Sunday, February 12, 2006

"I'll Sleep When I'm Dead"

No, I've never heard of this movie either, but I think it did well in its native UK. Still the title is rather catchy, if disturbing, and introduces today's topic: Call vs. Sleep.

I've written a piece about overuse of imaging in the ERs and another one about night call. Nothing much has changed in the meantime. We do now staff the other hospital I mentioned, and there is a call service in place over there that does a very nice job from 11PM until 7AM. We have voted to extend the service's coverage to our entire practice, and this should be in place in a month or two, depending upon how quickly credentialing can be accomplished.

The whole concept of call troubles me, and it always has. Yes, I realize that people get sick in the middle of the night and require immediate care. No question there. However, the American public has been conditioned to come to the ER with any and every twinge, and once there, the ER has to X-ray, scan, or otherwise bless them with modern medical technology before they leave. There is a significant subset of ER patients known as "frequent flyers" whose charts are longer than the Encyclopedia Brittanica and whose Xray jackets from the old days of film have enough silver in them to make a car. (Of course now in the digital era they could get their jackets as their own personal Greatest Hits CD collection...a 15 disk K-Tel special.) I have taken to mentioning this in reports..."Today's CT of the head for altered mental status is compared to the 20 previous head CT's for the same indication, with the most recent prior study being from...." Bet I get in trouble for that eventually, huh? I have to confess with some degree of shame that I actually begin to get angry about reading these studies, and the more fatigued I get, the nastier I feel about it. A colleague tried to set me straight, if you will, by explaining the ER's attitude: "We do such a great job of diagnosis with a CT that they now rely on us completely." I'm supposed to feel better about that? Do you mean to tell me that medicine has become little more than imaging? No more Marcus Welby, M.D.? Pretty soon, we will be little more than auto mechanics (no offense, but you know what I mean.)

Anyway, a spot-check of ER clients reveals a potpourri of reasons for their selection of 3AM:

  1. The headache I had for the last 3 days got a little worse tonight.
  2. I work during the day.
  3. The ER isn't as busy at 3AM.
  4. The nurse at my Nursing Home just noticed this.
  5. I'm going on a trip in the morning.
  6. I'm scared.
  7. I can't afford a doctor of my own, so I came to the ER.

And so on. Frankly, I think this whole situation is an embarassing indictment of American Medicine. We have failed these people during the day, and so they come back to haunt us at night. I wish I had the answer to fix it. You can bet that if a certain female Senator from New York ever gets back to the White House, she will fix it, and us, with socialized medicine.

But back to the question of call and sleep. I chose the movie title as an opener to reflect the apparent views of lots of doctors in general, and radiologists in particular. Sleep? What's that? Only weenies need sleep. My talents are needed NOW. I'll sleep some other time. Basically, we can't or won't realize that we (and our colleagues) have to sleep. But pushing ones' self to the limit and continuing to work after 24 or more hours of wakefullness is a really bad idea. I can cite article after article after article that shows we make more mistakes when sleep-deprived. It's a no brainer (almost literally!) Somehow, in Medicine, we don't take this for granted as we would in any other industry or situation. DM Gaba noted in a paper presented at the Proceedings of Enhanced Patient Safety and Reducing Errors in Health Care in 1998 that, most high-hazard industries the assumption is that fatigue and long, aberrant work hours lead to poor performance, and the burden of proof is in the hands of those who believe that such work practices are safe. In medicine, concerns over discontinuity of care, and difficulties in changing medical culture have pushed the burden of proof into the hands of those who wish to change the status quo. Given that medical personnel, like all human beings, probably function suboptimally when fatigued, efforts to reduce fatigue and sleepiness should be undertaken, and the burden of proof should be in the hands of the advocates of the current system to demonstrate that it is safe.

The sleep-deprivation starts in medical-school, and was long institutionalized by internship and residency. In the past few years, government regulation has limited resident's weekly hours to 80, and their continuous shift time to 24 hours. This presents somewhat of a problem in staffing, and there is indeed an impact upon the continuity of care by the residents. Still, does the benefit of continuity override the detriment of an exhausted resident pushing the wrong drug, or falling asleep whilst operating? These things have indeed happened, you know. (Or do you?)

My interest and maybe ire were rekindled by an presentation from Nabile Safday, M.D., cited in RSNA News. Dr. Safday found lots of interesting stuff, like radiologists have good vision by and large with mean acuity of 20/16, better than normal. But here is the part that hurts (italics are mine):

When asked, “Have you ever fallen asleep while driving after being on-call overnight,” 28.5 percent said, “Yes.” Almost half (47.6 percent) said they had nodded off while reading a patient study during on-call hours. Finally, the trainees self-reported that an average of 17.5 percent of errors they made on-call were due to a lack of sleep.

Bottom line: we are hurting EVERYBODY involved by pushing ourselves to the limit in this manner. We are guaranteed to make more mistakes in reading, and anyone who says they are as accurate after being up all night is fooling you, and probably him/herself. I couldn't find any figures on whether any rads or other physicians have actually died in car crashes attributable to sleep-deprivation, but you can bet it has happened.

So why do we do this to ourselves? About 95% of the answer is MONEY. Covering your hospitals, and especially your ER's, is a zero-sum game. Either you do it yourself, you hire more people to do it so you all have call less often, you hire a nighthawk to do it for you, or you hire a call service to give prelims (or final reads). The only currency we have is money and time off. If my partners and I take call and then work into the next day, as we are doing now, we get more money (ignoring for the moment the fact that a lot of ER cases don't pay anything), and we allow somebody else to be off the next day. Our theory has been that you can't enjoy the day off after call anyway, because you are so tired, so you might as well work a half day, right? Wrong, buffalo-breath, but not everyone agrees with me. If you don't want to pay a call service, and you don't want to hire an internal night-hawk, there is, of course, the option of going to shift work. Some of my partners think this is a great idea. One would work a week of 11PM to 7AM, with the day off afterwards. Just wonderful. Except there is one problem...remember the zero-sum calculation. Somebody has to be working during the day for the call guy to be off! So you see, this is yet another form of robbing Peter to pay Paul. You can't get something for nothing, you know.

Personally, I think the internal 'hawk is the way to go, but those birds are few and far between, and they don't seem too disposed to coming to our little town. There isn't much to do here during the day, so why come here to work at night? That leaves the call service, and this is the path we have decided to follow. There are those who are not happy about the cost of $50 per study, and that for just a preliminary report that we will have to reread in the morning. But tell me, what price do we put on our patients' health? Or our own, for that matter? Hmmmmm?

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