Work Hours, Sleep and Patient Safety in Residency Training

Recently I read a disconcerting article on sleep (or really, sleep deprivation) and residency: Work Hours, Sleep and Patient Safety in Residency Training by Charles A Czeisler, Ph.D., M.D. Ever wonder why we'll have to work such long hours during residency? Here's an excerpt from the article:

Extended duration work shifts, like many other features of graduate medical education in the United States, were the product of the postgraduate medical education curriculum developed by William Steward Halsted, M.D. Professor Halsted, who was Surgeon-in-Chief at the Johns Hopkins Hospital, was internationally renowned for his innovations in medical education. He founded the surgical training program at the Johns Hopkins Hospital in the 1890s, which served as a model for postgraduate medical education. He required physicians-in-training to live in the hospital (they were quite literally residents) and discouraged them from marrying so that they could devote themselves to medicine. He required residents to be on a “q1” call schedule, i.e. they were on call 362 of 365 days per year. He taught devotion to the profession by example, working heroic hours with his trainees. Only recently was it revealed how he maintained this grueling sleep-deprived schedule. Professor Halsted was in fact addicted to cocaine, an addiction that was an unfortunate by-product of his pioneering work developing cocaine as a surgical anesthetic. He spent more than a year in a rehabilitation program at a Rhode Island hospital trying to shed his cocaine addiction prior to his appointment as the first Professor of Surgery at Johns Hopkins Medical School. However he only gained an addiction to morphine there, which had been used to treat his cocaine addiction.

It's a very long article, so if you don't have the time or inclination to read the whole thing, here's the summary at the end:

The work schedules of physicians in training require them to work extraordinarily long work shifts and long work weeks. These schedules, which are based on a tradition that dates back to the 19^th century, result in acute and chronic sleep deprivation. Sleep deprivation, misalignment of circadian phase and sleep inertia adversely impact cognitive performance and increase the risk of error and accident. Interns working extended duration shifts make significantly more serious medical errors while caring for patients in intensive care units, and make five times as many serious diagnostic mistakes. In addition to the deleterious effects of extended duration work shifts on patient safety, we also found that the risk of motor vehicle crashes is more than doubled driving home from work after such shifts. We conclude that the practice of working extended duration work shifts, which continues to be allowed by new ACGME regulations, are hazardous to both interns and their patients. Academic medical centers are urged to eliminate this now-dangerous tradition.

Something to think about. Yes, I plan to "suck it up" like everyone else and work my tail off during residency. But I'm convinced that in spite of the work-hour reforms of 2003, there is still room for improvement.

If you ever feel powerless, future doctors, remember that famous quote by Margaret Mead: "Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has."

Another reason to learn genetics....

$21 million awarded for 'wrongful birth'

By MITCH STACY, Associated Press Writer

Tue Jul 24, 7:25 PM ET

In what is being called a "wrongful birth" case, a jury awarded more than $21 million to a couple who claimed a doctor misdiagnosed a severe birth defect in their son, leading them to have a second child with similar problems.

But because the doctor works for the University of South Florida, the family will have to persuade the Legislature to award most of the money. State law limits negligence claims against government agencies at $200,000.

Daniel and Amara Estrada, whose two young sons aren't able to communicate and need constant care, sought at least enough money to care for the second child, 2-year-old Caleb.

"This is a severely impaired child who will need a great deal of care for the rest of his life," said Christian Searcy, one of the attorneys who tried the case. He called the award "conservative but fair."

The couple claimed that Dr. Boris Kousseff failed to diagnose their first son's genetic disorder, called Smith-Lemli-Opitz syndrome, which is the inability to correctly produce or synthesize cholesterol, after his 2002 birth.

Had the disorder been correctly diagnosed, a test would have indicated whether the couple's second child also was afflicted and they would have terminated the pregnancy, according to the lawsuit.

Instead, Kousseff, a specialist in genetic disorders, told them they should be able to have normal children in the future.

The jury decided Monday that Kousseff was 90 percent negligent and that an Orlando doctor not named in the lawsuit was 10 percent at fault.

A USF spokeswoman didn't immediately return a call seeking comment Monday.

Searcy said he would push state lawmakers to pass a bill awarding the Estradas money over the $200,000 cap.

"I believe that this case is so powerful and this tragedy was so preventable and is so poignant, that it is the kind of case that should rise above the fray and rise above party politics," Searcy said.

http://news.yahoo.com/s/ap/20070724/ap_on_re_us/wrongful_birth

Hope everyone's summer is going well!!

Should organ donors be paid?

An interesting piece from my graduate school's alumni magazine: http://magazine.uchicago.edu/0778/features/organs.shtm

What do you think?

Brad

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Should organ donors be paid?

