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Are Sleep-Deprived Medical Residents More Likely To Make Mistakes?

As of this writing, 5 air traffic controllers have been found asleep at the switch. By the time this piece is posted, several others may have joined the slumber party. Keep in mind, there’s a lot more snoozing in the towers than we’re aware of. We don’t know the denominator here. Our wise reactive government has recently issued orders that airport control towers must not be manned by only one individual. Somehow, prior to NappingGate, our bloated and inefficient government that is riddled with redundancy, thought that one sole guy watching the radar at night was sufficient.

There are some jobs where nodding off poses no risk. Let me test my readers’ acumen on this issue. Which of the following professions would not be at risk if an unscheduled siesta occurred?

  • A race car driver
  • A congressman
  • A circus clown (not to be confused with above listing)
  • A lawyer (not to be confused with the above listing)
  • A school bus driver

Let’s face it. Some folks on the job simply can’t safely snore their way through it. We don’t want Read more »

*This blog post was originally published at MD Whistleblower*

Emergency Medicine Residency Doesn’t Prepare Docs For The Real World

Emergency Medicine News:
February 2010 – Volume 32 – Issue 2 – p 5, 24, 25, 26

Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.

In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. Read more »

*This blog post was originally published at GruntDoc*

How To Know If A Doctor Is Good – Ask A Nurse

In a comment on my last post, faithful reader and frequent commenter Anonymous asked, “How do you get a good reading on interpersonal skills in a brief interview?”

That’s a good question.  I suppose the simplest answer is, you don’t, at least not in any sort of comprehensive way.  In some cases you can — a person who is warm, engaging, and able to hold up their end of a lively conversation in an interview setting is always going to be near the top of my list.  But I make a lot of allowances for people in their interviews — they are nervous, know they are being watched and judged, it is a high-stakes encounter for them, and most people are a lot more constrained in an interview than they are in their day-to-day lives. Read more »

*This blog post was originally published at Movin' Meat*

Rural Emergency Medicine: Stigma & Stereotypes


Lee Falls, SC

I practice in the rural, northwest corner of South Carolina, also known as “The Upstate.”  It is a place of expansive lakes, white-water rivers and the mist covered foothills of the Blue Ridge Mountains. The area includes thousands of acres of Sumter National Forest.  The natural beauty is breathtaking.  Sumter National Forest and our various parks are laced with hiking trails, which are lined with unique plants and trees, some found nowhere else.   Fish and game abound.  In fact, our wooded hospital grounds support a flock of at least 30 wild turkey.  And last deer season, the only deer I saw were the three does grazing at the end of the ED driveway one night, spotlighted by two of our paramedics.

We have a lot of wonderful things here, things that are gifts of the rural life.  We have good people, the salt of the earth types who care about personal morality and Southern courtesy.  People who bring you a glass of sweet tea when your car breaks down.  We live with a low crime rate, and minimal illicit drug use compared with more populated areas.  It is a good place to raise children.  It’s also a cool place to practice, where a busy summer shift can bring an acute MI, a near drowning (from inner-tubing on Class IV white water while drunk), a pit viper bite, a bull goring and many other pathologies, more or less interesting.

But, as physicians in a rural area, we pay a price.  Because we have to endure a certain stigma.   Read more »

Work Hour Restrictions Protect Patients From Sleepy Surgeons

Surgery Residency, Massachusetts General Hospital and Work Limits – Health Blog – WSJ

It’s not surprising that newly minted doctors at one of the most prestigious hospitals in the country, and in a specialty with a particularly demanding residency, have been violating national limits on work hours.

But the Boston Globe’s report that Massachusetts General Hospital must rein in surgical residents’ hours is a reminder that the work limits put in place several years ago remain unpopular with many residents and senior doctors.

