Monday am shift- obviously well over 48 hours. Most nights we did sleep, but if you were unlucky enough to stay up all night Friday night, it was a hellish ordeal until Monday am. At which point I would always take the day off, though my partners didn’t.
The good part about residency is there was always light at the end of the tunnel- or, rather, the tunnel had an end. In private practice the tunnel can be very, very long, especially in parts of the country like mine where there aren’t enough doctors.
I guess if you took a whole weekend it could amount to a “48 hour shift” at some point. If you didn’t find time for sleep in a weekend such as this, it is a reflection on your own poor time management skills.
Right. Because women in labor always call you first to see when it’s convenient.
Sounds like you are generalizing from your experience with a crappy practice/partners. Do you think you would have been better prepared for that kind of ordeal if you had gotten more sleep as a resident? Ain’t no 80-hour/week limitation in a lot of places. Individuals who can’t suck it up need to find another line of work. I guaran-damn-tee you they won’t be there when their patient(s) need them.
I remember those days, sort-of. Much like “k. pablo,” above, my hospital ran residents roughly 30-35 hours at a time (at least emergency physicians), at the worst. And, further, as “pablo,” spoke of, if you couldn’t handle the pressure, you weren’t wanted or needed. There is a reason that doctors are often thought of as above and beyond the fray, and emergency specialists and surgeons even more so: because we have to be. Of course it sucks being the low man on the totem pole, but that is a part of residency: you have to prove yourself.
1389 has a great point too, though: I was always a jackass, though I did my best and I aways felt bad about my attitude later….and my wife would argue that that hasn’t changed….
The jackass part, that is….
Of course, it raises the obvious question; would you have wanted to be treated by yourself fully rested and wide awake?
8 carla
(would you have wanted to be treated by yourself fully rested and wide awake?)
ha.
Reminds me of Abe Lincolns comment.
“A client that represents himself in a court of law,
has a fool for a lawyer.”
I am thankful for the surgeon that implanted a pacemaker-defibrillator in my chest and saved my life,
whether he was half asleep or not..
We topped out at 32 hours on q3 (which was about all an 80 hour week will allow). I don’t know where this program was that interns got 3 hours of sleep a night, I doubt I got 3 hours in a month. The big discussion revolves around two competing factors: is it good for patient care in the immediate (probably not, but with good senior oversight maybe fine), and is good for patient care in the aggregate from training value (absolutely!).
I think the primacy of immediate outcomes will dictate that the long-term training will suffer so administrators can have the short-term win. Most of the residents will not work for them as attendings and someone else will have to live with their training deficiencies. This is not sour grapes, I am reboarding and I am very concerned my new training is not going to vulcanize me in the scary big world.
It is terrifying that there are physicians responding to this who see their working in a sleep deprived state–on people whose lives literally depend on them–as a badge of honor.
And you wonder why malpractice insurance costs are through the roof.
It is one thing to keep working as long as one can if there is absolute need–it is quite another to do this because some sludge brained moron thinks it builds character.
It does not. It breeds error–and in a doctors’ case ‘error’ can mean death.
Sleep deprivation is used by interrogators to break down reluctant detainees. It’s also used as torture.
Anyone lacking sleep can make a mistake. Sleep deprived residents and interns make mistakes on human beings that can cause pain, injury or death. Hospitals like to get as much cheap labor out of these physicians in training as they can.
This unreasonable practice has to stop. If you must go to a hospital and the attending doctor appears too fatigued to treat you, request another doctor.
However, I will say this; military combat vets have related to me that the doctors in our field hospitals sometimes worked non-stop for days on end treating the wounded. Perhaps the long duty hours as interns and residents prepared them for battlefield emergencies.
In any case, let’s hope the best, brightest and most humane keep pursuing medical careers and becoming our doctors, nurses and technicians…and that Obamacare doesn’t drive them into other occupations…
Don’t you find it odd that with all the medical emphasis on sleep apnea and CPAP and sleep deprivation on general health and performance, that the ones pushing it the hardest would not think a good night’s sleep an important thing?
I know fom personal experience that having to work 48 hours on a critical, attention demanding job is not impossible. I also know that I am not worth a S**T for the next two days.
I also know, again from personal experience that working ten hour shifts is fine for about a week. After that, productivity suffers to such an extent that it is no longer worth it…you’ll accomplish more in eight.
By the way, I do use a VPAP, and it has changed my life. It’s not the air, it’s the SLEEP!
Someone should maybe tell a doctor.
