Do Sleepy Surgeons Have a Right To Operate?

Hugh Pickens writes "BusinessWeek reports that a commentary from the New England Journal of Medicine calls on doctors to disclose when they're deprived of sleep and not perform surgery unless a patient gives written consent after being informed of their surgeon's status. 'We think that institutions have a responsibility to minimize the chances that patients are going to be cared for by sleep-deprived clinicians,' writes Dr. Michael Nurok, an anesthesiologist and intensive care physician. Research suggests that sleep deprivation impairs a person's psychomotor skills — those that require coordination and precision — as much as alcohol consumption and increases the risk of complications in patients whose surgeons failed to get much shuteye."

Comments

Develop a test

[StripedCow]

Why not develop a test (perhaps a video game) which a surgeon should pass before entering the surgery room?

Re:Develop a test

[Toth]

Ten or so years ago, our trucking division experimented with such a program. It ran on a PC and had a controller with a single knob which could be rotated left or right.

You used the knob to keep the cursor in the center spot on the screen. The cursor would become more difficult to control during the test (about 30 seconds)

Drivers would sign in for the first time and establish a baseline for themselves by taking the test multiple times until the program indicated that a baseline was established. (About a dozen attempts, I think)

Once a baseline was established, a driver had to pass the test before starting his shift. If he failed, he had to see a supervisor.

I tested it on myself. After two (unmeasured) shots of vodka, I would have had to see a supervisor were I a driver.

An additional advantage was that you would also fail the test if you had the flu, were sleep-deprived or emotionally unfit to drive.

The program never went into full production at our place. Currently drivers are tested when hired and after any accident or delivery process incident.

I forget what it was called (I tried googling). I thought it was "fair". If you couldn't pass the test, you probably shouldn't drive a truck that day.

If you smoked a joint a week ago, it wouldn't affect the test but if you were up all night watching movies, you'd likely fail.

Re:Develop a test

[Dr_Barnowl]

Please don't diss NHS doctors. Having been in exactly that position, a junior doctor too tired to do a proper job, I can tell you that the major reason the NHS is in such a world of pain originates from the top down, not the rank and file.

The NHS has for some time been dependent on the goodwill and vocational motivation of it's healthcare professionals, because they sure as hell ain't motivated by the working conditions, pay, and benefits.

The real problems in the NHS stem from multiple sources, including the increasing cost of healthcare consumables (increasingly expensive technology and pharmaceuticals), the costs of revolting profiteering (aka the "Private Finance Initiative"), targets set by politicians, an excess of managers, a decrease of basic common sense and an increase of feelings of entitlement amongst the UK population (I've seen people turn up in A&E (ER) depts for things as basic as a cold or a knee graze).

Yet despite all this, we still achieve better health outcomes than the USA despite spending a quarter per-capita what they do on healthcare. Does this mean we are more than four times as competent?

The story itself is from the New England Journal of Medicine - so has originated from doctors themselves, trying to improve the care that patients receive by fighting against the market forces that increasingly try to reduce medical professionals to the same depth as any other druge worker stuck in a poverty trap.

Re:Develop a test

[FatalChaos]

Part of the problem with this is that any video game (or other) test that is reasonably quick is going to be reaction based. Surgery is not about quick reactions. I've watched open heart surgery, and it took a good 4-5 hours to complete. Surgery is about slow, slow precision, and by the time you could test for that, the patient is probably already screwed. Think of it this way: go to a hospital, and ask who are there best surgeons. You'll find out a lot of them are at least in their 40s, if not 50s and 60s. When was the last time you found ANY 40, 50, or 60 year old who was a legit gamer?

Re:Develop a test

[uglyduckling]

The problems do apply to nurses, but on of the real issues for junior doctors in the UK is that we move around departments and even hospitals/trusts every 3-6 months. The longest job I've done has been for a year. So although nurses do have a rough time, there's a lot more scope for them to figure out how to have a workable life/work balance because they stay in a dept. for a long time and figure out the system. For junior doctors, it's like starting 2-4 new jobs every year. Having said that, most juniors are better paid than most nurses.

Re:Develop a test

[stevelinton]

Just needs a different type of game. Maybe something like threading a needle (could use actual needle and thread, or a Wii or something). Or slowly guiding a point of light down a narrow twisty track with the mouse.

Re:Develop a test

[MMC Monster]

The problem is that most of the best surgeons are in their 40s or higher.

This is because the younger ones don't get the sheer number of cases required to be a great proceduralist. Why not? Well, it's mostly because they're required to go off shift after 24 hours, or 12 hours if they're on for a 24 hour shift the next day, etc. Who scrubs in on those cases? Well, the hospitals are hiring more physicians assistants to take up the load.

