Safety Sciences

Doctors’ work schedules – who are they designed for?

Ever since the ACGME regulations came out that strictly limit working hours for residents to 80 hours a week, there has been much discussion and protesting about these regulations. Strangely, there has been very little discussion about work hours or work schedules for attending physicians, nurses, and other health professionals. Work schedules for attending physicians require a lot of attention, because in many institutions such physicians work long hours without a break and continue to work even when obviously fatigued. I’ve known surgeons who worked over 100 hours a week – some of them were over 60 years old and they would be obviously tired – slow in their speech, unsteady on their feet, delayed in their reactions, and often cranky from exhaustion. Working when in such an unsafe state probably leads to more medical errors and harms patients, although I am not aware of specific studies to prove this. Why do attending physicians continue to work under such arduous schedules, and increase risk to patients? From what I’ve observed, there are several reasons:

1) For physicians to work in optimal schedules requires many more physicians than are currently employed in most hospitals. In most hospitals there are not enough attending physicians available to staff a unit optimally. Hiring attending physicians is expensive, and hospitals may not be willing to spend the money to hire more physicians. In private practices, the revenue and profits have to be split between all the physician partners. The fewer such physician partners, the higher each one’s income is. Therefore existing partners may decide to spread themselves thinner rather than hiring additional physicians and lowering their income.

2) Even if enough attending physicians are available, they may not wish to work in an optimal schedule because they may prefer a schedule that gives them the maximum time away from clinical work. Working a schedule that is optimal for patient care might require them to perform clinical work for shorter durations more frequently, thus interrupting their non-clinical time. Physicians value their non-clinical time, which may be spent on academic activities (research, teaching, traveling to conferences), or with their families, or engaging in recreational activities. They often want their non-clinical time to consist of long blocks uninterrupted by clinical work. Thus, an emergency room physician may choose to work, in a week, two shifts of 24 hours each rather than four shifts of 12 hours each. In doing this, if physicians voluntarily are cramming clinical work into long periods to maximize their non-clinical time, they are putting their own needs first and the needs of patients second.

3) Physicians may think that working in long stretches is better for continuity of patient care. While this is well-intentioned, in reality, continuity of care results from consistent information about the patient and plans of care being available when required. It is not a result of the same person being present all the time. Ensuring good communication between well-rested physicians as they hand off patients to each other, and using good sign-out tools can lead to as much or more consistency of patient care as having the same tired physician present throughout. Although well-intentioned, schedules in which physicians work long hours and thereby become unsafe for patients probably result in more hazards for patients than benefits.

4) Finally, there has been profound neglect of this issue by researchers and regulators. There aren’t many studies about fatigue and work schedules in attending physicians. There is no regulatory organization that recommends or mandates work-hour limits and optimal schedules for such physicians.

It’s time for conditions to change. We need to shine a spotlight on the problem of fatigue in senior doctors, and ensure that work schedules for attending physicians are designed in such a way that patient care is not compromised, while ensuring that such physicians still have time for their research, other scholarly pursuits, personal development, and their families.

The Tragedy of Radiation Therapy Errors

Radiation Offers New Cures, and Ways to Do Harm

Walter Bogdanich, New York Times Jan 23, 2010

Radiation is a common therapy for cancer and is delivered using a linear accelerator, a machine that delivers beams of high-energy radiation. It is an effective treatment for many types of cancer, but when errors occur in its administration, the results can be disastrous to the patient. The New York Times just published an article following an investigation into radiotherapy errors. The paper “examined thousands of pages of public and private records and interviewed physicians, medical physicists, researchers and government regulators.”

The article describes in graphic and heart-breaking detail the stories of two patients who suffered from inadvertent overdoses of radiation therapy. It also reports that more than 90 prostate cancer patients received the wrong radiation dose at one Philadelphia hospital, and that at a Florida hospital 77 brain cancer patients received a 50 percent higher dose than they were supposed to receive. The article cites some statistics from 621 incidents (from 2001 – 2008) of radiotherapy errors in New York state. In 133 of these incidents, devices used to shape or modulate radiation beams were left out, wrongly positioned or otherwise misused. In 284 incidents, radiation missed all or part of its intended target, or was directed to the wrong body part. In one case, radioactive seeds were mistakenly implanted in the base of the penis instead of the prostate. One patient was treated for prostate cancer when he actually had stomach cancer. Fifty patients received radiation intended for someone else.

