Should hospitals be held liable for legally overworking interns?

Great Debates
21

Well someone has to play the devil’s advocate here …

How would you regulate this and what would be the consequences?

Running a tertiary care hospital is costly. One reason is that they are often located in inner cities and have more than their share of public aid and uninsured (and not uncommmonly nonpaying) patients. These teaching hospitals cannot just pass on the costs to the paying customers. There are contracts involved, and no payor wants to pay significantly more to the teaching hospital for the same service than what they’ll pay to a good community hospital. Some of these hospitals are in pretty dire financial straits. For years they have indeed balanced their books on the backs of residents. Eliminate that option (by another unfunded mandate) and some may fold and care for the indigent will be impeded and education for doctors will be reduced.

Did working absurd hours in residency teach me much? Nah. Did I make mistakes because of sleep deprivation? Nah. Most was pretty automatic and a new situation wakes you up pretty fast. I was, however, a lot less compassionate becuase I was so tired. I certainly spent less time on the psychosocial than I would have if I was rested.

There are fewer long shifts than there used to be though.

Smiling, yes, cite please. Including on the ratio of applicants to spots. If I recall accurately, there had in fact been a decrease in the number of applicants for quite a few years only recently incresing again.

22

When Rush Medical Center loses this lawsuit, and I hope they do, they’ll figure out a way.

Remember the first time a bar was sued for getting a patron too drunk? Everyone said that it would be impossible for a bartender to know if someone had had too much to drink, but when faced with huge monetary penalties, they figured out a way.

23

Well, I’d make the schedule so that no one was working 32 or (Og forbid!) 56 hours straight. Of course, if I’m short on staff, that means no 48 hour spans off work either, but given public health, I’d rather wear my Residents out by asking them to work seven days a week at reasonable hours that insure they can get 8 hours of sleep each day, then wear them out by working insane hours for four or five days a week.

Would I be any more popular with my Residents by never giving them a day off? Prob’ly not. But given the atrocious rate of physician error (Google “physician error” for studies and numbers), and the fact that Residents hate the guy who makes the schedule now, I really don’t care much. This would be the new, safer way of “paying your dues.”

If we need to institute a punch-in/punch-out system to track the hours the Resident is actually working, so be it. Independent audits with fines so high the hospital will feel them for violations.

24

That’s certainly true. But oftentimes, specialists may be the only person around who can do a certain thing, and they’ll charge what they please.

I’m having a hard time finding data on this, so I won’t press my argument if I can’t get anything more. No matter what data I look for I keep getting med school application forms.

25

The big question here (legally, at least) is whether Rush violated the residency teaching guidelines by allegedly working the resident in question for a 36-hour shift.

Background on the regulations and why they were instituted.

AsDSeid noted, the economic impact of markedly scaling back residents’ hours would have a big effect on hospital finances.

To be sure, it would also tick off attending (supervising) physicians who’d have to work harder to assure proper patient care. In my hospital, the most bitter complaints I’ve heard about lower resident hours have come from the attendings. I have to think that part of the resentment is due to the not entirely rational wish to continue long hours as a “rite of passage” which will toughen up residents to face the crises of their profession. Sometimes this attitude is hard to distinguish from the mindset that promotes fraternity initiation rites.

26

The impact on an individual who is killed or injured because of an overworked resident is more important. The medical profession may just have to rethink some of the ways that they do business. Perhaps they can expand the medical schools so that there are more residents. Perhaps they can look at a new class of physician who is allowed to do certain procedures but not others.

27

And if some hospitals are forced to close down or curtail services because of increased costs, that has an impact on sick people as well.

Any further decisions in this area will have multiple impacts.

28

Why should we take this any more seriously than some old trucker claiming that he never had an accident due to driving 24 hours straight, and that he always woke up pretty fast when a pair of hi-beams hit him in the face? Are you seriously saying that fatigue doesn’t impair judgement, in spite of the overwhelming evidence that it does? Or are you saying that the decisions made by residents aren’t important enough to worry about that impairment?

29

El Zagna, So, you’d make it an unfunded mandate. It’s important enought to you that it gets done as long as you do not have to pay for it. Doing that would cost. Would you be willing to pay some additional tax to fund teaching hospitals for the costs associated with teaching, specifically for the additional costs associated with decreased hours for residents? Pay more for your health insurance? Or live with teaching programs shutting down and even less access to healthcare for inner city populations? Which one?