This is what the director of surgery at a major New York City teaching hospital told me earlier today.

Re:Develop a test

[countertrolling]

Pfft! We've had that for almost 50 years..

Re:Develop a test

[FiloEleven]

Sounds like a form of impairment testing, which is a pretty big win for everyone but has not been widely implemented. Employers who have used it found that it consistently reduced accidents, and employees like it since they don't have to pee in a cup--a demeaning and annoying procedure. It should also be cheaper for employers: even at a couple thousand bucks for the machine and software you used, the payoff in reduced accidents and mishaps along with not having to pay drug testing companies all the time means it'll pay for itself in a very short period of time.

It doesn't unfortunately seem like it's going to catch on anytime soon. Most companies haven't heard of it, and my guess is that most who have are waiting for it to gain a reputation before thinking about making the switch themselves.

Re:Develop a test

[Shotgun]

You would think it would be a big win for everybody. You would be wrong.

It's a BIG loser for the dispatchers and salesmen. When I hired on for RTC, they gave us an indepth class on how to get more driving hours in a day. It involved sleeping and driving in four hour shifts. Now, WHY would they do this?

Because, clients would gravitate to the company that could deliver on time. There were penalties, up to and including simply refusing to accept the load, for not delivering on time. Salesmen would indiscriminately put tickets for hauls in. No consideration was taken for capacity. Dispatchers were responsible for seeing that the loads got hauled. Dispatchers could say something along the lines of, "Yeah. That's not possible. Trucks don't move that fast." Dispatchers who said something along those lines would end up asking, "You want fries with that?"

The bottom man on the pole was the driver. He got handed a ticket that said he had to haul a load 1000 miles by noon tomorrow. He could say something along the lines of "Yeah. Given our current space-time continuum and the laws of the Interstate Highway System, that is not physically possible." The next thing he would say is, "You want fries with that?"

The impairment testing would document that a driver was unfit to drive, something most drivers know already. After an accident, the first thing the insurance company would ask for is to see the results of the impairment test, and then deny the claim because the driver had been turned around with a forged log book after a 1500 mile marathon run.

Impairment testing is a win for everyone, except for the people that would be responsible for installing them.

Re:Develop a test

[MillionthMonkey]

I used to do more surgery, but it cut into my xbox time.

Re:Develop a test

[leromarinvit]

Impairment testing is a win for everyone, except for the people that would be responsible for installing them.

Sounds like a good candidate for a law then, doesn't it?

This is just another waiver

[santax]

Come on, so you get into the ER, need treatment right away, you're gonna tell the only doc available to first get some sleep? Don't think so. The hospital/doc should have made sure that the staff is fit enough to even be on watch. This will just mean: yes sir we are very sorry you lost your kid due to bad handling from are doctor, but look here: that is your signature. So you can kiss that lawsuit goodbye. Hospitals shouldn't have people who are sleepdrunk on the watch. Simple as that.

Re:This is just another waiver

[nbauman]

I agree. If the surgeon's abilities are impaired for lack of sleep, he shouldn't operate, and it's the responsibility of the surgeon and the hospital to enforce that rule.

They can't dump the responsibility on the patient, especially by shoving an informed consent form under his hand in the 15 minutes before surgery. The patient isn't qualified to evaluate that risk.

This wasn't a BusinessWeek article, btw. It was a HealthDay rewrite of a New England Journal of Medicine article http://www.nejm.org/doi/full/10.1056/NEJMp1007901 [free]. The NEJM article more clearly made the important point that hospitals shouldn't get into these situations in the first place by letting surgeons schedule elective surgery after a night of being on call. Here's the hypothetical case from the original article:

A surgeon on overnight call responds to an 11 p.m. call from the hospital, where a patient has presented with an acute abdomen. After working up the patient for several hours, the surgeon decides to call in an anesthesiologist and perform a bowel resection. By the time the procedure is completed and the operative note has been dictated, it is time for morning rounds. The surgeon has not slept all night and is scheduled to perform an elective colostomy at 9 a.m. Does the surgeon have an obligation to disclose to the patient the lack of sleep during the past 24 hours and obtain new informed consent? Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon? Should the hospital have allowed the surgeon to schedule an elective procedure following a night he was scheduled to be on call? Should it allow a surgeon to perform elective surgery after having been awake for more than 24 hours? What potential unintended consequences of disclosing a clinician's sleep deprivation should be considered?

Re:This is just another waiver

[mfh]

It'd be nice to see a cure for the requirement of sleep in human beings. This is a bad flaw. Not to mention it cuts back on my WoW time.