Why did these errors occur? Four types of causal factors are described in the article: (1) Problems with the computers that control the linear accelerator – flaws in the software or programming; (2) Poor safety procedures; (3) Inadequate staffing and training; (4) Failure to follow a good quality assurance plan. The tremendous increase in the complexity of linear accelerators and treatment planning over the past 20 years has apparently increased the number of opportunities for error. Hospitals and health professionals are too trusting of the computer systems that run the accelerators. In the Florida case, the linear accelerators had been programmed incorrectly for nearly a year before the error was discovered.

Human performance too was at fault. For example, in one case, the therapist mistakenly programmed the computer to not use a ‘wedge’ (a device to make the radiation beam narrower so that it strikes only a small area of the body) when the wedge should have been used. This error was caught neither by the medical physicists who checked the treatment records weekly, nor by other therapists (on 27 occasions!), even though the computer screen clearly showed that the wedge was missing, and even though the state health department had recently sent hospitals a notice that therapists should closely monitor their computer screens.  

In another case, the computer crashed multiple times as the radiation therapy dose was being programmed into the linear accelerator. As a result, the multi-leaf collimator (a device that narrows the radiation beam to focus it solely on the tumor) was wide open, and the patient was exposed to a wide swath of radiation that targeted his entire neck instead of just the base of his tongue. This was not caught by the medical physicist until it was too late. Also, a test to check that the computer was programmed correctly was not run before exposing the patient to the first dose of radiation. Finally, even though the computer screen was displaying the collimator as being wide open, this was not noted by the therapists. As a result, the patient received three excessive doses of radiotherapy that ultimately led to his death.

Other points the article makes are: (1) the exact frequency of medical errors with radiation therapy is unknown; (2) the exact degree of harm caused by radiation overdose is hard to determine because often the adverse effects occur years later; and (3) inadvertent underdosing of radiation therapy is hard to detect, because there is no apparent harm. Because of the last two points, lawsuits related to radiation therapy errors are apparently rare.

This article is a sobering reminder of the power of radiation therapy to hurt patients as well as to heal. It also reminds us how computers can cause serious errors and how blind faith in computers can lead to serious errors being overlooked.  

What's the Most Dangerous Month in Hospitals?

Rate of undesirable events at beginning of academic year: retrospective cohort study

Haller et al BMJ 2009; 339: b3974

"Don't get admitted to the hospital in July" is advice that is commonly passed around, based on the belief that the quality of patient care is poorer in July, when the new batch of residents typically starts in the US. This transition period when trainees begin their training has been called 'the July phenomenon' in the US and the 'August killing season' in the UK based on the belief that this is the most dangerous period of the year to be admitted to the hospital. 

This belief persists, even though numerous studies that have not been able to prove that patient outcomes are worse in the months immediately after an influx of new trainees arrives. In a recent study however, Haller and colleagues were able to show that there is indeed some truth to the belief that patient care by new trainees leads to more adverse events. 

In this study, the authors analyzed data on adverse events related to anesthetic procedures. In their hospital (Alfred Hospital in Melbourne, Australia), a special form is completed for every anesthetic procedure - this form asks the trainee to report, for every single procedure, whether or not each of 44 predefined incidents occurred. Examples of these events, which the authors call 'undesirable events,' are central and peripheral nerve injury, inadequate oxygenation, vomiting/aspiration in the OR, technical failure of endotracheal intubation, accidental upper airway obstruction, respiratory arrest during local-regional anesthesia, technical failure of arterial line insertion, uncontrolled hypertension, and uncontrolled hypotension.  

The authors analyzed the accumulated data from such reporting, on procedures performed by trainees between October 1995 - December 2000. In Australia, the new trainees usually start on February 1.