Whynot 48 hours off? What 48 hours off? As a resident you don’t get no stinking 48 hours off. You round every day already on many rotations. Sure some days are supposed to be short but you know how it goes. And despite the bravado of most of us many of slept some on call many nights. Yes it was interrupted sleep and always at risk, and yes some nights were worse than others, but they weren’t all staying up all night.

smiling, Not pressing is a good idea. Specialists can charge whatever they want, sure, but they’ll only get paid what the insurance company or the government has decided is fair or negotiated for. A lot less. Only the uninsured are actually asked to pay the charged fee. A perverse system but reality nonetheless. It is not possible in medicine today to just pass the costs on.

Gorsnak, actually I’m saying that only a little of what you you do as a resident requires much judgement at the point that you are asked to do it. By that point it is reflexive. I once woke up post call to find some notes on my clipboard telling me to check on the lab results of the septic work-up of a child with fever who was with a very low white count from cancer treatment done at 3 am. All appropriately done and documented. My handwriting. I had no recollection of having done it. Not saying that was a good thing but no mistake was made. I had done several hundreds by then and really could do it in my sleep. Besides systems were in place to help prevent me from making a significant mistake - good nurses who would ask me if I really meant that medication, pharmacists who would question a drug dose that was out of whack (each of which occurred, but not when sleep deprived, just when trying to hurry through a day.)

There is one judgement I want a resident to be able to make, especially a first year. I want them to know when they need some help and to ask for it. Call their senior resident or the fellow, or if the senior call the attending and ask what to do. The mistakes that I see made by residents are not made as a consequence of sleep deprivation or out of lack of knowledge or intelligence, they are made by the smarter residents who get a little too sure of themselves and forget what they don’t know, who are too proud or arrogant to call for help. no matter what the hour.

I am sorry that that accident occurred, but having taken cross country trips and ridden into the sun, I know that I need to know that I need to pull off the road and rest. That resident needed to recognize that (s)he was too tired to drive and pull off.

Please understand, I want the system to change. But the patient safety issue, let alone the driving safety issue, is a red herring in the main. I think it should change because it encourages the transformation of caring idealistic individuals into less caring prigs. And I think that you had better come up with how your are going to pay for it before you just try to say the hospitals will figure out a way.

30

Well, that doesn’t seem like a difficult question. Here, allot more tax money to teaching hospitals. The federal govt is running a budget surplus, they can afford it. There, increase the fees charged to insurance companies, who can either take a hit on their profits, or pass the cost on to their policyholders. Hmm. I can guess which way they’ll go on that. The point is, I’m willing to pay the extra cost to have the resident who sees me be awake. It’s not like that’s going to impact the cost of health care delivery like the rising cost of pharmaceuticals does.

31

Oh, and I also think you are being extremely cavalier about how well you function when extremely fatigued. You say it’s mostly routine, etc., but it’s still the case that the health of the patients depends on you making correct decisions. And when you’re fatigued, your ability to make correct decisions, even the decision that you need help, is impaired. This is incontrovertible fact. So either residents’ decisions are so unimportant that they could be replaced by chimpanzees, or having them work such long hours is an accident waiting to happen.

32

They don’t become coke addicts because they prefer the side-effects of addiction to amphetamines or unhealthy levels of caffeine. Actually, that’s not entirely true. Some are coke addicts.

As for whether changing the rules make health care more expensive: Between the expense of catching & fixing the errors of the sleep-deprived & speed-addled, the malpractice lawsuits, the loss of personnel due to burnout, & all the people who never even try to become a doctor due to horror at the hours, reform of the system would save money & get more bodies in the hospitals. Also, all those experienced doctors would have to come in off the golf course & work more cheaply.

US health care is notoriously expensive, & they want us to accept unreliable care & public endangerment because this saves costs? Ha! I’d like to see what medical training is like in other countries. If it turns out that in most other developed countries they let the residents sleep, & the care they provide is lower-cost for equivalent service, the advice “don’t get sick in the USA” is even more confirmed.

33

Just some info:

In US residency programs, there are now fairly strict rules limiting working hours. I was in the last intern class to have no such official restrictions; my internship ended on June 30, 2003, and the Work Hours Rules went into effect on July 1.

The rules include:
–No more than 80 hours in a week.
–No more than 30 hours in a stretch. The last 6 hours of that are for transfer of care and educational purposes; there are no new admissions after that.
–At least 10 hours off between shifts.
–At least one day off every week (averaged over four weeks).