Re:This is just another waiver

[bill_mcgonigle]

Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon?

Both of these are problematic - in first case because the patient has scheduled a work vacation for the surgery and in the second case, because the primary surgeon is familar with the case and has spent time doing pre-operative planning. You don't just throw in another surgeon at the last minute unless it's an emergency.

The correct answer, as mentioned previously, is to consider on-call time as utilized and to not schedule the surgery after on-call hours. Truck drivers have more sensible rules.

Re:This is just another waiver

[Hoi Polloi]

If they allowed/required docs to get 8 hours of sleep a night they'd not only be doing the patients a favor but they'd be doing the doctors a favor. It isn't good for their health either. They require truckers to get some sleep, I'd think that a person performing surgery is at least as important.

My brother is a doctor and sister a head nurse and from what I hear there is no good reason beyond macho tradition for doctors to work without sleep for so long.

Re:This is just another waiver

[SuiteSisterMary]

Lots of other professions, such as, say, airline pilots, have rest requirements. This isn't new and uncharted territory.

Re:This is just another waiver

[demonlapin]

Harder than you think. On-call duties don't just include doing surgery. I'm an anesthesiologist, not a surgeon, but I did play one for a month as an intern, so I may be able to give you a bit of an idea how things work.

The way to reduce call is to increase the number of people in your group. Larger group = less frequent call. HOWEVER, larger group = larger number of patients admitted to multiple hospitals to care for overnight, and less familiarity with those patients. If you're in a 3-man group, and you're on call every third night, you'll get to know your partners' sicker patients better. If it's a 10-man group? You'll rarely see the same patient twice, and there will be a lot more of them. In the 3-man group, you'll have a manageable list of patients, and given the number of things that happen in an average night, you'll probably get a bit of rest. The bigger the list of patients, though, the more likely you are to get called about something during the middle of the night. Maybe the primary surgeon forgot to write an order for Tylenol for the patient; maybe the patient is constipated and wants something for it (an astonishingly common complaint); maybe they want a sleeping pill. Doesn't matter; you've got to take a call and deal with it.

Furthermore, surgeries are scheduled by days of the week - you will have (e.g.) one room on Mondays, two rooms on Tuesdays, and one room on Friday afternoons. Regardless of what night you're on call, that's when you can operate. Since surgeons only make money when they operate, there is an enormous incentive not to miss an operative day. Since the hospital only makes money from ORs that are in use, if you don't use your operative time you'll lose it. Cancelling a day of surgeries has enormous costs - you already have a nurse anesthetist, a scrub tech, a circulating nurse, and housekeeping personnel scheduled to work there. Do you send them home early, effectively docking their pay for something that isn't their fault? Or do you pay them to do nothing?

Re:This is just another waiver

[dkleinsc]

They can't dump the responsibility on the patient, especially by shoving an informed consent form under his hand in the 15 minutes before surgery.

Oh yes they can (legally speaking), and as long as it's profitable for them to do so they're going to do exactly that. That's the problem with a health care system driven by the profit motive - actually caring for patients well is highly unprofitable.

Re:This is just another waiver

[countertrolling]

Truck drivers have more sensible rules.

But a doctor can usually only kill one person at a time. Depending on the cargo, a truck driver can take out a pretty large area.

Re:This is just another waiver

[Surt]

There are also a lot more truck drivers than surgeons. The payoff for beneficial rules comes a lot faster when amortized over a larger population.

Re:This is just another waiver

[alphastrike]

I agree. Being a resident I have some additional points to add on to your arguments. It may seem simple to reduce work hours, but it's over-simplified solution to a very complex problem.

Resident physicians are physicians who have finished medical school. They have a MD behind their name but are still in training. Say that hospital A has a training program for doctors. In order for the community to recognize the doctors graduating from hospital A's program is competent, hospital A must get approval from the ACGME(Accreditation Council for Graduate Medical Education).
The ACGME evaluates the program intermitently to assure the program's training fits the acceptable standards. Say the Residency program has 5 residents per year.

Right now the ACGME has a limit that no resident physician can work over 100 hours per week.(Let me point out that is actually 2.5 full time jobs). Say the ACGME drops that to 80 hours per week. Now suddenly you need more residents. If all 5 residents work 20% less, they will need at least 2 more residents per year to make the schedule happen. If the program have 20 residents, they'll need 6-7 more residents to make it happen. The ACGME however, might not approve of this. All hospitals have a patient load. If your residents are barely getting enough experience, diluting the load by adding more residents might put the training program below standard. Thus the ACGME can deny your request for additional personnel.

