Physician: get over thyself

If any member of the medical profession wonders why more than a few people prefer to seek "alternative" treatments, wonder no longer. While ignorance and gullibility among the lay public are rampant, there is also the very serious problem that people simply don't believe that conventional, accredited doctors always have the patient's best interests at heart. Yesterday I came across a recent study that offers some good justification for that lack of confidence.

The paper, in the June 2006 issue of the American Journal of Obstetrics and Gynecology (subscription required), reports the findings of a survey of opinions on just how many hours a resident should be required to work every week. The participants were directors of accredited obstetrics and gynecology residency programs -- the people in charge of those residents. Most, though not all, directors are in favor of some kind of restriction. That's the good news. The bad news is a lot of them see no problem in forcing young doctors to work more than 80 hours a week, despite solid evidence that such long hours result in medical errors.

"The perceived impact of duty hour restrictions on the residency environment: A survey of residency program directors" by a group at University of Alabama at Birmingham concluded that "Variations in current opinions regarding the impact of residency duty hour restrictions reflect ongoing bias in those most influential to resident education." In other, harsher, words that I came up with, executive-level physicians are letting personal, unscientific, and anecdotal evidence interfere with the care of the women and children the doctors they supervise are supposed to be looking after.

Less than half of the survey respondents (41%) said the maximum work week should be equal or less than the current mandate of 80 hours. The balance preferred longer work weeks -- as much as 120. This is sane? Does anyone really expect a resident who has worked 100+ hours won't be significantly more likely to make a misdiagnosis or prescribe an inappropriate drug or dose? I'd say that it's virtually guaranteed that such errors will occur in such a work environment.

Of course, that's just common sense. The authors of the survey weren't satisfied with that, citing some good research to back up what everyone already knows:

In the fall of 2004, the Harvard Work Hours, Health and Safety Group, released the results of 2 seminal studies that provide convincing evidence for the link between fatigue, clinical performance, and medical errors. They found that interns who worked a reduced clinical schedule (80 hrs/wk). In a related investigation, this group found that interns who worked an extended shift schedule in an intensive care unit setting made significantly more serious medical errors than when they worked a shortened schedule. In conjunction, these studies suggest that reduction in the number of hours worked in these settings can reduce both attentional failures and the rate of medical errors.

So what could possibly explain the preference for absurdly long work hours, conditions that could fairly be described as a prescription for tragedy?

Well, among the most common arguments was that fewer hours worked will compromise the educational experience for the resident. Shorter hours on the job means fewer opportunities to learn about different diseases and treatment. The survey team dispenses with that notion by pointing out that there's no evidence to support the claim.

Furthermore, as much as "one third of resident effort is expended on activities of no educational benefit," suggesting that the limiting factor is program director management skills, not time. Improved assignment distribution and scheduling could achieve the same level of educational experience in fewer hours.

It is no surprise that a professional would resist changes to the way he or she has been doing things. In my experience in newsrooms, editors usually make for terrible managers. Mostly because their training was dominated by tasks designed to make them good reporters, not managers. And what management training most editors get comes from short seminars from MBAs who know nothing about the journalism business. I don't know much about the medical profession's management-training habits, but I'm guessing it's much the same: senior doctors get promoted to program director based largely on their expertise in treating patients, not their administration skills. Feel free to correct me if I'm wrong, but it would appear that the study in question supports my theory.

Another curious finding from the survey is that female program directors would set longer work weeks than their male counterparts. The authors speculate that this is because most of the female directors entered the field back in the day when it was so male-dominated that they had to work extra hard to prove themselves, and so they are determined to make sure the next cohort has to work just as hard. It's the same twisted logic behind the humiliating initiation rituals that upper-classmen force on first-year students in college. Pathetic, really. But very human.

Coming back to my main point: if doctors, who are supposed to be schooled in the value of the scientific method, can't get beyond childish attitudes and baseless justifications for making their younger colleagues work ridiculous hours, then it should not be surprising that more than a few people are skeptical of their commitment to patient welfare.

None of this should deter a reasonable person for seeking scientifically valid medical treament. But lay people are expected to make dubious decisions based on inappropriate criteria. Physicians should be better than that.

On a personal note, I came across the AMO&G journal while my wife and I waited at our chosen Ob-Gyn clinic for a monthly checkup for my wife, who is six month's pregnant. We'd already switched clinics once because of our concern over the high rate of caesarian sections being performed in the U.S. It's now at 31% and rising another 1% each year. In Canada and many European countries, by comparison, it's closer to 20%. And according to a 2005 study (Am J Obstet Gynecol 192 (2005), pp. 102-108) "ever higher primary CB [C-section) rates have not led to any improvement in overall neonatal outcomes." Indeed, there are 25 countries with lower infant mortality rates lower than the United States.

Clearly something is out of whack with the establishment.

The last thing I want is for the attending physician, who will be overseeing the midwife that helps deliver our child, to be so tired that he or she can't think straight. The decision on whether to perform a C-section must be based on a lucid and alert doctor's advice. And I have a great deal of trouble believing anyone who has worked much more than, say, 60 hours in a week, let alone 120, will be meet that description.