After adjusting for case mix using a clustered multivariate analysis, the authors found that the number of adverse incidents per 1000 patient hours of procedures was higher in the first month of academic training than in the rest of the year (137 vs 107 per 1000 patient hours, a 40% higher adjusted rate, p < 0.001). 

Surprisingly, they also found that trainees at all levels of training, even those in their fifth year of training had higher rates of undesirable events in the first month compared to the rest of the year. (Note: all these trainees, even those at higher levels, were working in this hospital for the first time. In Australia it is common for trainees work in multiple hospitals through their years of training, and not stay in one program throughout). 

The authors' speculate that their results are different from those of other previous studies on this topic because they collected detailed data on each patient (instead of analyzing administrative databases like some other studies), had a larger sample size than other studies, and studied anesthesia care, which is inherently a riskier specialty than other medical specialties. 

This study clearly shows the existence of a learning curve for trainees (at least in anesthesia) and also emphasizes that trainees at more advanced levels are still at higher risk of committing errors in the first month, perhaps because of unfamiliarity with the work environment (remember that even the advanced trainees were new to this hospital), excessive cross coverage, poor handovers, and insufficient supervision. 

The authors suggest that adverse events in the early part of the academic year can be prevented by improving the orientation of trainees, using simulation, not assigning clinical tasks to trainees right from day one of training, systematic use of well documented standard working practices, teamwork training, and closer supervision. 

Are Physicians like Cobblers with Bad Shoes? Part 1.

“The cobbler always wears the worst shoes” is a phrase that reminds us that physicians may not really take care of their own physical and emotional health. Such lack of physician self-care can have negatively affect patient care, the functioning of hospitals and clinics and the costs of healthcare. These topics are addressed by a recent Lancet article by Wallace and colleagues. 

In this article the authors point out that physicians commonly suffer from physical and emotional health problems, but are not good about seeking help and getting care for such problems. As a result they often function in a sub-optimal state of health and burn-out that can lead to low job satisfaction, increased turnover and low morale in the healthcare organization. More importantly, such ‘professional malaise’ leads to poor patient care, increased healthcare costs and medical errors. The authors propose that therefore the ‘wellness’ of physicians is an important quality indicator that healthcare systems should routinely track.

Here are the main facts that I gleaned from the article:

Frequency and Types of Health Problems among Physicians

Studies on physician health have mostly focused on illness. Such studies have shown that they often suffer from burnout, stress, depression, substance abuse and relationship troubles. In some studies, up to 75% of physicians were burnt out. Suicide rates are six times higher among doctors than in the general population. Doctors have a higher than average cardiovascular mortality. Stress and burn out are common among medical students and residents as well. 

However, health or wellness should not be considered just the absence of disease or sickness, but a positive state of well-being, including being challenged, thriving, and achieving success in various aspects of personal and professional life. Studies measuring this positive state among physicians are sparse, so we do not know exactly how often this ideal state is achieved. 

Reasons for Physician ‘Unwellness’

The reasons for physician illness and stress include external and internal factors:

External Factors

• Heavy workloads that are increasing over time (increased patient-care demands)
• Fatigue and sleep deprivation
• Having to deal with emotionally charged situations (that are associated with suffering, fear, failures and death)
• Difficult interactions with patients, families and colleagues
• High cognitive demands (the need to quickly process an overwhelming amount of information over long periods)
• Growing bureaucracy
• Increased accountability 
• Having to negotiate conflicts between the needs of the organization and patient needs, and 
• Loss of autonomy from restrictions on practice placed by external regulators and payors.

Internal factors

• Physicians commonly have certain personality traits such as perfectionism, workaholism and ‘Type A’ attitudes. These traits are associated with burnout, depression, anxiety, eating disorders and cardiovascular disease. 
• Female physicians often have to balance work and family responsibilities, which can increase work-family conflict and stress.
• Immigrant doctors can suffer from additional stressors and strains in addition to the stressors experienced by all trainees and physicians.

[to be continued.........]

Reference

Physician wellness: a missing quality indicator.Wallace et al. Lancet 2009; 374:1714