Well, John, that is an excellent point, but it is grounded in a misunderstanding about the nature of sleep. In obstructive sleep apnea, the patient is awakened during the most productive part of the sleep cycle: that of REM sleep. In the kind of sleep deprivation that residents experience, it is not so specifically targeted at REM; it is more global. Thus, such a resident immediately slips into REM when they get a chance to sleep. Because REM is the most restorative phase of the sleep cycle, one can make a case that their sleep is more efficient this way. Regardless of the validity of the preceding sentence, it is clear that the comparison tio OSAS is inapt.
I am senior citizen. Many years ago, I knew medical students who told stories about the very long hours they worked. People literally were passing out and work was done in a haze. They viewed this as some kind of obstacle course they had to navigate. I said nothing, but viewed it as patient abuse. Since then I had read about studies which indicate that a sleep deprived person reacts the same way an inebriated person does. It was a shameful practice forty-five years ago and still is today. It says a great deal about how the medical profession views and treats their patients.
I am a senior citizen.
Something to ponder about the medical profession you seem to think is uncaring.
If the interns work fewer hours what work is not going to get done?
Then consider the expected decrease in doctors under Obamacare.
Then consider the expected increase in patients demanding medical attention.
Our nation is run by fools.
“Then consider the expected decrease in doctors under Obamacare.”
Decoded, that means doctors are going to throw a tantrum and leave the profession — why? Because it may mean they can’t gain wealthy status nearly so quickly? Where is the professions moral dedication to human health care that use to make doctors so special and rightfully respected by all?
Solution? Like we do in most other areas of the hard sciences — import dedicated health professionals.
I detect a pretty strong anti-doctor animus in your comments, Zeke, so I don’t know how useful it is to engage you on the topic, but I would invite you to consider that your proposed “solution” is sheer fantasy. Where are you going to “import” “dedicated” medical professionals from? Is there a source of these people that you feel is readily available? You think foreign medical grads have the same high level of training or dedication?
No, my friend. You will see a greater and greater reliance on various kinds of physician extenders. You will see mid-levels like physician assistants and nurse practitioners — many of them fine people — asked to do more and more tasks beyond their skill and training. Quality will suffer, and access will be denied. Mark my words.
Thanks for your reply. I don’t really bite.
Okay! Lets look at the nationalities of MD/PhD medical researchers. With a phone call I could get the demographics to include those granted immigrations to the U.S. Next, Lets look at the numbers of undergrad and graduate professors from non U.S. origins teaching in the med tracks. Then of course there is the case of global partnerships with the NIH, CDC and other healthcare agencies and NGO’s. I don’t know of any college or university with med programs who do not allow for a certain number of chairs to foreign students. Most research is done these days within a global platform.
From the 70s forward I worked closely with vets around the world involved in livestock nutrition. I found that just in the U.S. they did their research largely in parallel with human research and did so on a global platform. I also found that the fruits of researsh was applied globally just as is the case with human physicians. On the military side from my experiences I’ve found that doctors of NATO, doctors of the old SEATO were of equal knowledge and applied qualifications.
I address this background information for only one purpose. I think there is a bit of professional arrogance and isolationist attitude within the U.S. medical profession. Within most of the developed(ing) nations of the world, there is little difference in the academic standards today. On the otherhand, there are instances of difference in training modalities in some places. One can agrue, I supose, that these differences mean for some applied deficiences in their practices. I would disagree. The medical profession with all it disciplines have become and continue to be global. In the case of any noted deficiencies I believe there are corrective measure in place for immigrating physicians so that matter has long been addressed.
I’m old school and well up in age. I grew up where doctors were 2 and 3 generations. We lived in a county that sometimes rose to 5,800 population counting the college students and was served with six doctors and a thriving hospital. Everybody received the same level of care whether you paid USD or worked off your very reasonable bill. The doctors and their patients were not just friends but a family of sorts. Doctors were a different breed then. They didn’t didn’t even consider chasing wealth — just keeping their family of patients healthy and watching them grow up and have their own families was their greatest and proud reward. That is not the case today even in those communities of old. Today, they have to subsidize physicians to even come and practice there so that there will be at least one doctor serving the county. Usually, a husband and wife team with one of them qualified in OBGYN to serve 8,900 population with no longer a hospital.
The moral fabric of most doctors changed over time and most chase wealth over service. Thats my observations and my opinion.
Thanks again for a kind response!
Geting to old to remember everything I intended to say at one sitting!
I forgot to mention and important factor. Most immigrant physicians are far less politicized then their american counterparts and I feel that to be a most critical advantage to their practice and their patients..
import dedicated health professionals.