So the ACGME is forcing hospital A to reduce work hours, yet at the same time refuse to approve more residents. What do you do? Hire some physician assistants? Their average salary is more than 150% of an average resident, and they work far less hours. As a hospital/group who is trying to make profit, it would be less than ideal. Like the "don't ask don't tell system" it's easier if they just didn't report the work hour violations.

So if the problem is sleep, if you set thinigs up so residents work only 12 hour shifts instead of a 24 hour shift(call) then it would be okay right? No so. Continuity of care is not as good. A nurse sign out to the next nurse when their shift is done, but they have upwards of 6-8 patients on the floor. When a physician sign out to his/her relief, you are talking about any where from 10-50 patients. The more hand offs = more room for error, so you are trading exhaustion for hand off errors. Plus you have to now staff nights, which increases the number of staff needed. Previously when one person is staffing you now require 2 to provide 24 hour coverage.

The ACGME is making work hours more strict, but is the hours the surgical resident working really going down? Are they going to scrub out of a 12 hour case early so they can go home? no. Are they going to come in late and miss the next day's cases? no. Are they willing to lengthen their training from 5 years to 8 years because of a reducting of work hours and cases? hell no. Are they going to report their own program, have it shut down and end up having to look for new place to train? Again no. So most of the time they just don't report it when they work over their limits.

The institution try to fix the problems on the surface. The real problem lies in the cost of hiring medical personnel, the large debt from medical education, and the sharp difference in wages between a resident physician and an attending physician. Medical care when treated as a business is going to be squeezed for profit like any other business. Work hours is one of the scenarios where patient care and profit clash.

NO

[zero.kalvin]

Any other question ?

Would Patient Consent Work?

[Major_Small]

I like the idea of patient consent, but it wouldn't always be possible. I just got into a motorcycle a few months ago and had surgeries, chest tubes, intubations, and couldn't even breathe on my own for a bit. I wouldn't have been able to consent to any of this, but it was necessary to keep me alive.

I work a night shift in a hospital. If you've never worked one before, know that some nights you will be absolutely exhausted. I'm sure most night-shifters have fallen asleep at work before, if not on a regular basis. Doctors are not above this. Our hospitalists have on-call rooms to sleep in every night. If you code in a hospital overnight, chances aren't bad that one of the doctors that shows up was woken up by your code seconds before he showed up in your room.

My point is, hospitals are open 24/7. There is a night shift. Those people are usually tired. Also, emergencies happen 24/7. Sometimes patients can't consent to anything.

Imagine this: A patient shows up at 2am with an injury that would kill the patient before the morning shift came in. All the surgeons are asleep. You'd have to wake up an entire surgical team. All of them will be tired when they come in. The patient, however is unconscious. Bringing this patient back to alertness would risk their life and put them in so much pain they wouldn't be able to sign or agree to anything. What now? (

I think attention should be paid to organizations overworking clinical professionals, but it should be kept in mind that sometimes work that a patient may not even want to save their life has to be performed by people who are incredibly tired and just woke up just to keep the person alive. That's just how it is.

Re:Would Patient Consent Work?

[kyrio]

That must have been a really big motorcycle in order to get into it!

Re:Would Patient Consent Work?

[TapeCutter]

"Fortunately, the stay was covered, which was lucky because my insurance company only covers one of the local hospitals for things which aren't trauma care or preapproval."

As an Aussie who enjoys cheap and effective universal health care, I cannot for the life of me understand why Americans are not outraged by that sort of bullshit.

Re:Would Patient Consent Work?

[TechNit]

I agree with your description of the current system in the USA. The point of the article is it is asking if there is a better way. I am of the opinion that there is but it will require sweeping changes to the whole system. It is the responsibility of the system to insure that doctors/staff are not impaired prior to treating a patient. Asking the patient if they consent to having an overworked resident conduct surgery on them is ludicrous! The patient should never be put in such a dilemma! The attitude of "That's just how it is" is lame to the extreme and it is this exact attitude that needs to be remedied!!

Re:Would Patient Consent Work?

[Rakshasa Taisab]

I'm pretty sure prisoners in America get better healthcare than the average american. ^_^.

Trust a doctor

[pehrs]

Asking me to sign a waiver should a surgeon about to cut me open be tired seems only like a CYA policy. I can't make an informed decision, and I am most likely in distress and need of the surgery and saying no would delay it.

I am already putting a huge amount of trust in his abilities, and that includes him being able to decide if he skilled and in shape to do the operation or not. If I can't trust my doctor to make that decision I can't trust him to operate at me anyway. Therefor this seems completely pointless.

