By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website
It all seemed so bizarre. In 2014, with little fanfare, two large trials that imposed longer work hours and sleep deprivation on physician-trainees (interns and residents), ostensibly to combat the problem of excess hand-offs of patients among physicians. Both trials involved multiple academic medical centers, including some of the most prestigious in the US. Within a year, the American Medical Student Association (AMSA) and Public Citizen called for a federal investigation of the trials, calling them “highly unethical.”
This unprecented conflict between prestigious academic medical institutions and the largest organization of medical students and a respected watchdog group suggests either the former have serious ethical problems, or the latter have gone a little crazy. The minimal media attention to the dispute did not explain what is going on. My suspicion is that these events open a window on how respected medical academics are now in the thrall of the managerialist leaders of health care.
Background of the Studies
My Personal Experience on the Medical Housestaff
Let me start by disclosing the axe I am grinding. I was an internal medicine intern from 1978-79 in a program known to be very arduous. For much of the year, I worked up to 36 consecutive hours every fourth night, often without more than a few hours of sleep. My on call shifts were extremely busy, involving admission of usually 4-5 complex and acutely ill patients, handling exacerbations and emergencies affecting my own patients already in the hospital, and three other interns’ patients for about 12-15 hours of the shift. The workload was augmented by a hefty amount of “scut,” that is, tasks that either did not involve direct patient care, or could easily have been done by someone who was not a physician, e.g., paperwork and phone calls, other bureaucratic tasks, drawing blood, starting IVs, and even transporting patients. As the shift dragged on into the evening, I knew my mind was getting fuzzier and my coordination was getting clumsier.
The notion that working 36 hours straight was educational, was good for my patients, or was good for me seemed nonsensical. One reason I went into medical education was to improve the experience for future trainees.
Addressing Housestaff Sleep Deprivation
I was hardly the only person who thought the work requirements imposed on medical housestaff were nonsensical. The first notable improvement was the advent of night float systems that allowed on-call housestaff to get at least some sleep. Eventually, in part after the infamous “Libby Zion case,” (see NY Times retrospective here,) teaching hospitals were required to limit work hours. In 2003, Accreditation Council for Graduate Medical Education limited the total work week to 80 hours, required one day off a week, and required call schedules no more frequent than every third night. (Note that my old program fulfilled all but the first.) In 2011, the rules were tightened further, limiting interns to shifts no longer than 16 hours.
Pushback Against Duty Hour Restrictions
Yet soon after the pushback began. A 2014 MedPage today article that described the two studies noted,
The rule change elicited mixed reactions from residents and program directors of residency programs, who worried that increased hand-offs led to worse patient care and shorter hours reduced education opportunities.
I agree that the increasing number of hand-offs could be problematic, and discuss that below. On the other hand, the notion that sleep deprived housestaff could learn anything useful while in that condition seems bizarre. There is plenty of evidence about the adverse cognitive effects of sleep deprivation, including affects on learning. (See, for example, Durmer et al.)(1)
A brief discussion of one of the two trials, the iCOMPARE trial, put it this way:
Policy limiting duty hours in graduate medical education training programs has become a
central point of debate amongst stakeholders. Evidence from human chronobiology and sleep science argues for shorter shifts, because fatigue leads to errors. Evidence from operations research argues for more continuity because patient handoffs also lead to errors, and may reduce the effectiveness of education necessary to produce independent clinicians for the nation’s future.
Poorly Conceived Study Question
The two controversial trials were thus designed to answer the question of whether allowing increased consecutive duty hours would lead to better hand-offs and better outcomes. This question seems poorly conceived, and was not clearly justified.
The trials were apparently based on the idea that housestaff training programs can exist in only two possible states: allowing longer duty hours with fewer and better done hand-offs, or allowing shorter duty hours with more and badly done hand-offs. Therefore, the only choice seems to be to maintain the current system (tighter duty hour restrictions) or go back to the old system (more relaxed restrictions).
However, these are not the only possible alternatives. One can easily think of other choices.
Oddly, the spotty materials about the iCOMPARE trial available online did not include any consideration of why the more restrictive duty hour regulations may have led to bad handoffs. Perhaps the current problem with hand-offs, while it may be real, may have not come about only due to a decrease in the consecutive hours housestaff were allowed to work. Perhaps it came about because the consecutive hours regulation was imposed on the closed systems of housestaff training programs in which the clinical and non-clinical responsibilities of the housestaff were fixed. So, cutting consecutive work hours without decreasing the number of patients that need to be managed, or the housestaff’s total workload, including “scut,” may have pushed individual residents to try to do more work in less time. This could have had various detrimental effects, including increased numbers of hand-offs occurring under too much time pressure.