Translation: strip needed resources from developing nations by giving medical professionals far more money than they would get at home to give greedy — and dishonest and lazy — Westerners cheap health care.
How cruel and insensitive are you? No wonder why people like you are hated all over the world.
Why not just let home-grown Americans work hard to become competent doctors and then be rewarded for their work?
What about the lowering of standards? Due to affirmative action so many unqualified from the U.S and other countries are becoming Doctors it is not the same profession that it once was.
No, it means that people are never going to enter the field in the first place because they have, like me, concluded that becoming an MD simply isn’t worth it. I wasn’t about to spend $300k and four years of my life becoming a doctor when I knew this nonsense was waiting for me.
No doubt that ‘most’ doctors of today will subject themselves to a rigorous boot camp of sorts to become wealthy. Then most, after boot camp, become livestock ring auctioneers in practice. The more cattle they push through the auction ring the more money they make. The more pills they push the more money they make indirectly through dependency. And we haven’t even gotten to all the financial and criminal corruption in the medical practice profession. The most moral physicians are those who choose to work with America’s military and veterans and those who choose to practice in America’s rural and poor areas.
Gotta love when physicians gather around to hold a boo-hoo self pity party for their choices and consequences of chasing wealth. Try manning an outpost for days on end with little or no sleep engaged in fire fights as potential death surrounds you — for the pay our military gets.
Pablo has good points. We are beginning to see the results in the surgical graduates who are less experienced, less confident and whiny if they have to work 12 hours or more. In England the Royal College has been forced to set up simulation labs for registrars (residents) to learn surgery for the training hours in the five years has dropped from 21,000 hours to around 6,500 due to the EU work rules that classify surgeons on the same schedule as lorry drivers.
The data need to be stratified for age and experience. The young can handle a 36 hour shift for extended periods…at age 68 I cannot. The other flaw in our system is “coverage”. If one is the only provider in a sub-specialty within a geographic area, then call is continuous in addition to the work you need to do to earn a living. The more training a doctor has the greater the burden on the clock.
Obama Administration: We Can and Will Force Christians to Act Against Their Faith By Terence P. Jeffrey December 29, 2012
http://cnsnews.com/news/article/obama-administration-we-can-and-will-force-christians-act-against-their-faith
Zeke finally took his gloves off in post #15. He doesn’t like docs, nor does he understand what we do and why we do it. Some practices, like family medicine, have such poor reimbursements and so many mickey-mouse patients that the only way to make a decent living is by volume. I say decent advisedly; Zeke might educate himself on the median incomes of family medicos–not Fat City then or now.
In the “olden days” beloved by Zeke, GPs were not overly prosperous because they really could not produce good results for the seriously ill. We have seen an explosion of good medications, technologies (imaging, fiberoptics, stents, stereotactic radiosurgery, laparoscopic surgery, robotic surgery, etc) and as a result family docs have little to do other than the Rx and the referrals to specialists. One must specialize; generalists have disappeared because there is simply too much knowledge to master, and stay current with. Family docs are like traffic cops; they don’t do hazmat, or SWAT, or the solving of serious crimes like specialized cops do, because they CANNOT do it adequately.
Perhaps Zeke should stick to comments about livestock nutrition, a field in which he professes to have knowledge and experience.
I respect your comments. However, you seem to make a lot of erroneous assumptions. The most grievous, is your justifications to trash the general or family practioner.
“In the “olden days” beloved by Zeke, GPs were not overly prosperous because they really could not produce good results for the seriously ill.”
And some day, some wet behind the ears physicians will be saying the same about you.
“We have seen an explosion of good medications, technologies (imaging, fiberoptics, stents, stereotactic radiosurgery, laparoscopic surgery, robotic surgery, etc).”
And every generation to follow will be able to make the same claims. You really so arrogant as to believe that in the good old days physicians did not have justification for such claims? Your generation DID NOT invent medicine and health care NOR did it provide the continual advancements in health care through the decades and centuries! The sciences build upon themselves from one generation to another — one research afer another from somebody elses work in another time frame.
“Family docs are like traffic cops; they don’t do hazmat, or SWAT, or the solving of serious crimes like specialized cops do…”
You started out on the right track then you fell into the toilet. Without the doc’s you just reduced to menial traffic cops, you BIG specialists wouldn’t have much business brought your way — would you? And as you’ve so elequently admitted, your specialties are about one centimeter wide and what you don’t use from your ‘general’ medical educations and experience — you lose.
I stand on the points I presented, from arogance right on down to a lesser moral fabric as your comments lend creedence too. Ashame that you lack the maturity to respond in a like means as k. pablo was able to do.
