Sunday, April 14, 2013

More than just being tired?

I picked up the following off the Medical Post otherwise known as the Medical Enquirer who email me a digest of news unsolicited everyday (I could block them, I guess)
There was a sigh of relief across the country in 2011 when a Quebec arbitrator ruled that the 24-hour shifts required of medical residents violated the Charter of Rights and Freedoms. Finally, there was recognition that this treatment of neophyte doctors not only violated their health, but the safety of patients. Doctors shared stories of car accidents after long shifts and of mistakes made in the daze of exhaustion.Key thinkers on health care called it a common-sense ruling. A few months later, Quebec capped on-call duty for residents at 16 hours, down from 24. With mounting evidence about the adverse effects of long-call shifts, it seemed like a move the rest of Canada should follow.Or maybe not, new research suggests.Two studies in the Journal of the American Medical Association argue that the 16-hour limit might not actually improve the lives of residents or the safety of patients. In fact, it may make matters worse.A longitudinal cohort study, published in JAMA, used a first-year resident health survey to track the effects of 2011 duty-hour reforms in the U.S. (which, like Quebec, limited call to 16 hours but only for first-year trainees). Dr. Srijan Sen, a psychiatry professor at the University of Michigan who led the study, told Science-ish that his data busts assumptions. Shorter shifts did not lead to more sleep—nor did it improve the well-being of residents. In fact, they made more medical errors. “There are unintended consequences—negative consequences—associated with capping hours,” he said.For example, most hospital residency programs didn’t have the resources to hire new physicians or physicians’ assistants, so residents were expected to do about the same amount of work in less time. Dr. Sen linked the resulting “work compression” to medical error. “There’s clear evidence that working so long isn’t good for cognitive functioning. But it looks like we’re creating new problems by cutting down those shifts.”The second JAMA study looked at medical house staff at Johns Hopkins Hospital, randomly assigning them to a 30-hour cap, or to one of two groups with a 16-hour cap. The investigators used wrist watches that measure movements to find out if the groups working fewer hours managed to catch more sleep. The lead author, Dr. Sanjay Desai of Johns Hopkins, told Science-ish that the interns who worked less slept an average of three hours more around the period during which they took call, but otherwise got no more sleep than the control group.“Is three hours enough sleep to change levels of fatigue and response times?” he asked. “For us, this introduced potential flaws in the logic that if you cap hours, people will sleep more, and meaningfully more. That doesn’t seem to hold true based on the data we have.”There were other alarm bells. Dr. Desai says residents who worked night shifts felt their education was compromised, since learning and educational activities generally slow down at night. Hand-offs in the 16-hour groups increased between 130 to 200 per cent compared to the previous 30-hour model. As a result, patients were juggled between more doctors than before. (It’s well known that transitions of care can be akin to a game of broken telephone, a major source of medical error.)So what now?Dr. Chris Landrigan, a professor at Harvard Medical School, who did asystematic review on the effects of the 16-hour call, said most literature points to reducing shifts, and notes serious limitations in the designs of the new studies. The first by Dr. Sen relied on self-reporting of medical errors, well-being and sleep patterns. Dr. Desai’s study also made no direct measure of patient safety. Instead, investigators looked at sleep and hand-offs, which weakens the argument that caps lead to more errors.Still, some of the findings in the JAMA studies have been illustrated by the Quebec experience.Dr. Charles Dussault is president of the Fédération des médecins résidents du Québec, which represents the province’s medical residents. The FMRQ is trying to find ways to supplement education in the OR after surgical residents complained they weren’t learning enough. ”OR time is precious,” he explained. “Some of the models we proposed limited the number of hours residents can spend in the OR.”Quebec doctors have also reported concerns about the increase in hand-offs. “People are feeling the fact that there is more patient transfers than there were before could increase the risk of mistakes.” Dr. Dussault said hospitals are looking for ways to improve hand-offs. “We are still in transition,” he added. “People had the same debate when they went from a 72-hour cap to 36, from 36 to 24, and now from 24 to 16.”And that’s exactly it: shift length is a systems challenge that requires a systems solution. Resident duty hours need to be more humane, but cutting hours without redesigning the hospital infrastructure—standardizing hand-offs, addressing work compression or paying attention to resident education—won’t get doctors very far.Both Drs. Sen and Desai pointed out that it wasn’t just the shrinking of shifts that may have increased errors; it was the lack of planning and organization around the changes. Importantly, they cautioned against the 16-hour limit, noting it was too prescriptive — that a one-size-fits-approach is not suitable for every hospital.In Canada there is currently no consensus on the regulation of duty hours. We can do better. Somewhere between the U.S. and Quebec is a model for the way forward. 
There may be a few explanations.