That hypothesis suggests that measures other than allowing more consecutive work hours could address any unintended effects on hand-offs of the mandated consecutive work hour reduction. It seems plausible that shorter duty hours combined with measures to decrease total housestaff workload, starting with offloading “scut” work, could produce as good or better results than simply going back to the old system.
Nonetheless, the two trails were set up as if the only alternative to the current situation is to return to the old situation (longer work hours allowed). Thus it seems that the reasoning underlying the trials was based on a false dilemma.
Summary of the Studies’ Methods
This apparently badly conceived study question led to trials whose design and implementation raised further concerns. Per the 2014 Medpage article:
The Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) will compare the current duty-hour regimen (16-hour maximum continuous work period for interns) to what the trial calls a ‘more flexible regimen’ that eliminates the 16-hour cap.
A total of 59 residency programs are enrolled, including academic and community-based programs.
The 12-month study, led by investigators from the University of Pennsylvania, Johns Hopkins University, and Brigham and Women’s Hospital, states that its goal is ‘to provide evidence to help policymakers evaluate whether the current duty-hour standards should be changed.’
Measured outcomes will include ‘patient safety and trainee education,’ with data from Medicare claims, exam scores, and participant surveys.
The study comes on the heels of a similar year-long, randomized trial for surgical interns (Flexibility In duty hour Requirements for Surgical Trainees, or FIRST), which began in July 2014 and is currently underway.
The programs in iCOMPARE’s intervention arm will adhere to three rules, which are consistent with the ACGME’s July 2003 duty hour regulations:
An 80-hour weekly limit
1 day off in 7
In-house call no more frequent than every 3 nights, averaged over 4 weeks
In November, 2015, the complaints about the two trials were announced by AMSA and Public Citizen. The main issues were summarized in a Huffington Post article by Dr Michael Carome of Public Citizen. First he stated that on its face, making house staff work long hours, as they are in the intervention group, is dangerous.
The iCOMPARE and FIRST trials have allowed first-year medical residents to work shifts lasting 28 consecutive hours or more — nearly twice the current maximum number of hours allowed by the Accreditation Council for Graduate Medical Education (ACGME) for such residents. The ACGME’s awareness of the known harms to both residents and patients caused by excessively long work hours led the organization in 2011 to tighten restrictions on resident physicians’ work hours, including limiting shifts for first-year residents to a maximum of 16 hours.
Substantial evidence shows that sleep deprivation due to excessively long work shifts increases the risk of motor vehicle accidents, needle-stick injuries and exposure to blood-borne pathogens, , and depression in medical residents. It also exposes their patients to an increased risk of medical errors, sometimes leading to patient injuries and deaths
The last statement cited seven references. I should note here that I could not find in the current media reports, or in the spotty documentation of the ICompare trial avaiable online any engagement with the evidence that sleep deprivation is bad for trainee physicians (and everyone else).
The next important point is that the housestaff who were research subjects of the trial, and their patients who also were at least indirectly research subjects did not give their informed consent for participation in the trial.
Among the many disturbing aspects of the trials is the researchers’ failure to seek the voluntary informed consent of either the resident doctors or their patients who are forced to be part of these experiments.
According to a recent media report, the University of Pennsylvania’s IRB — the designated lead IRB that reviewed and approved the iCOMPARE trial — incorrectly found that the trial involves only ‘minimal’ risk and therefore waived the requirements for obtaining informed consent for all subjects.
For the FIRST trial, the administrator of the IRB at Northwestern University, the lead institution for that trial, shockingly determined that the trial was not even ‘research with human subjects’ and, therefore, that IRB review and approval were not required. As a result, there was no opportunity for the IRB to discuss the risks of the research and the need for obtaining the voluntary informed consent of both the general surgery residents and their patients. This determination represents a colossal failure of Northwestern University’s human subjects protection system. This same failure presumably occurred at many of the other institutions that participated in the FIRST trial.
An article in the business section of the Chicago Tribune added that Public Citizen claimed the failure to obtain informed consent was all the more serious because the house staff and patients were exposed to danger contingent on their trial participation.
It claimed the ‘highly unethical’ experiments, including the other led by the University of Pennsylvania and Johns Hopkins University, exposed doctors to an increased risk of making serious medical errors and suffering personal injury.