Lots of misinformation in some of the above posts:
As regards physicians becoming extraordinarily wealthy by medical practice, the fact is we are piece-workers just like Chinese workers assembling parts for iPhones. Truth is, the average salary for a Chicago teacher is higher than that of a pediatrician in Washington, D.C.
If you are a rally smart, hardworking individual, you expect that your expertise and hard work will be rewarded. Confronted with a choice between a fixed-payment job, where no matter how great you are at your job, you will never be paid more than the most incompetent slimy, greedy dullard, or a job where you will earn more the better you do your job, which do you choose? But don’t worry–the mortality rate for mediocre or average doctors is only a few percentage points higher that for really good docs.
With respect to work hours, I view residency training much like SEALS training. Demands are placed upon you in a SUPERVISED situation, so that you can acquire the skills to work under demanding conditions AND know your limits. Good docs do the high-stress things like surgery early in the day, the simple things later. The famous Libby Zion case, which precipitated the 80 hour work rule, was a failure of supervision.
Studies show that it takes about 7000 hours to become skilled at an activity. But since the government has frozen residency training placements and payments since the 1980′s, there is no money for the extra years of training to replace the lost experience due to limited work hours.
Now do a little math: if a primary care doctor wants to earn $120,000 a year, with a 60-70% office overhead and a nine hour day, at typical levels of physician payment (Medicare, HMO, PPO), each patient gets about EIGHT minutes, including exam, ordering tests, reviewing tests, communicating with other care providers, and completing the chart. Now consider the average education debt, income taxes, Social Security and Medicare taxes, factor in the lost earning years from college graduation to starting practice (8 to 12), and see just how “rich” a modern doctor gets. There’s more, but I don’t want to give you a heart attack.
Dr. Mike – Thanks for your response. I think your comments; “the fact is we are piece-workers just like Chinese workers assembling parts for iPhones” and “if a primary care doctor wants to earn $120,000 a year, with a 60-70% office overhead and a nine hour day, at typical levels of physician payment (Medicare, HMO, PPO), each patient gets about EIGHT minutes.” pretty much sums it up for far to many doc’s today. I know what my one daughter and son make and I know the kinds of practices they run and how much financial investments they give back into their communites. Then I know what my brothers son-in-law makes as an anesthesiologist and boohoos day and night as he goes home to his $800K home and his four wheel and two wheel toy collections, debt, etc.
Perhaps the lack of sleep is the reason why you are almost twenty times more likely to die from a medical error than by firearm in the USA. Pilots cannot fly if they have not had the requisite sleep periods. Even long-haul truckers have requirements as to how long they can drive in a 24 hour period. Why not physicians and nurses, etc? I have had a nurse put a dry IV into my arm and let the bag of antibiotics drip on the floor. I had to kink the tube when I realized what was happening and yell for help. I have had a doctor who obviously was sleep deprived (or high) order an antibiotic for me which was plainly marked on my chart to which I was severely allergic (anaphylaxis). I have had a tired doctor attempt to inspect a wound without sanitizing his hands. All in all, I trust legal concealed firearms carriers more than I do doctors. I ALWAYS question medicines and procedures and orders, as I could have become a statistic if I did not. Doctors hate it when you question them (get on their high horse about all their college and training) and they absolutely DESPISE it when you catch them in a dumba** mistake as a result. They have to get used to the fact that this is my body and my life, not theirs, and I’m gonna ask questions and not agree to anything until they have explained to my satisfaction what they are attempting. Twelve years of schooling be damned. They will hardly miss a dead patient, but I have no desire to die because a doctor was tired or stupid.
You bring up some interesting points. As a doctor I agree that every patient has to be vigilant regarding the care he or she receives! Your firearm analogy is a bit off, however. As long as the gun owner keeps his pistol holstered and the doctor keeps his pen in his pocket, your risk of being harmed are about equal. But put your CHL holder on a pop-up firing range with bad guys and good guys confronting him without pause for eight hours a day, I suspect your gun-owner’s harm rate would be substantial. That doesn’t mean you shouldn’t learn to use and carry a gun; it means you should treat your health care with the same wariness as you would a gun. As to whether your doctors are stupid or sleep deprived, just remember that like it or not, you get what you pay for (at most). Pay your doc less than a teacher or longshoreman for a lot more responsibility, and you get lots of tired, angry, overworked stupid doctors. The smart guys went into something less stressful and more remunerative. But don’t worry, for most health care a doctor is almost superfluous. You only need one when you are really, really sick.