I

Re:Well, of course, it should be the other way aro

[Anonymous Coward]

Killed five people while she was at it. Good for her! Now she has a shitty BMW to show for it!

this is just dumb

[Triv]

Your relationship with your doctor is based on trust and consent - you don't ask your taxi driver to submit to a breathalyzer before he drives you home, so why should you ask your doctor how he's sleeping? If you don't trust your doctor to be operating on you in good condition, you need to find yourself a different doctor.

Re:this is just dumb

[hedwards]

Well, perhaps you should require a taxi driver to submit to a breathalyzer. Drunken driving is a killer.

People, in general, do not have the knowledge necessary to figure out the difference between a surgeon that's competent and safe and one that just presents well. Likewise, the anesthesiologist is every bit as important and one really doesn't have any good way of knowing if they're up to it.

Re:this is just dumb

[hedwards]

The bigger problem is drug abuse. I'm not sure what the rate is, but it's high enough to be of concern. Especially since it happens on occasion where the doctor is using some of the medication that's supposed to be used on the patient to get high during the procedure.

It's a concern, although, the vast majority of anesthesiologists aren't doing that. They do have one of the highest rates of substance abuse of any profession.

Re:this is just dumb

[demonlapin]

Really not that big of a deal. The abuse issue is a perennial favorite, but people get found out pretty quickly - one of my former partners was using fentanyl, but the incredibly high rate of habituation to the stuff meant that he triggered a pharmacy investigation less than three months into the habit.

The rate of abuse is primarily an issue of access: we hold the keys to the candy store. If you were a high-functioning individual who liked using drugs, what would you choose? Pediatrics, where you get all the cherry-flavored Tylenol you want? Or anesthesiology, where you get the good stuff?

Proper rest

[Anonymous Coward]

You know, in a country where even truck drivers have regulations requiring proper rest, you'd think there'd be some sort of standard for medical practitioners of any kind. Of course, if any politician ever tries it those AMA campaign donations will dry up like the Gobi Desert.

Re:Proper rest

[couchslug]

I get some great reactions from medical folks when I mention that the Air Force generally enforces a 12-hour shift limit for aircraft maintainers, even in wartime. Tired people fuck up, and anyone who pretends otherwise is full of shit.

The medical world should borrow two things from military aircraft maintenance. Limit shifts to 12 hours except in emergencies where manning is insufficient, and CHECKLISTS.

Pilots, who are at least as studly and narcissistic as physicians, KNOW ignoring checklists is a great way to fuck shit up. That's why it is PUNISHED.
They also know, even with training, that no one can remember every detail of every complex task they have to perform. From maintainers to aircrew to the folks in the control tower, checklists are considered orders to be obeyed.

Physicians have little time to see each patient, so they have to match symptoms with their concept of a "template" for a particular malady. Checklists are ideal for this sort of thing.

As to the civilian custom of working interns to exhaustion, that's just stupid. The military can train enough folks for wars, the civilian side of the house should "militarize" medical care (including quality control and open chain of command for complaints) and get shit done.

Re:Proper rest

[dkleinsc]

3 cheers for checklists! My sister is studying nursing right now. Those checklists are life-savers.

I also have friends who are or recently have been medical residents. That kind of pressure, with shifts that last well over 12 hours, is quite simply an abusive labor practice.

Re:Proper rest

[bill_mcgonigle]

The military has a culture that's designed to take ego out of the decision processes. Perhaps imperfect, but the danger is recognized and dealt with. Now, try working at a hospital...

Actually, it would be interesting to compare military hospitals with civilian and see how they rate on important measures.

Re:Proper rest

[Daniel Dvorkin]

Actually, it would be interesting to compare military hospitals with civilian and see how they rate on important measures.

Having worked quite a bit in both, I'll say that I think military hospitals are ahead by almost any measure you care to name.

Re:Proper rest

[couchslug]

Proper checklists aren't constraints, they are reminders of proper procedures. There is even a saying in aircraft safety, "add but don't take away".

Pilots can fly highly complex combat missions and adapt to changes on-the-fly, yet basic procedure checklists reinforce memory. The pilot doesn't always read the checklist verbatim while doing a task, but does have it available to supplement his skill.

Have some Atul Gawande:

http://www.npr.org/templates/story/story.php?storyId=122226184

""We brought a two-minute checklist into operating rooms in eight hospitals," Gawande says. "I worked with a team of folks that included Boeing to show us how they do it, and we just made sure that the checklist had some basic things: Make sure that blood is available, antibiotics are there."

How did it work?

"We get better results," he says. "Massively better results.

"We caught basic mistakes and some of that stupid stuff," Gawande reports. But the study returned some surprising results: "We also found that good teamwork required certain things that we missed very frequently."

Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.

"Making sure everybody knew each other's name produced what they called an activation phenomenon," Gawande explains. "The person, having gotten a chance to voice their name, let speak in the room -- were much more likely to speak up later if they saw a problem."

article's title

[underqualified]

"Doctors Urged to Admit Fatigue Before Performing Surgery"

I wish we had something similar in my previous company.

"Developers Urged to Admit Fatigue Before Fixing Bugs"

Here's a crazy idea.

[BlueParrot]

How about ensuring doctors work humane shifts as opposed to trying to squeeze every penny out of the system?

This is not just a problem with the US btw. I've spoken to doctors from lots of different countries, including Sweden, the US and England.
In general they are overworked, get little time to recover between shifts, and are expected to work overtime as part of the job description.

That's not going to be good for either doctor or patient.

Re:Here's a crazy idea.

[bill_mcgonigle]

There are several things that need to be done. They're mostly interdependent, so in no particular order:

1) stop the hazing culture in medicine
2) striate the practices. The concept of an Uber-doctor is antiquated. (LPN's and PA's are starting to help here). Cooperating teams is the smarter approach.
3) decrease doctors' hours
4) decrease doctors' salaries
5) get the government out of licensing doctors and medical schools (the chronic shortage is purposeful)
6) get the AMA out of dictating government policy for licensing doctors and medical schools (the chronic shortage is purposeful)
7) destroy the third-party payer system
8) get the States out of regulating insurance
9) privatize medical charities (the Shriners are a great example)

The current system is not designed to produce the best patient care, and that's all that needs to be said. In most industries we praise the "customer first" approach, even for ultimately stupid and inconsequential stuff. We know by experience that if the customer is placed first that the rest of the business succeeds, but somehow fear that approach when it comes to one of the most essential industries.

Re:Here's a crazy idea.

[chooks]

Another issue is that residency training (which is basically where doctors learn to take care of people) is funded for the most part via Medicaire. Without that money (which is substantial) hospitals cannot afford to train doctors. So even if there were sufficient medical students in the system, under current licensing laws (which require at least 1 year of post-graduate residency training) the bottleneck would be on residency positions and funding.

Re:Here's a crazy idea.

[bill_mcgonigle]

For someone that is pushing a very libertarian philosophy that sounds like some pretty strict regulation.

Like I said, interdependent. If there are more doctors, fewer responsibilities for doctors, and they work fewer hours, their salaries will go down. Supply and demand are sufficient forces here.

I don't know about you but I don't want someone slicing me open and operating on me based on a piece of paper from a degree mill.

Why would you go to a doctor that had a degree from a paper mill? There are already many 'rate your doctors' websites for post-graduation feedback.

8) get the States out of regulating insurance

Would you invest in a mutual fund without reading the prospectus? Why would you buy insurance from an insurance company with a bad credit rating?

Granted, some of these ancient regulatory laws may predate wide availability of the requisite information to make good decisions.

Re:Doctors/Nurses do not get speeding tickets

[neapolitan]

This is simply not true.

If you are legitimately speeding (safely) to perform an urgent operation, the police may escort you to the hospital, enter with you, verify you are about to do an operation, then leave you without a ticket (it happened to several of my colleagues, usually late at night.)

Just being pulled over and showing your hospital badge / white coat is not going to help you 99+% of the time. *Especially* if you were driving in a dangerous fashion. One of my friends has a funny story on how he tried it after being pulled over, and his ID says:

".... ..., MD
DERMATOLOGY"

The police officer laughed and gave him the maximum fine.

an institutional illness

[tverbeek]

Part of the problem is the medical profession's method of "training" physicians by putting them through an extended period of hazing: working around the clock, being awakened at random intervals, etc. Many of the ones who get through it develop the delusion from it that they can do the work properly under any conditions, especially sleep deprivation. It's a badge of honor for them, and they will engage in all sorts of denial and rationalization to keep at it.

Re:an institutional illness

[Kilrah_il]

I can assure you that most doctors I know, me included, know that the long hours endager our patients. We do not take pride in taking someone to the OR at 4AM while barely being able to tie our shoelaces correctly. It is not pride, but necessity.
The present situation is that doctors need to work a lot. Why? Lack of personnal, lack of money lack of resources (Actually, it can all be summed up in: Lack of money). The reason is not important. The bottom line is that a doctor needs to operate a patient. Ideally, he should be wide awake. Unfortuntly, sometimes this is not the situation, even for elective surgeries.
We shouldn't point the blame at the doctors, but at the system.
Yes, it's nice to tell horror stories of what I have to do in the middle of the night after 20 hours of working without a minute of sleep. But every doctor I know will have the situation changed to 8 hour shift at the first chance possible.