They mention the issue of hand-overs and unfortunately the quality of communication between doctors is not that great; something medical schools need to work on.

Maybe 16 hours is too long a shift, maybe we should look at 8 or 12.

Our department has for years covered night call on a 1600 - 0700 basis.  Let me tell you, a lot of nights when I have to do something at 0400, I am pretty shaky (some nights not so much).  Not that I have knowingly done anything bad; I tend to just simplify things and go a little slower.  Maybe we need to teach doctors shift work management or how to work when tired.  Unlike a lot of shift workers, most of us sleep poorly if we have to sleep during the day; I can rarely manage more than a two hour nap without the aid of pharmaceuticals.  That is assuming you have the opportunity to nap at at.  There are a lot of other factors; how busy were you in the first 8 hours, were you woken from a deep sleep etc, how boring what you are doing is.

Are we talking big or little mistakes.  If you are doing a study on errors, you obviously want to have as many errors as possible.  So if for example I give the little old lady 200 mg of propofol when I only should have  to given her 150 mg and have to give her phenylephrine for her BP of 60, is this a significant error.  Are we just measuring a lot of trivial errors with no global effect, just because we can?  Further because medicine is an art not a science, many errors are just judgments which could have gone either way.

Patients are sicker after hours, procedures are more complex there is most opportunity for error no matter how well rested you are.  Because of the hierarchical system that still exists in medicine, more junior staff will be working after hours with less supervision.

And anyway do we have to make patient safely a justification for not making somebody work 24-36 hours or can we just say in civilized society, that is not how we should train people?

Just a few thoughts.

Monday, April 1, 2013

In the trenches.

As I previously blogged we are in a fee dispute with our government who want to cut remuneration to specialists in particular anaesthesiologists in order to redistribute the money to physicians who are "working in the trenches", meaning family docs, geriatricians and psychiatrists.  One of my colleagues copied me on a letter he sent to the president of our union and I really could not have said it better.
So to hear that I'm now being told to take a 25% pay cut and be insulted every second day by this minister really rubs me the wrong way. He has said that he needs to support the "workers in the trenches" (family practice, gerontology, psychiatry) and this causes me to scratch my head. If looking after a young pregnant woman with PIH at three am is not "In the trenches" what am I doing then? Missing my kids soccer games, dance recitals or just bedtime because I am on call? 

There are few lucky anaesthesiologists who work in cosmetic suites, dental offices or just do arthroscopies and ACL repairs on health ASA 1 and 2 patients.  These are a very small minority.  For most of us we take whatever comes in through the door and try to get as good a result as we can.  Not to sound bitter but our job is made one hell of a lot more difficult by those front line "in the trenches" family docs, geriatricians, emergency docs, (don't get me started on internists) etc who haven't worked up their patients properly, haven't treated their medical concerns and often sat on their obvious problems, turning what should have been an urgent procedure done during the day into an emergency in the middle of the night.  And unlike most specialists in our city, when an anaesthesiologist is on call, he is in the hospital caring for a patient or else he is at home, on a 30 minute leash, NOT sitting around having residents and hospitalists look after his patients for him.

Not to mention that when you phone most GPs offices now, after hours or even during the day, you get a message telling you to go to the nearest emergency room or call 911.  (Of course they can't take your phone call, they're busy out in the trenches!)  At least in the city now and in a significant amount of the country, GPs no longer do house calls, work in the emergency, deliver babies, work in hospitals or do nursing home visits.  So who the hell is in the trenches?  Not the person doing well-baby care from 9-5 and weekdays.  Geriatricians, who are for the most part GPs who took a weekend course, are insulated from any patient care by layers of nurse practitioners.  I don't see a lot of them at night in the hospital.

In defense of GPs or as they like to be called, Family Doctors, they were largely forced out of hospitals, emergency rooms and obstetrical units over the past 30 years that I have been in practice.  I don't remember a lot of kicking and screaming but it did happen.  They certainly have never gotten much respect for anybody, have been blamed for much of the increase in healthcare costs in past and had to put up with practice restrictions.  And quite a few of them do provide reasonably good care for their patients.  And unlike my generation who got a one year hospital based rotating internship where they saw lots of sick patients, FPs now go thru a two year family practice "residency' where they predominantly work with academic family docs and learn how to deal with healthy people and wash their hands of everything else.

Working in a quasi community/teaching hospital one realizes how much infrastructure is necessary for doctors to do their jobs and it is these people who are actually in the trenches.  This includes residents, hospitalists, nurse practitioners, physios, lab etc all of whom insulate doctors from their patients.  These people are the real people who are in the trenches and I don't think any of them are going to see the money that is about to be stripped off me.

Every doctor of course thinks what he does is the most important thing in the world and the best strategy from a government point of view is to get us fighting over who gets paid how much for what.