‘Substantial evidence shows that sleep deprivation due to excessively long work shifts increases the risk of motor vehicle accidents, needle-stick injuries and exposure to blood-borne pathogens and depression in medical students,’ according to the complaint. For patients, the long hours could lead to increased medical errors and death, the complaint said.
Furthermore, the trials apparently did not include mechanisms for house staff to refuse participation, or to stop participating. An article in Medscape quoted Dr Karl Bilimoria, a professor of surgery at Northwestern who led the surgical trial,
Dr Bilimoria said that for first-year general surgery residents assigned extended hours at intervention-arm hospitals, the trial was no secret. ‘They were told, because they had to monitor their hours,’ he said. ‘Residents knew which arm of the trial they were in.’
‘This has been very public.’
Asked whether this process amounted to informed consent, he replied that if residents strongly disagreed with the prospect of longer hours, ‘they could choose to work elsewhere.’
The news coverage of the controversy included several statements that the trials were particularly and severely unethical. For example, a BMJ news article quoted
Charles Czeisler, professor of medicine and director of sleep medicine at Harvard Medical School [who] told the BMJ, ‘I was shocked when I heard about this study assigning resident physicians to work marathon shifts.‘ Czeisler said that even as little as one week of sleep deprivation was knwon to cause serious harms.
Other ethics researchers found it difficult to understand how such a trial could be approved by an institutional review board.
‘Because you’re looking at deaths of patients as the major outcome, that makes it much more difficult ethically to support because patients may be harmed,’ said Dr. Robert Klitzman, director of the master of bioethics program at Columbia University. ‘If you find that twice as many patients died under anything but the current system, you could say they died unnecessarily.’
Apparent Violations of the Nuremberg Code
[Photograph: Defendants in the dock at Nuremberg trials. Link here.]
In fact, in my humble opinion, the two trials appeared to violate several major components of the Nuremberg Code, the set of principles for ethical research that was developed after Nazi atrocities visited in the course of supposed medical experiments were revealed during the Nuremberg Trials. These principles include,
1. The voluntary consent of the human subject is absolutely essential.
This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements of the subject matter involved, as to enable him to make an understanding and enlightened decision. This latter element requires that, before the acceptance of an affirmative decision by the experimental subject, there should be made known to him the nature, duration, and purpose of the experiment; the method and means by which it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person, which may possibly come from his participation in the experiment.
The two trials did not get true informed consent from the housestaff subjects. As trainees required to complete housestaff training to become surgeons or internists, informing housestaff that their program would be participating in the trial, and their only option if they did not want to participate would be to seek another program surely seems like any consent they provided was given under duress. Furthermore, it is not clear that they were ever informed of “all the inconveniences and hazards reasonably to be expected; and the effects upon” their “health or person[s].”
2. The experiment should be such as to yield fruitful results for the good of society, unprocurable by other methds or means of study, and not random and unncessary in nature.
Again, if the major rationale for doing the trials was to mitigate the postulated effects of increasing hand-offs, there are many other ways one could try to do this which do not involve increasing duty hours and sleep deprivation.
3. The experiment should be designed based on the results of animal experimentation and a knowledge of the natural history of the disease or other problem under study, that the anticipated results will justify the performance of the experiment.
Again, there is a considerable body of research that sleep deprivation is harmful to patient and humans in general. Thus, the science suggests that increasing sleep deprivation will have unfavorable results, and thus the performance of a trial of increasing sleep deprivation seems unjustified.
9. During the course of the experiment, the human subject should be at liberty to bring the experiment to an end, if he has reached the physical or mental state, where continuation of the experiment seemed to him to be impossible.
Again, the housestaff could not easily opt out of further participation. At best, to do so, as one of the investigators said, they would have to quit their training programs, which could jeopardize their careers and entail major financial costs.
The main arguments of the trial proponents in response to the complaints seemed weak, and often appeared to be based on logical fallacies.
The ACGME and the IRBs Approved the Trials – Appeals to Authority
In the Chicago Tribune article:
But Northwestern said the council [ACGME] granted a waiver for the longer hours and helped fund the study.
‘It was done with their approval,’ Dr Karl Bilimoria, principal investigator for the trial … said.
An article from the Milwaukee Journal Sentinel and MedPage Today quoted Dr Thomas Nasca, CEO of the ACGME,
He said institutional review boards at all the participating hospital reviewed the trial protocols and determined the patients did not need to be informed.
