As someone with a large supply of frequent flyer miles, I wince along with many others at every story of a somnolent or inattentive air traffic controller. There, but for a timely nap, go I! But I -- and you -- might have cause to wince at the remedy, as well.
The only way to ensure we never again hear of an ATC officer's ill-timed siesta is to take steps that will place one or more well-rested, fully-alert, suitably trained and unfailingly diligent controllers in every tower of every airport, all the time. Airlines pay overflight fees that cover the salaries of ATC, and of course pass the costs along to us. So if we want this security, we will pay for it.
Presumably we would be willing to pay some amount for peace of mind. But there is also a line over which incremental gains in security are too small to justify a deeper reach into our pockets. The question is: where is that line?
A similar issue arises all the time in medicine, where decisions about how best to proceed are often encumbered by trade-offs. The trade-offs are concisely expressed in terms of sensitivity and specificity.
Sensitivity is the reliability with which we find a condition that's there. Specificity is the reliability with which we exclude a condition that isn't. The trouble is: it's hard to have both.
The more faithful we are to sensitivity, the harder it is to be faithful to specificity -- and vice versa. If we never want to miss what's there, we risk getting carried away, and reacting to what isn't. If we never want to react to what isn't there, we risk an inadequate response to what is.
This same trade-off governs the adequacy, and potential excesses, of air traffic control. To ensure that every plane is overseen by a well-rested, fully alert ATC officer, we more or less guarantee ourselves many salaried hours of ATC oversight of empty skies.
For those of us concerned with medical education, a parallel dilemma related to the working hours of medical residents is playing out at lower altitudes. There has long been attention to, and controversy over, the notoriously long shifts of doctors in training. Over the years, increasing restrictions have been imposed by the relevant authority, the Accreditation Council for Graduate Medical Education, or ACGME for short.
Residents are currently restricted to 80 work-hours per week, averaged over any given four-week span. We routinely quip in medicine about the "days of the giants," referring to our own training, when we worked much harder. But what constitutes a giant is relative! I recall my own training with call every third night, and weekly work routinely exceeding 100 hours. But my father, a cardiologist, scoffs. Back in his day, call was routinely every other night, and work weeks of 120 hours were far from rare. In fact, some weeks he simply didn't leave the hospital at all.
There is currently pressure on the ACGME to restrict resident work hours further, resulting from public attention to medical error and its consequences. But this is only a remedy if it fixes the problem, and that is far from clear. We have no reliable data. It may be that sleep-deprived residents are relevant to this concern; it may be they are a handy scapegoat.
And this issue -- like air traffic control and all matters medical -- is subject to trade-offs.
The obvious trade-off is between time and money. Residents are salaried by the work week, not work hours. In fact, I recall another reason for wincing -- when we lined up to receive our weekly paychecks that insultingly stated "40 hours." Enduring the "injury" of 100-hour-work-weeks was bad enough, but the insult of getting paid for only 40 was almost too much to bear! But the fact is that salary is what it is, however many hours residents actually work. So shorter work weeks mean more residents, which in turn mean more resident salaries, and as with the ATC officers -- someone has to pay.
There is an alternative, of course: less resident coverage. But that in turn means fewer doctors to attend to patients in teaching hospitals. This could well take us from the frying pan into the fire. After all, it would take pretty severe sleep deprivation for the physician running a resuscitative effort to be as inadequate as no physician at all!
There is another trade-off as well. Given how much medical care is out-patient, hospitalized patients these days tend to be pretty darn sick. The sicker and more complicated a patient, the more time and involvement with their case is required to really be on top of all the details. The sooner and more often the primary resident involved in the care of such a patient hits the wall of work-day restrictions, the more often he or she needs to "sign out" that patient to a colleague. No matter the diligence, each such passing of the baton risks dropping it in some fashion.
I was not just a resident myself; I was at one time a residency director as well. And in both roles, I acutely felt the trade-off between fatigue and continuity of care. In both roles, I felt there was some irreducible minimum in work hours and patient contact required. Those long work hours kept the physician who knew the patient best on hand for as long as possible. When it was me, and I was exhausted and wanting to go home, I still felt the tug of staying on the scene where my patient needed me. Leaving a scene of crisis because your shift is over is not an easy call.
Those long hours also served as the incubator for the sense of what it meant to be a doctor: that lives were at stake, and you needed to stay the course for the sake of your patients, however painful that might be at times. Personally, I can say that profound sense of responsibility, duty and privilege served me well over the years.
I am not sure about the optimal work hours for medical residents, nor the optimal number and distribution of ATC officers, because I'm not aware of any good data. Studies can and should inform such decisions. Different models could be tested, in both cases, and an evidence-based case built for the optimal trade-off between costs, and benefits. Guessing -- at the risk of guessing wrong in either direction -- is unacceptable when money, mission and lives are potentially at stake. In both of these scenarios, they clearly are.
Whether the control of nocturnal air traffic, or the oversight of residents who race along hospital corridors in wee hours to crises in the ICU, we can -- and should -- do better than fly-by-night decision making.
Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org
Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz
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2011 college graduates left college with $22,900 of debt. That's without any guarantee of a career or employment.
Medical education is in need of a serious overhaul; it has been 100 years since the Flexner Report, the document which has defined and dominated training in medical schools - not to mention the undergraduate coursework that medical schools require. Flexner needs updating to reflect our current state of knowledge, but that is another matter.
Residency training needs a Flexner of its own; medicine is far more complicated now and will only become more so as we go forward. Fatigue is only one issue that residencies face; adequate exposure to the complexities of 21st medical care demands an extended training cycle and the level of competency that once could be achieved in 3 post graduate years more reasonably requires 4 such years now.
Moreover, the funding of post grad education requires review (currently, residencies are funded under Medicare and private insurers get a pass) and one of the things that medicine does exceptionally poorly is retrain physicians later in their careers. Even if funding for a second residency were available (BBA of '97 precludes this), it is a practical impossibility for most and attrition of experienced clinicians is high.
Please state how much income you plan to have when you are 45. How much education debt you plan to have.
---I am 36 years old and JUST finished my sub-specialty, academic training. I make 150K/year (approx 90K after taxes, 72K after loans) and have 300K to pay back. With interest, I will be paying back the 300K ( for 30+ more tears from now after taxes). I live in an urban area, very modestly.
----In 9 years, when I am 45, I will still make 72K post taxes/loans (if Medicare does not decrease reimbursement) and will have approx $250K to pay back (interest). I work about 60 hours a week and have 2 small children (to whom I give full attention when I am at home...except that my pager is ALWAYS on. I take call every 6th weekend (4-8 hours in the hospital rounding on patients). We have no savings because we do not make more than living expenses during training. (My husband is in the same boat, but in a lower paying specialty).
---Indeed, foresure, I will be overworked and underpaid at age 45...but I will never regret my decisions. I love being a doc. I feel terrible when my patients' care is limited by a draconian health-care system and when I spend time fighting with insurance companies instead of taking care of patients. You and good docs are on the same side. In 10-20 years, MDs (save some specialties) will not be rich. I hope this doesn't discourage the best and brightest to join our profession.
Are we really to believe that anyone employed to do a job that requires mental attentiveness can be as good at the end of a fourteen hour shift, as they were at the beginning? Can we really believe that a person who has had four hours of sleep can do a job requiring mental attentiveness, as well as a person who has had eight hours sleep?
Would you really want a automobile mechanic to work on your car after being awake for twenty hours?
Do you want an electrician to wire the electricity in your house who feels angry because his boss works him till he is exhausted, whose employer forces him to violate established safety rules in oreder to increase profit?
The fact that doctors in a sometimes high-stress and life-or-death environments lack decent rest periods is absurd. The only "reason" for it that comes to mind is that the doctors who went through it want new doctors to do so also for some twisted reason.
Many docs do want to perpetuate the suffering they went through....but believe me, if I could save my daughters from 1/4 of the suffering I went through I'd happily limit work hours. It's just that, no one has found a solution, and we need competent docs.
Maybe if you mentioned exactly how much money you earn for ten hours in the operating room, we would all be much more sympathetic.
Surely, you could afford to take the next day off, after all of that work.
During the four or five years of residency: Did you learn a great deal when you had no sleep and were working a 14 hour shift?
Did you know a PhD in many subjects take about as long as your specialist training. Do nuclear scientists make as much as you?
After you complete your full training, how long before you have enough money to have a luxurious life style, complete full a full investment portfolio?
Come to work at the VA - I am an ER doc and we have a union. Moreover, it is possible to do the right thing for a patient at the time the right thing needs to be done; there are no reimbursement issues and no overhead.
Though the VA system is more efficient than even Medicare (which itself is more efficient than any private insurer), there is more within the VA system which could be done to facilitate care, especially in terms of access to primary care.
My VA hospital is also a fun place to work; everyone I have talked to at other VAs says the same thing.
HAH !
"There were they in great fear, where no fear was."
"The fear of the wicked shall come upon them, but the desire of the righteous shall be granted."
staff has a "don't care" attitude. They are aloof and intimidating and have no interest in helping
the patients who are in a difficult envorinment.
I am 5 years done and only now can I say that I am regaining my sense of compassion. If you want an insight into how residency warps your thinking, read "House of God," by Samuel Shem. Expect that we didn't hook up with the nurses as is depicted in HoG, it's a pretty accurate rendering of the dehumanization that residency inculcates.
Anyone seeking a career in medicine unless it is situated in a research setting is crazy. Dozens of years of training, huge indebtedness, long work hours, and few returns. Find a rewarding and less personally destructive career instead.
well as other things. For example, I have a friend who's first reason for becoming a doctor
was to follow in his fathers footsteps. That said, I think the way our society has deteriorated
(my opinion) over the years I would guess these days more people become docs for dollars as opposed to altruistic reasons. Again, just my opinion
A: Doctor.