With 96,000 Americans on the organ wait list and only 29,000 transplants performed last year, the transplant community constantly tries to encourage more people to donate. Yet some observers believe the volunteer system will never meet the need. Market proposals to increase the organ supply, MacLean Center for Medical Ethics Director Mark Siegler, MD’67, noted in his Ryerson lecture, “are attracting a lot of discussion in Washington.” The currently illegal practice of paying donors is also a hot topic within the University, where medical, business, and law faculty have taken part in the national debate.

Proposals range from a free-market system, in which individuals pay for organs, to a regulated system where the government (Medicare or Medicaid) or private insurance pays donors, at suggested rates from a few hundred to tens of thousands of dollars. The idea isn’t new: in a 1997 Business Week column GSB professor Gary Becker, AM’53, PhD’55, asserted that “the federal government might be designated as the only authority with the power to buy organs for transplants and would allocate them to hospitals with patients that need transplants.” In a working paper Becker and Julio Jorge Elías, AM’01, PhD’05, argue that monetary incentives could increase the organ supply, eliminating the long waiting list “without increasing the total cost of transplant surgery by a large percent.” They estimate the value of a kidney at around $15,000 and a liver around $35,000.

Yet cash might not be the preferred incentive, notes law professor Richard Epstein, who organized a July 6–7 Law School conference on transplant policy and in April 2006 argued for a market system before the President’s Council on Bioethics. A “package of benefits to cover illness or death,” he says, might serve a donor better. He’s not sure which forms the transactions would take “because no one’s allowed to try them.” Several hospitals, including Johns Hopkins, have begun successful paired-kidney exchange programs, showing, Epstein says, “that markets run better than you think.”

Market incentives, however, raise concerns. Moral objections include the arguments that buying and selling organs demeans human beings, commodifies the body, and changes the relationship between doctors and patients into a commercial exchange. The practice also could exploit the poor, who would be more likely to accept money for organs. Yet patients already pay for services and medications, Siegler says, and the poor, unfortunately, get exploited in many areas of life. He’s more concerned “about the utilitarian aspects of shifting from a voluntary, altruistic system to a commercial system.” Until the 1970s the United States used commercial blood banks, he notes, and studies showed the paid-for blood was more likely to carry hepatitis than volunteer blood; paid organ donors likewise may prove riskier. Siegler also worries that paid donors would replace, rather than supplement, volunteers. “If you do the experiment of a market system and end up with fewer organs,” he says, “you not only spend a lot of money but you also cost a lot of lives.”

For Chicago transplant surgeon Richard Thistlethwaite, the moral concerns are convincing. Thistlethwaite, president of the International Pediatric Transplantation Association, spoke against financial incentives at the group’s March meeting. Although increasing the supply is a dire need, he says, market proposals are “not about the recipient but the donor.” Asking for organs in exchange for money, he says, violates “human dignity,” changing donors “from an end in themselves to a means for someone else.” In Iran, which has a highly regulated paid system, “the majority of donors are worse off afterward,” he says, because they don’t seek follow-up care. The $1,300 government fee doesn’t improve their lives. India, which banned paid transplants in 1994 but where the practice continues illegally, faces a similar situation. The poor who donate don’t have sick leave and often lose their jobs during recovery. Yet in the United States, Epstein argues, donors would continue to be physically and psychologically screened, and they would receive much more money and possibly health care.

While proponents contend that individuals should have the autonomy to decide whether to donate an organ, for Thistlethwaite absolute autonomy is “an extremist view that could justify anything.” In the United States “you can’t sell yourself into slavery” and “people have to wear seat belts. Autonomy doesn’t trump everything else.” In the free market a woman can sell her egg for about $10,000. “But if it’s the right race and athletic ability, it could get $100,000.” To him such pricing, and college-newspaper ads soliciting egg donations, are “an atrocity.” And if the government set the price like many proposals suggest, he says, the autonomy argument becomes moot.

Then there’s the exploitation issue. No matter how much you pay donors, Thistlethwaite says, it’s “the upper class preying on the lower class.” It may work in an economic model, he says, but not in a “justice model.” And even with their health costs covered, poor people may not seek out postsurgical care. Although anecdotal evidence shows health risks to donors are rare, long-term studies haven’t been done on a large enough population. In the end, he says, “the ethical justification for doing this to people doesn’t exist.”

For Epstein, on the other hand, ethics demands the United States try a market system. In a May 2006 Wall Street Journal column decrying the Institute of Medicine’s recommendation against financial incentives, he argues that potential lives saved outweigh other concerns. “Only a bioethicist could prefer a world in which we have 1,000 altruists per annum and over 6,500 excess deaths over one in which we have no altruists and no excess deaths.” And with the money saved from reducing “the horrifically expensive dialysis program,” the country could provide organ donors with social services.

Epstein isn’t holding his breath. Though the President’s Council on Bioethics plans to issue a report on the topic in coming months, council member and Chicago professor of medicine Janet Rowley, PhB’45, SB’46, MD’48, notes that a market system is “highly unlikely to happen”—at least until “the list gets so big that it’s politically effective, or if someone who’s a big name dies” waiting for a transplant.