These arguments amount to assertions that the trials must have been ethical because external authorities said they were. Thus they appear to be based on logical fallacies, appeals to authority.
The Arguments and Evidence Supporting Duty Hour Restrictions are Weak – Burden of Proof
In an unfortunately misnamed ModernHealthcare article (it refers to medical students rather than housestaff) , Dr Bilimoria was again quoted,
The key piece is that we just have never had prospective, randomized high-level evidence to inform our decisionmaking….
Similarly, in a Medscape article Dr Nasca, the ACGME CEO,
calls resident scheduling rules a work in progress, especially because only very small, single-institution studies have examined the effect of long hours on residents and patients.
On the other hand, there are no big randomized trials to suggest that longer duty hours or increased sleep deprivation is advantageous. However, there are huge numbers of studies that show that sleep deprivation is bad for patients and people in non-medical settings, as well as medical trainees.
In any case, the supporters of the trials seem to be arguing that the burden of proof should be on those who want to limit duty hours, while it seems more reasonable that to justify a trial of increased sleep deprivation, the burden of proof was on those who proposed the trial. Thus, this appears to be a version of the burden of proof logical fallacy.
Increased Hand-Offs are Bad, and the Only Alternative to Having Them is to Increase Duty Hours – False Dilemma
In trying to defend their work the advocates for these trials further corroborated my concerns above that the trials were conceived without any consideration that measures other than increasing duty hours (and consequent sleep deprivation) was the only possible alternative to the current situation. For example, in the Modern Healthcare article.
‘There’s always a trade-off,’ [senior RAND natural scientist Dr Mark] Friedberg said, noting the increased number of patient hand-offs that occur with shorter hours. These hand-offs reduce consistency of care and open patients up to more mistakes and miscommunication among providers. ‘It’s not clear-cut. That’s why you have to do the science,’ he said.
However, he did not argue that increased hand-offs are so bad that a trial of increasing duty hours and sleep deprivation to achieve fewer hand-offs could be justified. He also did not consider whether there might be some way to mitigate the effect of increased hand-offs without causing sleep deprivation.
Similarly a New Haven Register article quoted Dr Thomas Balcezak, chief medical officer for Yale-New Haven, saying
one issue is that there are ‘more handoffs between caregivers’ when residents work shorter hours. ‘There’s always a risk that important information could fall through the cracks’ because of ‘a lack of consistency or continuity.’
Again, that seems to be at best a theory, but not evidence based argument. Besides, the article quoted Dr Carome of Public Citizen on just one of many other possible approaches to mitigate the effects of increased hand-offs,
hospitals could overcome that problem by hiring doctors to work overlapping shifts.
There is no evidence that the people who were so concerned about hand-offs thought of any alternative ways to mitigate any problems the duty hour restrictions could have created. This corroborates my concerns that the trials were fundamentally based on a logical fallacy, the false dilemma.
Managerialism and Tunnel Vision
So why would medical educators at some of the most prestigious US teaching hospitals launch trials to see if increasing housestaff sleep deprivation might benefit them and their patients, mandate partcipation of housestaff and patients in these trials without obtaining informed consent or allowing these subjects to opt out of the trials, thus seemingly violating the Nuremberg Code, and then defend their actions with logical fallacies?
I do not think they have gone mad. I do suspect they are in the thrall of their managerialist hospital executives.
Recently we discussed the rise of managerialism in the leadership of health care organizations. Managerialism, which wraps up what we have called generic management, the manager’s coup d’etat, and aspects of mission-hostile management into a very troubling but coherent package, was first described for a medical audience in 2015 by Komesaroff in an article in the Medical Journal of Australia(2):
The particular system of beliefs and practices defining the roles and powers of managers in our present context is what is referred to as managerialism. This is defined by two basic tenets: (i) that all social organisations must conform to a single structure [defined by management theory and dogma]; and (ii) that the sole regulatory principle is the market. Both ideas have far-reaching implications. The claim that every organisation — whether it is a mining company, a hospital, a school, a professional association or a charity — must be structured according to a single model, conforming to a single set of legislative requirements, not so long ago would have seemed bizarre, but is now largely taken for granted. The principle of the market has become the solitary, or dominant, criterion for decision making, and other criteria, such as loyalty, trust, care and a commitment to critical reflection, have become displaced and devalued. Indeed, the latter are viewed as quaint anachronisms with less importance and meaning than formal procedures or standards that can be readily linked to key performance indicators, budget end points, efficiency markers and externally imposed targets.