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a good post. here's my take. there is a cult mentality in residency programs that seeks to take over the doctor's life completely and crush all ties to the outside world. reasons for this include the making of dedicated physicians (seasoned and able to perform under duress), simple hazing military style, a feeling of "I worked 120 hrs a week in residency, and why should the next generation have it any easier? hospitals are increasingly underfunded and financially troubled, and if you subtract the slave labor most residents provide (i routinely worked 120 hrs a week for $37K in my day), then they'll be in even worse shape (not that I care, perhaps the hospital administration shouldn't expect to make typical corporate salaries).
hours used to be much worse, and if enything they are better than ever with the institution of the 80 hr work week, so your inferences about public mistrust are a little off? (you would think it would be improving with recent reforms). that mistrust stems from our cooperation with big pharma, the barriers thrust between doc and patient (third party payors, malpractice fears, hipaa, etc) and general ignorance about scientific principles that we rely upon to separate the snake oil (chiropractic, homeopathic) from the aspirin.
and good luck with your ob care. it's a miracle that students still chose to do ob-gyn, sacrificing their social/family life and personal health to work horrendous hours to cover $150,000+ yearly medmal insurance rates while they continue to get sued for not doing C-sections early enough. if we weren't getting reamed from all sides we might have more sympathy for your lack of trust in us, but honestly being a doctor is increasingly becoming a thankless minefield of impossible public expectations in this business model/trial lawyer hellhole.

*deep breath*

I think you are correct about the issue with management skills in residency directors. Physicians get no formal training in management. The expectation seems to be that they are generally smart people who should be able to figure it out as they go along.

There is one aspect to the argument in favor of long work hours, that you did not cover. One rationale (which I do not agree with, by the way) is that if doctors spend longer hours in training, while they may make more errors during training, they will be less likely to make errors after training.

If a physician spends four years in a training program, and has a high error rate over those four years, but then spends 40 years in practice with a lower error rate, then overall, fewer errors will be made.

The problem with that argument is that there is strong evidence for the existence of the higher rate during training with the long hours, but no evidence for the assertion that there will be a lower error rate afterwards.

While it probably is true that people learn from mistakes, that is hardly a reason to intentionally put yourself in a position to make such mistakes.

What Dr. Charles said, for the most part. A response to this post would take too much space for just comments here; so I may do a more detailed one in the blog early next week, especially since it will give me an opportunity to review the scientific literature on work hours, which is not quite as clear-cut on the subject of medical errors and hours worked as you make it sound in your post. (Also, tomorrow's Your Friday Dose of Woo, appropriately enough, and now that I have it going I don't feel that I can interrupt its scheduled appearance.)

I also agree with Dr. Charles that it's a huge stretch to argue that a big reason the public doesn't trust the medical profession's pronouncements on evidence-based medicine is its attitude towards work hours. If that's even a factor at all (which I highly doubt, for reasons that I'll enumerate if I do that blog post), it's a very small one; Dr. Charles lists factors that are vastly more important in contributing to that mistrust, IMHO.

In the end, a lot of it comes down to money. The consequences of the work hours restrictions for residents tend to flow uphill, with higher level residents picking up the slack for interns and lower level residents and then attendings having to pick up the slack for upper level residents when they have to go home due to work hour restrictions. In my institution, a lot of the senior residents resent the work hour restrictions, because they didn't benefit from them when they were interns and now they have to take up the slack to make sure that the interns go home on time. (I realize that this will shake out over time, as tomorrow's chiefs were brought up in the era of work hour restrictions.) In any case, there are no work hour restrictions for attending physicians. Worse, with Medicare and insurance reimbursements being cut, many physicians have little choice but to see more patients and work longer hours just to stay even, and even then it's damned hard. Expenses (office staff, malpractice insurance, supplies, etc.) keep going up, but reimbursement per patient contact and per procedure keep going down. If we as a society truly want to decrease doctors' work hours (a laudable goal for simple humanitarian reasons, although I still remain somewhat skeptical that it would reduce medical errors as much as you imply), we're going to have to pony up the cash to fill in the lost hours and services. Even if physicians accept a considerable decrease in net income in return for more free time, this will likely still be true, given the cost of training additional physicians and the fixed costs that come with each one regardless of how many hours that physician works.

Dr. Charles is also correct about OBs. I have no idea why anyone would want to go into that specialty anymore, given the current malpractice and reimbursement climate, which is why I admire those dedicated enough to stick it out. The wife of one of my partners is a high risk OB, and I've joked with her before that she's crazy to be doing not just OB, but high risk OB, in one of the most litiginous states in the nation.

Damn. I've already written more than I had intended. I should save some for Monday or Tuesday.

The objection that no one really distrusts MDs solely because of the work-hour situation is well taken. But I wasn't trying to make a direct association. It's just an example of the kind of thing that leads to distrust.

There are many other systemic problems in the American medical field that also contribute, but all have to do with putting imaginary and/or unnecessary fears ahead of patient safety. Few other countries have the same problems, at least to the same degree -- largely, I would argue, because some of the profit motive has been removed from the equation. The fact remains that maximizing patient health care is not the highest priority in many an America hospital. And until it is, it is easy to see why so many will be tempted to turn to New Age quackery (Of course, the profit motive is even stronger there, but it is camouflaged in layers of warm-and-fuzzy feel-goodness.)