Re:an institutional illness

[Kilrah_il]

First of all, I was talking about the medical system. I order to have doctors working shorter hours, you need to have more doctors -> more money.
Secondly, in the US doctors might make a lot of money, but in Israel (where I am from) and many other countries, the doctors' salary isn't so lucrative. I am not saying I am starving, but considering how much I work, it's pretty disgracing. If I wanted to have a good salary, I would have gone to IT (yes, you read that right).
I will make good money, but only 15 years from now, when/if I have a private clinic, otherwise my salary will be above-average but I will not be making as much as you might guess.

Re:an institutional illness

[ShooterNeo]

The health care system in the USA gets a larger share of the richest economy in the world than any other health system anywhere. If the problem is lack of money, I must ask...where is the money going, then?

Re:an institutional illness

[amabbi]

Part of the problem is the medical profession's method of "training" physicians by putting them through an extended period of hazing: working around the clock, being awakened at random intervals, etc. Many of the ones who get through it develop the delusion from it that they can do the work properly under any conditions, especially sleep deprivation. It's a badge of honor for them, and they will engage in all sorts of denial and rationalization to keep at it.

Respectfully disagree. I'm a resident in a surgical subspecialty, a subspecialty I chose in no small part because there aren't nearly as many surgical emergencies compared to general surgery. That being said, residents don't go through "hazing" as much as "trial by fire." For instance-- awakened at random intervals. It's not as though residents got woken up for the fun of it (well... depending on the nurse.). It's because there's an issue for a patient that needs attention-- be it a new consult in the ER, a trauma being choppered in, or issues on the inpatient floor. Now, there's certainly (many) instances when I'm woken up for a completely nonsense page-- my favorite example is getting a page at midnight because the nurse thought the patient needed "butt paste." There should be mechanisms for limiting the amount of sleep disruption to the on-call staff; limiting work hours, IMO, raises as many problems as it solves. Particularly the new ACGME regulations for interns starting next July which limits you to 16 hours in-hospital and rules for "strategic napping." And there's no badge of honor. I value my sleep. When I finish my training, I don't intend to operate beyond the hours of 7am and 6pm. But I know that there will be instances where I have to. Even more so for general surgery, vascular surgery, neurosurgery, etc. And the problem is worse in rural settings where there might be one surgeon on call for weeks at a time. Do you tell them not to book any OR cases for a month or two? Ridiculous. As a resident, this is my time to learn how to become a surgeon. It's my time to learn habits that I need to use when I'm an attending, when I don't have a supervisor who can step in and tell me that I'm doing something wrong or can offer suggestions on how to improve my technique and habits.

Re:an institutional illness

[TechNit]

Mostly? New technologies and medications, they are the biggest drivers of increased healthcare spending.

I call bullshit. The bulk of the money goes to the middleman/medical insurance companies profits. That's where most of the $$$$ bleeding occurs. Look at countries that have a national healthcare system. Why are they able to spend 60% less per person per year than the USA? Because they cut out the middleman/medical insurance companies.

Re:an institutional illness

[careysub]

... Secondly, in the US doctors might make a lot of money, but in Israel (where I am from) and many other countries, the doctors' salary isn't so lucrative...

Funny story (IMHO) - in 1983 there was a doctors' strike in Israel complaining of the low wages - in U.S. currency they were $3600 for an intern and $6000 for an experienced doctor a year. That's right, that's what they were being paid - a specialist with 20 years experience was paid $6000 a year. But here in the U.S. the news media consistently reported the salaries precipitating the strike as $36,000 and $60,000 a year! News editors in the U.S. apparently could not believe the actual low salaries and multiplied them by ten to "fix" them!

Salaries are better now, but Israeli doctors don't get rich. The belief that doctors are or should normally be rich men is a peculiar characteristic of 20th Century U.S. medicine.

Some doctors in my hospital do cancel elective sur

[olddoc]

I am an anesthesiologist. When I am on overnight call I am always off the next day. Our group of Anesthesiologist strongly believes this is the right thing to do. On overnight call I don't come in until 3pm because 24 hours it too tiring. The motto of the American Society of Anesthesiologists is "Vigilance" You can not be vigilant if you are sleep deprived. On several occasions I have seen heart surgeons who are up at night with emergencies call off scheduled, elective cases in the morning. Perhaps we just have a good bunch of surgeons here, but all of the OR team (nurses, perfusionists, Anesthesiologists...) think it is the right thing to do.

Re:Do Sleepy Surgeons Have a Right To Operate?