Many of the prestigious teaching hospitals/ acacemic medical centers/ hospital systems participating in the two controversial trials may be led in the managerialist tradition. We have shown numerous examples of such leadership that may put short term revenue and the continuing enrichment of top managers ahead of all other concerns, including good patient care and the integrity of academics, has been frankly mission hostile, and jump on the latest management bandwagons as solutions all problems.
I postulate that housestaff directors at such institutions tremble at the idea of challenging such leaders. Yet to improve the handoff problem, teaching programs might have to do things that cost money. Spending money that does not lead to immediate increases in revenue, and boosts in management pay, could be an anathema to managerialists. Also, to improve the hand-off problem, programs might have to challenge management dogma, such as the worship of badly designed, time wasting electronic health records. So I suspect the leaders of the two studies consciously or unconsciously eschewed trial designs that could assess any educational alternative that might have made management uncomfortable. Thus boxed in, they wound up with an apparently indefensibly unethical research project.
I hope that the two studies create the degree of controversy they deserve, and that the federal government promptly starts investigating honestly and thoroughly. I further hope that this unseemly episode causes medical educators to rethink the cozy or at least conflict averse relationships they have with their managerialist leaders.
True health care reform would restore health care leadership that understands health care and medicine, upholds the health care mission, is accountable for its actions, and is transparent, ethical and honest.
1. Durmer JS, Dinges DF. Neurocognitive consequences of sleep deprivation. Sem Neurology 2005. 25. 117-129. Link here.
2. Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM. The scourge of
managerialism and the Royal Australasian College of Physicians. Med J
Aust 2015; 202: 519- 521. Link here.
Lambert’s two principles of neoliberalism:
1. Because markets.
2. Go die.
I can’t imagine a more classic case.
For guidance, why don’t we consider how teaching hospitals in other countries train physicians and schedule medical housestaff? Since there are many countries that handle every aspect of health care better than we do, and obtain superior results, why don’t we study what they do, and then copy them?
What you suggest is rational, humane and undermines the presumption of American exceptionalism. That’s why.
I think the use of junior doctors as cheap labour, and a macho insistence on long hours is a major feature in most countries. There is also a culture of senior doctors using the juniors to fill in anti-social hours. Within the EU, the Working Time Directive states that workers are prohibited from working more than 48 hours a day, no more than 24 consecutive hours can be worked at any one time, and everyone is entitled to 11 hours consecutive rest per day. But around Europe, especially in the UK and Ireland, this is widely breached, especially in those countries suffering from austerity – its a quick and cheap way for hospitals to fill in problem shifts.
I think you mean 48 hours a week…
Carla, yes, sorry, thats what I mean (I wish I could blame sleep deprivation…!)
Alex: “I was cured alright”……….A Clockwork Orange
Which part of the study examined the effect of sleep deprivation on the efficiency of transmitting data during hand-offs?
However, the whole basic premise is silly. The idea that doctors, unlike truck drivers, airplane pilots, nurses, etc. do not suffer from impaired judgement from sleep deprivation is wrong. Plus, handoffs are inevitable (patients rarely schedule their illnesses to coincide with the start of an intern’s shift) – so why not study how to make them more effective?
Good luck on this. Voluntary consent goes against pretty much everything in management philosophy today, from local hospital administrators to our national Democrats in a kumbaya circle with torturer in chief Dick Cheney himself this week.
I’ve often wondered why certain professions – financial and medial being the most obvious ones – insist so much on insanely long hours in the early years of the profession. As this article points out, and is of course very well known, is that long hours are ultimately counter productive. Most psychologists will tell you that human beings can only be truly productive for (depending on the task) a relatively few hours a day of intensive work. I’d make the distinction here between ‘real’ work (i.e. intensively crunching figures, running around hospital wards, etc) and ‘long hours’ involving sitting on first class airline seats, yawning during overlong meetings, etc.
Partly of course there is an element of macho ‘I had to do it, I don’t see why this lot shouldn’t suffer’. There is also of course a ‘gateway’ effect, of limiting incomers to the middle class and especially upper middle class professions in order to maintain a shortage, which I suspect is the primary reason. But it is astonishing that it persists even in the face of mountains of evidence that it is counter productive. A sensible boss knows when to tell his staff to just go home, have a drink and rest, because they will be much more productive the next day.
