Also, I
suspect that when it comes to the question of
accuracy and judgement during long shifts, there are
probably bigger factors than just time awake. I learned
early on that my coding ability isn't a monotonically
decreasing function of time since last sleep.
Would you make the same argument for airline crews? Or flight
controllers? Or are those "too" risky--if someone zones out because
of fatigue, hudreds could die, but there's only a single life at
stake in medical procedures?
But is there a good alternate solution other than shorter shifts? Here's
the potential downsides:
- Lower number of cases seen, requiring either a protracted residency or
accepting less skilled graduates. The former seems better than the latter
except when you realize how few doctors the American medical school system
actually produces, in addition to the real cost of residents having to
defer their debts longer. Medical education is highly experiential. This is
a bigger problem for surgical programs, but still for medicine/peds/etc.
- The subtle shift in medical focus from patient to task. Much is said (and I
will not give my opinion on it) in the current "health reform bill" about
improving outcomes. This sounds great. Almost nobody wants this as a patient
however, because the doctor doesn't see you as you but rather as a goal that
must be reached or a disease state that must be quelled. Losing the
commitment to the patient only furthers the perception that doctors don't
have time for patients as people any more. It starts when patient work is
seen as punching a clock and not a calling. This is not good for patients,
and it is not good for the profession.
- In a related vein, the loss of complete care awareness. This is squishy and
is best explained by what happened after residency work hour reform: more
work got slogged off on non-clinical personnel or the doctors remaining on
duty. Some of this work was unnecessary scut and no one is sad to see it go.
However, a fair bit of it was actual care delivery, and one thing that is
very important to witness in residency is the natural progression of disease
and cure. I know what to expect of a post-op because I saw the patient in
the pre-op clinic, in the OR (on my surgery rotation), in the hospital if we
had to admit them, and in the post-op clinic when they left. Pieces of this
are missing otherwise. You don't know what that wound is supposed to look
like on post-op day #2. You don't know that this is an expected effect of
medication Y. You may not realize you don't know this until you get out of
residency.
Mind you, I'm still not saying that crazy-ass long hours in internship is
wise. Clearly it is not, and clearly the practice as a whole was excessive (I
was at a program that was comparatively kind to its residents, for which I was
grateful, because some programs border on abuse). But bad as it is, I think
that it is as good as it gets, because erring on the other side tends to have
more subtle, long-range effects.
Medicine is a dangerous profession for patients (spoken as an MD). New doctors
have to start somewhere, and you don't want them turning out badly. I am
forever grateful to the patients who knew I was a resident, and saw me anyway.
The ones in the hospital didn't have a choice. The ones in the office did.
When I graduated from residency, the first thing that struck me as a new
junior attending was how little I actually knew.
--
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http://www.cameronkaiser.com/ --
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