When the numbers don’t add up…

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photo credit: stethoscope via photopin (license)

July 1st marks the first day of training for newly minted doctors, eager to start the journey towards becoming fully licensed, competent, independent physicians. But being an intern and resident in today’s day and age of medicine is proving to be more difficult than ever. I’ve written about resident work hours before, but now that I have finished intern year, I have a lot more to say regarding this issue.  I recently reread Dr. Chen’s article “The Impossible Workload for Doctors in Training,” and also read “The Real Problem with Medical Internships” by Dr. Jauhar published in NYTimes today, and it really got me thinking. An op-ed published in JAMA last year urged doctors and the higher-ups responsible for residency program accreditation to “treat the disease, not the symptom,” and I absolutely agree.

Here’s the problem. Residents had a long history of being overworked and undersupervised, especially at night, and in 1984, the death of 18-year old Libby Zion in a New York City hospital less than 24 hours after admission made national headlines. The details around her death are not exactly clear, but her father, who had worked as a NYTimes journalist and was friends with several other journalists in the city, released the story to the media. He even managed to convene a grand jury to try to charge the physicians involved with murder. He wrote in an op-ed piece for the NYTimes:

“You don’t need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life-and-death.”

The wheels were set in motion after a public trial that awarded Mr. Zion $375,000. The ACGME, the organization that is responsible for accrediting residency programs, began to set down a series of restrictions that were intended to improve resident work hours and in turn, help with patient safety. In 2003, 2009, and again in 2011, the ACGME put forth new duty hour restrictions. The latest change mandated that interns, freshly minted doctors out of medical school, were only allowed to work 16 hours a day and a maximum of 80 hours a week.

In theory, this sounds like a good idea. In theory. But the number of patients in the hospitals have risen nearly 50% from 1990 to 2010, and this patient population has become overall sicker as a group as well. The number of doctors to provide care to all these extra patients has only gone up by a mere 10%. Tell me this: how do you distribute more work to less doctors available to do it?

This may sound crazy, but the answer the ACGME came up with was to simply let the doctors deal with this issue. More work for less people? Figure it out. But the simple arithmetic doesn’t make sense. There’s no way to stretch each doctor more thinly to do more work without compromising patient care. At my training hospital, one intern covers over 100 patients by him/herself at night. Let me repeat: overnight, one sole intern less than a year of out of medical school cares for the same number of patients covered by 16 interns during the day. I will never forget my night shifts this year. I don’t want to say I was terrified, but I will be honest, I was pretty damn nervous. There are other residents in the hospital (2 admitting in the emergency department and 2 covering the Intensive Care Unit), but they were equally busy with their own patients as well. I remember being called to evaluate one decompensating patient with another call overhead 2 minutes after for me to see another worsening patient. By the time I finished quickly seeing the first one and then rushed to see the second, I had received around 30 pages on my beeper with other urgent questions for patients that I was not familiar with at all. I got paged on average every 3-5 minutes for the first few hours of the night, then it would die down to a page every 10-20 minutes in the middle of the night, and then ramp up to every 5-10 minutes again in the morning. By the time I left the hospital at 7:30 am, I was pinching myself to stay awake on the drive home. More than a few times, I’ve fallen asleep at a stoplight only to be woken up by the honking of an enraged driver behind me.

Residents working in the Intensive Care Unit regularly work 30 hour shifts in a row, taking care of the sickest of the sick patients coming through our hospital doors. This means making complex medical decisions and performing life-saving but invasive and potentially dangerous procedures, all on very little sleep. If you or your loved one were the patient, would you feel comfortable with that? One of my residents this year told me that he naps in his car after every 30 hour shift because he knows he will get into a car accident if he tries to drive home right away.

“Isn’t it crazy,” he asked me, “that I can’t even trust myself to drive home, yet I’m entrusted with making life and death decisions and performing complicated procedures on the sickest patients in the hospital?”

When I tell people who are not in medicine about this system, they are understandably shocked and question how safe this model is. For the most part, we survive night float and the ICU without many mishaps. But I could very easily see how a series of events during an exceptionally busy shift could lead to a big lapse in patient safety, a perfect storm of sorts, in the current model.

Some hospitals have hired extra non-resident staff to help out, but that’s more expensive than having the residents do the work. Residents make on average $51,000 per year when they first start intern year, and they work on average 80 hours per week the entire year. For comparison, physician assistants make a median salary of $92,970 per year, and they work on average 40 – 50 hours a week. Hospitals will be very hard pressed to find other doctors or physician assistants willing to work a residents’ number of hours for that type of salary.

But, you may be saying, have the duty hour restrictions been improving resident life? The data is rolling in. The new system with work hour restrictions has resulted in worsening educational opportunities for residents and deterioration in continuity of patient care and perception of care received by the patients. Residents aren’t sleeping more, and they aren’t happier either. Also, with the new duty hour rules, the percentage of interns who said they were worried about making serious medical errors rose from 19.9% to 23.3%.

There is no easy fix for this problem, but I think one thing is clear: We desperately need to expand the number of staff available, be it residents or other physicians, nurse practitioners, or physician assistants, to help provide safe patient care. My colleagues and I went into this profession because we want to help people, but the current model is making it difficult to give each patient the care he or she needs and deserves.

 

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