I was thinking this when reading a construction history of the Dublin docklands. At that time, many workers worked a mere 2 hour shift, five days a week for a full wage! The work was mostly in pressurised bells, as they excavated harbour wall bases. This was incredibly tough work, very physically demanding and dangerous. And so, very sensibly, the companies had waves of workers doing very short shifts – because they knew anything more was counterproductive. Having worked in construction I’ve no doubt that in a similar situation nowadays some manager would insist those workers hung around for another 5 or 6 hours doing some meaningless work just to say they were working a ‘full’ day.
In the medical field, I do think sometimes staff can be their own worse enemies. I spent way too long in hospitals when my parents were ailing and I could see nurses wilt under long 13 hour shifts, some looked exhausted at the end. I idly read some research into it, and it was generally very negative about the quality of nursing during long shifts (if anything, nursing is even more physically and mentally demanding than medicine). But it was actually the nursing unions who fought for those hours – many nurses witch children and long commutes preferred 3 day weeks.
Having been put through that sort of time stress myself (and to the point you allude to, it isn’t just the hours that are terrible, it’s often the time stress of “how can I possibly get all this done?”) I can offer only some answers.
One is that since it’s always been this way, the young people can “clearly” do it. But what has happened, at least on Wall Street, is the time pressures have increased due to tech. For instance, in the old days, when you rode in a cab or were on a plane (with no computer!) you got a mental health break. No more.
Second is hinted at in Poses’ discussion of handoffs. If management broke up the tasks and handed them out among more people, they’d have to manage more. But on Wall Street in particularly, management is looked down on. People are doing deals and making money. Managers are pussies. So having the more senior dealmakers do more management is considered to be a poor use of their time. Hence what is properly a managerial problem is dumped on young employees in the form of giving them insane amounts of work and deadlines and having them sort it out.
My internal medicine residency was from 1984-87. I always dreaded in-patient rotations and the first day I inherited new patients–many with with thick charts and long problem lists. Were we extending life? Or prolonging dying? Were drugs and treatments teaming up for good? Or were they causing side effects that we chased with new drugs and treatments?
The stress took its toll emotionally and physically. Post-call days, my brain was foggy. I was slow. I felt shivery from autonomic nervous system overdrive. My immune system was at its worst during my residency. One call night, I went to the ER for multiple nebulizer treatments because my otherwise normal airways had become wheezy after I had come down with a cold. I was sicker than many of my patients. Thankfully I was pulled off that rotation.
Needless to say, electronic medical records haven’t eliminated the stress of call.
In the end, my residency did very little to prepare me for the everyday work of clinical practice. Back pain. Chronic depression. Obesity. Addictions. Poverty. Why would managerialist hospital executives give a rip about overworked and stressed doctors?
Stress is big business for health care.
well Yves, you just gave a fine example of the downside (to the detriment of society at large) of progress! Progress does not necessarily = Good
Thanks for that Yves. I’m a little surprised to hear that it is a lack of management, even if that does make sense.
Just as a comparison, I once worked for a notoriously ruthless construction engineering company, which specialised on project managing major petrochem and infrastructure works around the globe. There were guys there who worked long hours, but in comparison to medicine and finance, it was nothing at all. The culture was very much of ‘if you can’t get your work done in a regular day, there is something wrong with you’. The majority worked conventional 8 hour days – the super ambitious construction managers did 12 hour days, but had the weekend off. There was a lot of pressure put on, but none at all to work very long hours – if someone did, it was generally considered a problem caused by poor recruitment. I’m continually shocked at my friends at the lower tiers of finance companies thinking nothing of 16 hour days and working through the weekends (it must be said that some of them genuinely love it).
I should have said by the way that the example I gave above of workers doing 2-3 hours a day in the Dublin docklands dates to the period 1880 to 1930! But having said that, I think that within the construction industry there has long been a recognition that excessive hours will, literally, kill. Nobody wants to die crushed under 5 tons of cement because the driver fell asleep at the wheel.
I believe that technology and advances in medicine have clearly increased the complexity of training. We have more options for treating many problems, but often the options are complex to implement, cause nasty side effects, require complicated monitoring, etc (and sometimes they don’t provide more benefits). Just having more options increases cognitive load. And then there is the EHR.
I don’t think we need more managers in clinical education. But we do no need more doctors, nurses, therapists, and technicians.