There are also limits on how many patients an intern or an upper-level resident can admit in a day or carry at one time.

Residency programs were dragged kicking and screaming into this; it was only the threat of legally-mandated limits that brought this about. We still hear the crap about not having continuity of care, not seeing an adequate patient volume, not having the dedication that our predecessors had, etc. I still say that anyone who says he can provide good patient care after working for 30 consecutive hours (which, as it happens, is about my limit of competence–after that, I’m useless at best) is just like the guy who says he can drive just fine after a couple of 6-packs.

This whole attitude will change eventually, when the doctors of my vintage start being the ones in charge. Most people say that we really do have a different attitude about being overworked, maintaining a life outside medicine, etc., than the “old guard” docs in charge now or even those just a few years older than us, and it isn’t just because they’ve been through it and we haven’t. They will always say that we’re lazy and less dedicated; I would say that we are more realistic. (Of course, there are folks in both camps who feel the opposite way, but the gestalt is there.)

I don’t know that the hospital should really be liable for this, since they weren’t doing anything that every other teaching hospital in the US does. However, if it would help make doctors stop denying that sleep deprivation leads to impaired judgement, it might be worth it.

(Oh, and *QtM–at least in my program, we still use “intern” interchangably with “first-year resident”, partially because the latter is bulky, and partially because the experience of the first year is still markedly different from that of the second or third years (which are pretty similar). It is outdated since it isn’t usually a separate entity anymore, but it’s still a handy term.)

34

If Sampiro is right that Hong was coming off a 36 hour shift and DoctorJ is right that current Work Hours Rules limit shifts to 30 hours, that would make it easier for plaintiff to prove negligence on Rush’s part, would it not?

35

Qadgop,

Out of curiousity, does the average practicioner who DOES NOT own the medical practice he’s working in get paid less if the procedures he performs are not paid for by the patient or others? The bankruptcy thread had me thinking about this.

36

Want to get a little more depressed go look into nursing shortages. Many people VASTLY underestimate the scope of practice of RN’s. Many treatments are administered by RN’s under the orders of an MD but rarely under an MD’s direct supervision. Expansions of nursing programs could make a huge difference in quality of care without the massive time and infrastructure needs that the MD’s require. They also make a lot less money than MD’s at least over the long haul.

37

There are rules like this for airline pilots, too. I’m glad to hear there are rules in the medical profession, but maybe they’re not enough.

38

Depends on the contract the doc has with the employer. I’m not a good expert on the subject, I tried to practice in settings where I was paid a set salary to do what was necessary, not get re-imbursed based on how much I did.

I was briefly in one private practice setting where you were paid based on what you “coded” for. Visit length, complexity of diagnosis, complexity of procedure done, all figured into it. And boy, the medical record had to support the coding, or there was hell to pay! We were discouraged from giving advice to our patients over the phone as it was not re-imbursible from insurance. Instead we were expected to have them come in, so they could be billed.

I didn’t care for that system.

39

Didn’t hospitals start working interns 24, 36, etc hour shifts during the Cold War out of fear that if the war went nuclear doctors would need to be able to work for days on end with no relief?

40

It could work a few ways. One problem is that the onus is often placed on the intern himself to comply with the hours, and to seek help if he is unable to do so. Interns being the independent and approval-seeking sorts that they are, getting them to do this is like getting trees to talk. More often, the interns will simply lie about how early they came in or how late they stayed.

This is often looked at with sort of a wink and a nudge by residents and even some attendings. (I most certainly didn’t as a supervising resident–I was a real bitch about the work hours rules, and if anyone stayed late, it was going to be me. It rarely happened.)

If the intern was being deceitful in any way, or if he was blatantly breaking the WHR when he had true remedies in place, then it will be hard to prove the hospital’s negligence (and easy to prove the intern’s, not that an individual intern will have much worth going after). However, if the intern’s supervisors were clearly looking the other way, or if his program is simply not making a strong effort to see that the WHR are enforced, then there may be a case.

I’m also not sure that holding the entire hospital liable is proper. It may be different at a true academic medical center like Rush, but in my case (as a small residency program in a large community hospital), the people who have say over the residents (and their hours) are competely separate from the actual hospital administration. I know that liability for something like this would inevitably go up the line of responsibility, but I’m not sure how straight that line is in this instance.