[Kilrah_il]

I, as a doctor, have the right to operate people, as part of my license, under the condition that I have been given informed consent.

Re:Economics vs Health

[chooks]

MRIs are pretty much universally better

This is a common misconception but is not true. Which imaging modality to use depends on the clinical scenario. MRIs have the downside of taking a long time, requiring the patient to be relatively still during this time, and being in an enclosed space (which some patients refuse to go into - hence the development of "open" MRI patients). And yes, they are expensive. CTs in contrast (pardon the pun) are quick, much cheaper, and do an excellent job of visualizing things like blood which is important in stroke management, trauma, etc...In the acute setting, your patient might die in the MRI machine while a CT scan would give you all the information you need in a much timelier fashion.

Re:Why is this an issue?

[harrytuttle777]

It sounds like your doctor was a great doctor. I don't knock that. It also sounds like market forces are askew if your doctor was cheaper than your Mother's. You should give out your doctor's name here so other people can go to him, and he could charge more.

As for your contention that the AMA is a certifying agency that ensures doctors are qualified, I could point out numerous counter examples, where the AMA has hurt patients. We all want the best qualified doctors. However, I would rather have an excess of slightly less qualified doctors that could be seen in under 10 minutes, vs. a few ultra qualified doctors, who need an appointment 2 months in advance and just may flat out refuse to see me if I do not have the right condition/ amount of money.

Casebook example of too few doctors killing someone

Here the women died because she could not be seen in a timely manner.

I also think there should be some standards. However there is something seriously wrong with those standards if have interns working 80 hours a week, and doctors operating on the wrong side of the body because they are so overworked.

A simple example from my medical history. I received a tick bit in Mass. Not wanting to risk a case of Lyme disease, I went to the emergency room after gnawing the tick that tried to eat me. I already knew I needed a dose of doxyclyclene. I told the front desk secretary this. The hospital would not just give me a prescription for doxy. I could not just go to the pharmacy because in the USA this is illegal without a prescription. Apparently there are a lot of doxycyclene heads that are shooting up doxycyclene all the time, so the state has to regulate this drug. Instead I had to wait 2 hours for a doctor to see me, and administer the Doxy. I do not have insurance, so I was concerned over the cost. The attendants could not tell me what the cost would be. Apparently they need a team of highly paid economics majors to calculate the price of treatment. When I expressed my concerns the attendant said not to worry because, if I could not foot the bill, the state would, as that health care was mandatory in this state. It ended up costing the state over $250.

Everything that is wrong with this could have been fixed if market forces had been involved. First off. I could have just gone to the pharmacy, and picked up my own drug. Secondly It would not have taken so long to see the physician. Thirdly costs would be less.
Lastly the hospital would have actually cared about what things cost.

Re:Why is this an issue?

[demonlapin]

The most important determinant of your physician's skills is the residency and fellowship (s)he did. Contrary to popular belief, highly academic centers do not always produce the best clinicians, because their focus is much more on generating research. Now, they're definitely very smart guys, and in some fields of medicine that's all there is. But in an interventional field, things get hairy. In particular, the collection of a few individuals can make an otherwise obscure place a powerhouse. In my field, anesthesiology, one of the best residencies in the country is at the University of Alabama-Birmingham.

Ban the knives too.

[angelena]

Given the dangers that terrorists could wreak by infiltrating hospitals and tiring out surgeons, I call on the TSA to expand its Historic Mission and install body scanners and breathalysers at the entrances to all hospitals operating theaters. Not only would that ensure the safety of the sick and injured who have to enter, it would also allow the TSA to stop the free flow of sharp pointy-cutty knives that are so dangerous in enclosed spaces.

Informed consent?

[wfstanle]

I wonder if informed consent is possible just before surgery. Even if the patient is alert, (and often elective surgery involves giving a sedative before surgery) can he observe the doctor long enough to decide he is sleep deprived? How much before surgery can informed consent be made? If the time delay is sufficiently long, the doctor might cross the line of being sleep deprived but the patient saw him an hour before surgery and decided he was not sleep deprived? Also, some surgeries are long affairs, the surgeon might cross the line sometime during surgery. I think informed consent in this case is worthless. It's just like the driver that had been drinking and starts driving just before he gets drunk. He wasn't drunk when he started driving but he soon will be.

As a patient I am not qualified to make this call

[lonecrow]

I really think it is up to the industry to decide on safety levels and then enforce them. If there is a concern to the point of wanting me to sign something then maybe they just shouldn't.

Am I also going to get a form that says the surgeon had a fight with his wife or is worried about his investments and so might be distracted?

Do the research, pick an amount of sleep, then enforce the rules.