One thing that is not well known about medical residents is that the majority of their salary is paid by Medicare. It is easy to see then why teaching hospitals have no qualms about overworking their temporary (since residents usually stay for only four years) employees. Teaching hospitals are adept at privatizing profits and socializing gains.
And all those old people are going to die anyways, right?
I think you misunderstand my point. Teaching hospitals view residents as free labor because they essentially are (since Medicare directly provides the funds to pay resident salaries, even for residents that do not interact with Medicare patients). I have no problems with Medicare and wish it would be extended to Medicare for All.
In a nutshell: Me macho PR**K, you serf to butt-kiss me!
Informed consent requires proof; usually a signature on a form.
NIH’s own tutorials on human subjects research are often required for IRB approval and the ethical standards have no place for the behavior described in this report. Even simple interviewing is considered human subjects research.
The details of the report are shocking.
I wonder what a class warfare analysis of this situation would conclude?
The neoliberal response to criticism is always the same- if you don’t like our system get out. The moral bankruptcy demonstrated by the elite and managerial class is displayed more openly every day. Getting out is indeed the answer.
How does one effectively fight this moral bankruptcy? How does one effectively get out? Ordinary citizens are stuck in a contradiction. The contradiction of being part of a society acting insanely, but needing by necessity to stay connected to that society. As Thomas Merton shared, No Man Is An Island.
Even the conception of “fighting” the moral bankruptcy seems misdirected-leading to failure. Less fighting and more living is needed. I see great potential in a radical passivity- a movement of not participating with the powers that be. Easily said, lots of hard work in reality.
I think we have to work to replace the morally bankrupt system with one that functions for the public and the planet. Am currently reading “Debt or Democracy” by Mary Mellor (subtitled “Public Money for Sustainability and Social Justice.”) It seems a good place to start. The next crash will be our opportunity, and we’d better be ready.
How does one “get out” after one has borrowed a hundred thousand “dollars” of imaginary credit which is treated as “real money” and which has to be paid back on money “really earned” . . . since the newly graduated new doctor cannot issue imaginary debt-extinguishing counter-credit the way the lender can issue imaginary credit to begin with. One doesn’t “get out” because one can’t.
Younger peoples’ only hope is to see and behold, and ponder . . . and decide whether they want to “get in” to begin with. Articles like this might help younger people understand that once they are “in”, they will never get “out” ever again. Some might even decide they would rather be poor than be doctors.
I’d like to hear more about radical passivity.
The whole thing about hand off problems makes about as much sense as saying that limiting duty hours for airline pilots is unsafe because it would lead to pilots having to go off duty in the middle of the flight leaving the flight deck empty. There are multiple ways I can think of that would increase continuity of patient care without having doctors work dangerously long hours. I have a friend who is completing her residence in and the hours she is forced to work strike me as being criminally negligent with regards to both the patient’s care and her own health. Maybe we can try improving health care by forcing the management to work straight 36 hour shifts over and over again. Since it would likely make them less effective it might work.
Apparently the Nuremberg Principles are “just a g-d piece of paper.”
This makes me glad the local hospital is not a teaching hospital – but, mind you, the hardest cases are always sent to a teaching hospital; they’re the standard of care, making this issue doubly urgent.
Not just this issue but the whole pattern of systematic abuse of interns is deeply, maddeningly offensive from a patient’s point of view. In the above case, the really extreme victims are not the “housestaff,” who at least stand to gain from their training, but the patients, who had no choice at all. That medical authorities are willing to take chances with helpless patients, and even defend the practice, is really alarming. Who are these people?
While “managerialism” makes sense, in fact the abuse is long-standing, part of medical tradition. I have a plausible but much less flattering explanation: it’s an initiation ritual, like hazing in fraternities (do sororities do this, or something like?) It serves to restrict the supply of doctors, along with the other psychological rewards of initiations – but at the cost of the patients. And the senior doctors making these decisions and excuses, having gone through it, feel that new doctors should have to, as well – an especially ugly bit of all-too-human.
Anybody whose loved one died or got worse at any of those hospitals during this “trial” has grounds for a lawsuit, though it’ll be hard to make the connection. The mere threat might be enough to straighten them right up.
I wrote this before reading PlutoniumKun’s; apparently we agree.
The efficiency expert corporate consultants should all be burned at the stake, then maybe we’ll all be able to breathe a little easier…
Profits or Bust: Inside the Mind of an Efficiency Expert
That’s what I always thought it was . . . a recreationally sadistic hazing ritual for the amusement of senior staff who carry on the tradition. And then maybe managers realized that since the sadists-in-charge practice torture for the fun of it ( and how is sleep deprivation in a teaching hospital any less torture than sleep deprivation in Guantanamo was torture), that the hospitals might at least learn to make some kind of profit off the torture.
