Averting Medical Mistakes

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When workers get tired, they make mistakes. When the exhausted laborers are physicians, those errors can prove deadly. A new paper in today’s Journal of the American Medical Association finds that first-year doctors, or interns, tend to experience notable sleep deprivation during their on-call hospital shifts. Moreover, these new doctors tend to be so busy that they often can’t find time to sit in on educational briefings and seminars.

So not only are these, the least-experienced doctors, not able to benefit from bonus educational opportunities, but they’re also so fatigued that they run a high risk of making diagnostic and treatment mistakes.

The findings come from a single teaching institution, the University of Chicago. However, its practices are typical of those in teaching hospitals across the nation, observes Kevin Volpp of the University of Pennsylvania School of Medicine.

In a commentary that also appears in today’s issue of JAMA, he and Christopher Landrigan of HarvardMedicalSchool note that the typical 80-hour-per-week work schedules for most new doctors are already much pared down from the 100-or-more-hour weeks that were all too common prior to 2003. Yet recent studies have generally found no improvement in patient survivorship or physician safety in the wake of this recent work-hour reform. Argue Volpp and Landrigan, this suggests hospitals need to make additional substantive changes to the way they train newly minted doctors.

And the pair offer some pointed recommendations.

For instance, they ask: Do doctors really need to work 30 hour shifts during which they’re expected to be fully functional for at least 24 hours? In fact, Volpp told me, many interns and residents actually end up working far more than 24 hours during a shift. In at least one study, he and Landrigan note, a 16-hour limit on work shifts reduced the number of preventable medical errors by 27 percent. The data came from a study of intensive care units. It’s now time to look at whether other hospital departments would benefit similarly, they say.

Or, they propose, if 24-hour work shifts are deemed necessary to safeguard continuity of care during the initial hours that patients spend in a hospital, perhaps the medical education accrediting body, ACGME, might consider mandating that doctors sleep — uninterrupted — at least 6 to 8 hours during each long shift. Doctors might be asked to log in and out on a computer, documenting when they were actively on-call.

I suspect ambitious docs might try to game the system, but one can also imagine ways to limit the risk that doctors work too long at any one stretch. Perhaps computers might lock out their ability to prescribe tests or meds when they’re supposed to be sleeping. Fines might be imposed on doctors for subverting the system by asking colleagues to put through the prescription requests under others’ names.

By the way, I asked Volpp why hospitals impose such Herculean work schedules on their youngest docs. The answer: They work cheap. When you divide their take-home by the number of hours they toil, it comes to something on the order of $11 per hour, he says. (Yikes. My 17-year-old earned that much life-guarding weekends at the local suburban YMCA — and twice that much for individual swimming instruction to primary-school kids.)

Aggravating the overwork problem, Volpp worries, is the current teaching-hospital practice of admitting up to five patients to the care of a given team of doctors once every four days. This “bolus” approach causes everyone to be stressed and overworked at the beginning of the cycle as they work out diagnoses and explore treatment regimens. His new commentary instead advocates for a trickling approach, where perhaps no more than one or two patients be admitted on any given day, allowing more focused attention on each patient.

Of course, the authors of the University of Chicago study point out, unless hospitals hire more staff, just cutting their interns’ and residents’ work load may offer zero benefits. The reason: Beleaguered young docs may now be asked to fit their former 24-hour workload into a 16-hour shift. Same number of patients treated in fewer hours may be a bean counter’s dream. But it’s not any hospital to which I’d want to be admitted. Let’s just hope the MBA crowd realizes they might save on malpractice suits if their docs-in-training are well rested.

An independent oversight agency — analogous to the Federal Aviation Administration — might be created to ensure that any reforms perform as designed. Volpp recommended that it be authorized to make unannounced inspections to confirm compliance.

In fact, carrots might be engineered to reward hospital programs that reduce overwork without sacrificing patient health. Medicare subsidizes doctor training to the tune of some $5.7 billion a year — or $110,000 per medical resident. Hospitals collect the money regardless of how they or their physicians perform, Volpp notes. His team’s JAMA commentary proposes taking a large share of that money and allocating it on a merit basis to institutions that find a way to reform workloads for their residents while improving rates of patient recovery. Institutions that don’t perform well would take a Medicare cut.

Now that would get the attention of hospital CFOs. And maybe hike the likelihood that all hospitalized patients receive a few more minutes of their young docs’ alert and undivided attention.