Not surprising in the least.  I’m actually astonished that there’s anybody with the chutzpah to defend extended work hours for residents.   I did my residency largely in the pre-hour-restriction era — there were hour restrictions on months in the ER, but effectively none for the off-service rotations — and it was a terrible way to deliver care.  I did my time of q3 call in the units and q2 call on surgical services.  This includes a memorable time when I was the sole intern on the pediatric surgical service and was on duty for ten days straight without leaving the hospital.  That gives a new meaning to being a “resident physician!”  (Actually, that’s the original meaning, if you must get picky about it.)

The care provided was just scary.  I prided myself on being a machine and able to get through 36 hours of uninterrupted work without cracking; I used to run marathons and endurance was my forte.  And I did get through it better than most.  But after 24 hours with no down time (and there was never meaningful down time), you get stupid, and you make mistakes.  I remember once, in the medical ICU I was surprised in morning rounds to find that one of my patients had had a swann-ganz catheter placed overnight.  Caught flat-footed by this in front of the attending, I asked the nurse who had put in a swann without telling me, only to be informed that I had done the procedure! Apparently I was too sleep-addled to recall that I had done it!  Fortunately, I had apparently done it right, because a swann involves threading a catheter through the heart into the pulmonary vessels and can be Very Bad [tm] if you screw it up.   But I apparently did it by reflex without actually achieving a state of full wakefulness.  This sort of thing was fairly routine, and I also remember well the overnight residents being excoriated in morning rounds for the errors and misjudgments they had made overnight.  Great training, but not so great for the patients who were the victims of the mistakes.

It seems to me that the defenders of the status quo have donned their rose-colored glasses.  They fondly remember the camaraderie and the pride in accomplishment that their residencies evoked, while conveniently forgetting the mistakes and omissions, while neglecting the depression and divorces and other personal costs of such an abusive training environment.  And there’s the faux toughness: “I got through it, they can, too if they’re not too weak.”  And the old guard romanticize the qualities of the “true physician” in their dedication to their patients above all else: “These younger doctors just don’t care enough.”

What a load of crap.

Look, it’s with damn good cause that other professions in which errors can hurt people have work time restrictions (truck drivers, airline pilots, etc), and it’s stupid and arrogant to think that we physicians are so awesome that we are immune to the human factors of fatigue and circadian rhythms that contribute to errors.  When it’s inexperienced trainees working the ridiculous hours with minimal supervision (in many cases), the potential for fatigue-related errors is compounded.

I also question the motivations of some of those who defend the status quo.  It seems strangely self-serving that residency directors who would otherwise have to find attending physicians or PAs to perform the work that residents do on the government’s dime are the ones to insist that the situation is just fine, or that “the evidence of benefit is lacking.”  How cool is it that they can ignore reams of research on human factors, take the a priori position that the system is fine as it is, and demand formal evidence on “efficacy, safety and cost” before making any changes?  That’s balls!  It’s also fairly blatant obstructionism and should not be given any credence.

Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed.   Flexibility is fine, but accountability should also be demanded.

I would also take issue with Dr Bob’s comment that this “training system that has served our profession well for many years.”  I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide.  They are terribly concerning.  I would not lay all of this at the feet of residency, but I would say that the abusive (I’m sorry, “rigorous”) environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients.  Nobody is well-served by the current system.

It is true that change might be painful.  Reducing hours might mean reducing patient contacts and reducing the training opportunities for physicians.  This might require academic centers to revalue the time of physicians in training, by which I mean that residents might no longer be used as free menial laborers.  Maybe it doesn’t make sense to have a surgical resident “running the book” — many surgical residents never see the inside of the OR till their second and third years.  The universities might have to hire PAs or NPs for the “scut work” instead of using MDs in training as glorified secretaries (what a waste of time and money).

I’m glad the Institue of Medicine and the ACGME seem to be on the right path with the recommendations.  The reactionary response from the change-resistant academic centers will take some time and political will to overcome. I remember when they first imposed the rules, they followed it up by decertifying the Internal Medicine program at Hopkins for violating the rules.  That effected the desired change, I can tell you!   Hopefully, as the restrictions evolve, there will be accountability and enforcement until the culture starts to shift.

*This blog post was originally published at Movin' Meat*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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