I wonder whether criminal prosecutions might be the way to go. Target the senior doctors who practice this form of torture on med students and Mengelexperiments on patients. Hit them with arrest after arrest after arrest, trial after trial after trial. And for those convicted, long hard time in America’s worst prisons. When will groups like The National Lawyers Guild advance from legal DEfense to legal OFFence and start the forcible bringing of citizen-demanded prosecutions against those Mengeliform darlings of the ruling class whom no prosecutor would/will ever touch on herm’s own?
The phrase ‘more flexible regimen’ is a tip off about the goal of the study. The question itself suggests they had a predetermined answer they wanted and built the study toward that end. As Lambert says, “Because Markets.”
Great post. Thanks.
Lets be honest here. Most physicians in charge of the majority of medical academic centers are likely to be in their mid 40’s and up, and are likely to have had no limits to their hours in training. We were called residents for a reason, and we were cheap labor and we had no rights. We’ve now been in practice for 20+ yrs and think we are at the top of our game. We have disdain for the financial bureaucracy we’ve been swept into, but look back at our training in mostly positive ways. Are we really the best people to create an entirely new system of training?
Despite the snowball of ever increasing knowledge and techniques to master both in the classroom and in the hospitals, and despite the work restrictions placed on residents, training programs have NOT gotten any longer! Does this make sense to anyone? How could med school have been 4 years long 50 years ago and as well today?Pick your residency to say the same thing about. Are new surgeons coming out with enough experience? You either lengthen medical school and residencies or completely change the educational system. There are reports of this in some circles, but not anywhere close to the degree needed. I admire the med students of today in their ability to stand up for their rights, but admittedly find myself preferring my training to theirs.
This isn’t a new problem. Back in the day (late 60’s) I spent some time at a teaching hospital on the East Coast where the house staff hours on the medicine service were “every other night, every other weekend”. But that was for being “on call”, and most nights we lost only an hour or two of sleep. It could be brutal though. One of my housemates achieved heroic status by admitting 6 MI (heart attack) patients during one snowy New England night. We had discussions of the policy, and the consensus was that it was probably a disservice to the house staff and patients. But we had signed up knowing the hours to get the certificates to show off, with their handsome blue block raised letters.
One person exposed to the program took the matter seriously, and later had a position at the AAMC (trade association of medical schools) where she made house staff hours a personal cause, to some effect. The Libby Zion case further vindicated her efforts.
The worry about “hand-offs” seems entirely spurious. I don’t remember it being brought up in any of our discussions of the policy. We had morning meetings where all acute patient problems were reviewed. And the nursing staff kept an eye on them. It’s difficult to see how you objectively determine the adequacy of a hand-off and whether it led to poor care. Given that the records required would be a bonanza for plaintiff’s attorneys, na ga happen.
In the early 1970’s I spent two years at Hopkins. It was a privilege. Yes, the hours were brutal, by some standards. You had no life other than the ward or ER or OR or ICU. But you got something priceless in return. You got to watch and learn the evolution of disease. Through repetition you could reflexively sense that there were problems and you learned to deal with them. As a surgeon today I see our current trainees released out onto the public with minimal experience. If you are not there all the time you don’t get to see the cases and do the cases. You don’t get to see what happens when things don’t go right. The younger surgeons I do work with complain about their lack of experience all the time. In those days the hospital did not bill out for physician services and the house staff just did the work. The Chief Residents saw to it that the juniors got staged experience. That all started to change subsequently. My sense is that a lot of the current problem is driven by regulatory capture and those, managers, that want to profit off medical care. Doctors should once and for all abandon the fee for service model and simply work for a fixed salary and that would solve a lot of this. Their focus should be on patient care. Don’t forget, Fleming did not patent penicillin.
When I was 19, I married a young man who was 20. He went to medical school and did his residency at a hospital in San Francisco. It was 1974. As an intern, he was required to work everyday with every other weekend off. On every third night he was up. There was no going home in the morning. He simply continued his day as if he had actually gotten sleep. He became a wonderful doctor. He also became a speed addict and it killed him in his 40th year. I can’t tell you how many other young doctors that I knew also had drug problems. It took me years to understand that he might have actually killed people.
Unfettered Capitalism Kills.