Surprise! Reducing doctors’ work hours doesn’t reduce mistakes

In 1984, the year I graduated from medical school, Libby Zion died.

According to the Washington Post:

After his 18-year-old daughter Libby died within 24 hours of an emergency hospital admission in 1984, Zion learned that her chief doctors had been medical residents covering dozens of patients and receiving relatively little supervision. His anger set in motion a series of reforms, most notably a series of work hour limitations instituted by the Accreditation Council on Graduate Medical Education (ACGME), that have revolutionized modern medical education.

Now, nearly 3 decades later, the results of those changes are in and they are an utter failure. In fact, reduced resident hours actually result in MORE mistakes, not fewer!

As a piece in The New Yorker by Dr. Lisa Rosenbaum, entitled Why Doesn’t Medical Care Get Better When Doctors Rest More?, explains:

… [T]wo recently published studies suggest that, right now, both quality of care and quality of education are suffering.

One study, led by Sanjay Desai at Johns Hopkins, randomly assigned first-year residents to either a 2003- or 2011-compliant schedule. While those in the 2011 group slept more, they experienced a marked increase in handoffs, and were less satisfied with their education. Equally worrisome, both trainees and nurses perceived a decrease in the quality of care—to such an extent that one of the 2011-compliant schedules was terminated early because of concerns that patient safety was compromised. And another study, comparing first-year residents before and after the 2011 changes, found a statistically significant increase in self-reported medical error.

Why have the reforms produced the opposite result from what was intended? There are two reasons for the failure:

1. The proximate reason for the failure is that Libby Zion didn’t die because the residents who cared for her were overworked. She died because they were grossly incompetent.

Libby was a college freshman with an ongoing history of depression who came to New York Hospital in Manhattan on the evening of Oct. 4, 1984, with a fever, agitation and strange jerking motions of her body. She also seemed disoriented at times…

[Later] Libby became more agitated. The nurses contacted Weinstein at least twice. Weinstein ordered physical restraints to hold the patient down and prevent her from hurting herself. She also prescribed an injection of haloperidol, another medication aimed at calming her down. Busy with other patients, Weinstein did not reevaluate Libby.

And that is malpractice. The woman had a fever. In no medical universe is it ever appropriate to ignore fever and neurologic symptoms in favor of restraining the patient and dosing her with powerful psychoactive medications. It had nothing to do with being tired; it reflected the doctors’ incompetence.

2. The larger reason, one we would do well to take to heart, is that the single most important thing patients need from doctors is their time.

The calculus is brutally simple. Reducing working hours without reducing patients numbers of increasing the number of doctors means less doctor time/patient and an increase in mistakes is an inevitable result.

Because, and this is the dirty little secret in medicine, being exhausted, overworked and irritated does not cause medical mistakes. Lack of time to talk with patients, both to listen and to explain, and lack of time to obsess about the details is what causes medical mistakes.

I will freely admit that the brutality of internship and residency did not make me a nicer doctor. When you are working 105 hours a week (staying up all night, every third night) you have little energy for being nice. But it did make me a better doctor.

I can hear younger doctors out there groaning about antiquated older doctors celebrating the hazing process, but the reality is that it made for better, safer patient care. As one of my chief surgical residents told me (actually he yelled it in my face) early in my career: “In medicine there are no excuses. YOU don’t matter; all that matters is what is good for the patients. I don’t care if you are hungry, tired or depressed. The only excuse for knowing less than everything about your patients is that you are currently treating a cardiac arrest or having one yourself.”

Rosenbaum relates the story of her own mother, also a cardiologist, who has the same work ethic that was beaten into me:

“Mom,” I said. “It’s 8 P.M. Why on earth are you going to the hospital?”

“I’m going to see my patient,” she said.

“But you have been working nonstop for five days,” I protested…

“Her boyfriend’s driving in,” my mom explained. “He really wants to talk to me.”

And then, without thinking, the words popped right out of my mouth: “But isn’t there someone covering you?”

“I’m her doctor,” my mom said. “I’ve been with her since the beginning. Don’t you think this is important?”

And it is only by providing long brutal hours of care and caring like these that doctors avoid mistakes.

It wasn’t the young doctors’ lack of sleep that killed Libby Zion; it was their lack of competence. It will only compound the tragedy if the legacy of her preventable death were more medical mistakes, not fewer.