Sleepy Doctors — An Unnecessary Danger

I remember my first time and I shivered with anticipation.

A kindly matron showed me the tiny bed and told me with a wink that I probably would not get much sleep that night.  It was an old bed and had seen a lot of use by a lot of people, but it would be special for me this night.

She was right – I was only able to steal a couple of hours of sleep.  But it was what happened when I wasn’t sleeping – and my colleagues congratulated me and cheered me on.

Wait a minute! Get your mind out of the gutter.  I’m speaking of my first night on call as a medical student.

What did you think I meant?

There was a little yellow box in the pocket of my white coat. It was my pager — primitive by today’s standards, with a tiny round loudspeaker on the top. Only two things could it do — make a sound or not make a sound. It was metal and rusty, I was quite certain that every substance used in making it had been around since Napoleon’s time. In fact, the joke was that it could have been Napoleonic issue — but not of good enough quality to make Musee de  l’Armee.

This was a major passage in the life of a French Medical Student.  Fourth year – and first time to be able to examine a patient without a senior doctor monitoring me, and to be able to report over the phone.  A milestone of trust in my journey to becoming a full-fledged doctor.

That night there were stitches and some minor medical procedures — nothing requiring the major Operating Room, so I had indeed managed to get a couple of hours sleep before I showed up in the morning to check into my (coincidentally) surgical rotation.

I had chosen neurosurgery early on, considering it a direct road to the brain and its mysteries. On other nights, a drunk might drive into a flagpole and rupture his spleen and I would work as first assistant on the surgical team, working hard to forget how my body ached from sleeplessness.  I would be no more than five or ten minutes late to rounds in the morning, wearing the double breasted white coat and the butcher-apron, with the waist ties strung all around the waist and tied at the front.

There would be blood on that apron — real human blood — and sometimes I would get hugs and kisses from my peers, because I was a pretty sturdy girl. But I would not get such reaction from the Chief of Neurosurgery, a formidable man who I think wanted to make it clear to me that this was going to be harder than I thought.

“A neurosurgeon is not a good neurosurgeon,” he said, “until he is able to make good decisions and do a competent and complete operation, from open to close, with no sleep whatsoever for the past four days.”

In French, the statement is not so sexist as it sounds in translation as the French pronoun in is pretty indefinite and he could have really been including me. But I knew he was wrong, and just like many other times, I said nothing.  Such a display of insolence and insubordination by an American student could easily have caused an international incident.

At my medical school in northern France — and doubtless at any other in the world — the first night of call is a rite of passage. Serving nights on call we students performed a genuine service, leaving the senior staffers “fresher” for the morning rounds, where they were unquestionably in charge.  To be on call was a leash you could pull at, but not break. The safety of the patient was assured by the fact that it could not be broken. “Real” doctors were fresh. Nurses were fresh.

However, in the often grueling aftermath of those overworked nights, I think patients have indeed suffered.

I thought back to those days when reading a recent article. I knew when my preceptor voiced his opinion that the idea of working without sleep was good training for a surgeon that this was something peculiar to the macho traditions of the medical profession and had no logical reason for being.  That feeling was reinforced when I spoke secretly with a female professor.

I did not see then and I do not see now why doctors do not work in shifts the way nurses do, so they can come in fresh and get the job done with adequate sleep.  It is only logical.  But it flies in the face of tradition, for which there is seldom a reasonable argument.

My female advisor was sympathetic, but advanced a logic that I find still drives much of medicine today and in our country also.

The only possible reason we could think of for letting doctors work such long hours was so they could complete operations that they started without handing off to another team. In neurosurgery, even mildly complicated operations could easily last 20 hours, by enduring this grueling ordeal, the surgeon could get paid for the complete operation.

Once again – when the question is “WHY?”, the answer is usually “MONEY.”

Frankly, I would have gratefully split the honorarium according to the time worked — but then, I do not think like a neurosurgeon, which is at least one good reason that I did not become one.

Of course, hospitals would lose money if they could not schedule freely. In this day and country, patients can and perhaps should — it is suggested in the above article — call the night before their operation to find out if their doc has been on call, and what he or she has done.

But let’s be realistic here — Does anybody actually believe a hospital would release such data to the patient, especially if it resulted in canceled surgeries and lost time?  I think not. I think VERY not.

This does not just apply to surgeons.  Everyone performs poorly if sleep has been compromised.

My bet is that this is indeed going no place without legislation.  There is some now in place concerning first year trainee medical doctors. The Graduate Medical Education folks have said there is a need to limit to 8 hours off and 16 hours on for trainees at that level.  Anybody who thinks trainees get smarter after that ought to be sentenced to be treated for their general medical needs by trainees in a standard county medical system.

That may actually be harsh – bordering upon “cruel and unusual”, but most people have long forgotten the reason for that law, known as the “Libby Zion law” in the industry.

A quick click on Wikipedia tells all about this unfortunate case. It took someone with power and anger and grief over the death of his own daughter to get this one started. But it does not go far enough. The article says plenty.

While some of the problems in medicine are hard to solve, I do not believe that this one is. The answer, presumably to this and to other problems, is frequently the use of lower-level staff often called “physician extenders” — who, frankly, are never part of the “ethos” of the profession and never expected to do more than shift-work.  I cannot endorse or condemn them en masse, but I can say I have met some whom I consider brilliant, who should have gone to medical school.  I have met others who would need at least three colleagues with whom they could consult before a single reasonable humanoid brain could be put together among them.

In our race to “contain costs” for healthcare, I have witnessed over the past 20 years a frightening willingness to transfer primary care to unqualified people.  My experience extends through half a dozen states and through a dozen different types of medical systems including community health clinics, HMO systems, Veteran’s Administration facilities, prisons and private-pay office practices.

In what I consider a reasonable statistical sample, I see a horrifying trend to give people lower and lower standards of care and widen the cracks through which they can slip.

I am perhaps naïve – or perhaps arrogant — enough to believe that there are some decisions only a doctor can make intelligently.  I have found no conclusive and believable literature about what a physician extender does and what a doctor ought to supervise, to lower error rates.

I can only say I have seen physician extenders with little or no recent memory and little or no logical capacities, and that they do indeed seem to be succeeding in their chosen (dare I call them) professions.

My favorite solution comes from Denmark and other Scandinavian countries, where it has been reported that surgeons scrub out and change shifts at preappointed times.  Of course, our United States has a very rich history of ignoring precedents that could be learned from other countries.

I for one would have loved to have known how Israel air transportation handled the threat of Arab terrorists safely for so long before our Transportation Safety Authority started stripping people of clothing and civil rights.  But I digress, again.

Examples of what sleep deprivation does to people who perform various jobs abound everywhere. Our government seems to care more about how many hours of sleep a commercial truck driver gets than how much a cardiac or brain surgeon gets.

Lots of things that get us through life on a daily basis can indeed be done during office hours, but emergency surgery can’t, so solutions are necessary. I believe in my heart – and have since medical school — that doctors should come in “fresh” on shifts, the way everyone from factory workers to airline pilots do.

Sometimes MDs are smarter than lesser-trained colleagues, and are able to do things that they cannot.  But we are not physiologically superior, and certainly not any better than anyone else at functioning without adequate sleep.
Both doctors and patients  have been battered and bruised in the name of cost containment. It is far rarer that we are aggressed for the purpose of patient safety.

It is time things changed.