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From: "Steve Harris" <>
Subject: Re: long work hours for medical staff
Date: Wed, 25 Apr 2001 22:42:11 -0600

"CBI" <replytothegroup@nospam.spamnet> wrote in message

> The real issue here is the value of continuity. A policemen may have to
> make complex decisions when patrolling an area but those decisions are
> not as dependent on knowing the recent history of the situation. They
> diffuse the dispute or make an arrest and that is pretty much the end of
> it. ER docs do not acquire as intimate a knowledge of the patient and
> are not as reliant on continuity of care.

If anybody believed this argument, there would be attending physicians
staying up 36 hours regularly (several times a week, year in, year out) at
all non-teaching hospitals, just to make sure those patients in the ICU,
CCU, and surgical ward got continuity of care.Alas, such mythical hospitals
exist only in the dreams of university system attendings (who don't actually
have to do this themselves, because there are residents to do it for them).

> Even if you tried to make the argument that there are other similar
> examples then you would have to admit that they may be sacrificing
> quality of service for convenience of the employee. The bottom line is
> that the available evidence suggests that sleep deprivation does not
> adversely affect decision making ability and that unfamiliar docs make
> more mistakes than sleepy but familiar ones.

Sounds like something out of your dreams to me. Post your evidence.

From: "Steve Harris" <>
Subject: Re: long work hours for medical staff
Date: Thu, 26 Apr 2001 03:15:06 -0600

> At least one study I have read showed that cutting back the hours hurt
> patient care because a covering doc makes more mistakes than a sleepy, but
> familiar, one.
> --

But this is a false dichotomy, since the idea is not to replace sleepy
covering docs entirely with fresh unfamiliar housestaff (which has to be
done eventually in any case to some extent), but rather to replace
night-admitting housestaff with an attending who has admitted and examined
the same patient in parallel the next day. Only in cases where the system is
attempting to care for patients with nothing but housestaff and teaching
attendings (bad idea), and no patient private attending, are they going to
have to have decisions made for the patient by somebody who ordinariliy
knows little about the patient but what was learned in sign-out and whatever
quick perusal of the chart is possible.  But this is simply a way of saying
that we are sleep depriving residents so we don't have to pay for private
attendings for indigent patients and the like. The basic problem is lack of
money for closely monitored in-hospital team medical care. We solve some of
it by making housestaff suffer. Bad idea.

From: "Steve Harris" <>
Subject: Re: long work hours for medical staff
Date: Thu, 26 Apr 2001 03:38:56 -0600

"Rachel Steinitz" <> wrote in message
> I'm looking for articles about the need for restriction of long
> work hours for medical staff. There was an article in JAMA in
> 1993. I want to know about researches done to prove the obvious,
> that physicians who don't sleep enough get sleepy, and that
> patients may suffer the consequences.
> Rachel Steinitz-Cohen


There's always medline. It's a mixed bag. NY changed its laws after sleep
deprivation was implicated in one patient death, but studies show all kinds
of things. Some effects on one thing, not on others. And some surprises.
Supose we must actually trade danger to residents (driving) off against
danger to patients, so long as we refuse to come up with patient care money?
And who among us thinks that somebody impaired driving a car should instead
be practicing medicine?

 Sleep 1996 Dec;19(10):763-6

Effect of sleep deprivation on driving safety in housestaff.

Marcus CL, Loughlin GM

Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins
Baltimore, Maryland, USA.

Sleep deprivation is known to affect driving safety. Housestaff (HS) are
routinely sleep-deprived when on call. We hypothesized that this would
affect their driving. We therefore administered questionnaires regarding
driving to 70 pediatric HS, who were on call every fourth night, and to
85 faculty members (FAC), who were rarely disturbed at night. HS were
questioned about events during their residency, and FAC were questioned
about events during the preceding three years. There was an 87% response
rate for each group. HS slept 2.7 +/- 0.9 (SD) hours when on call vs 7.2
+/- 0.8 hours when not on call (p < 0.001). 44% of HS had fallen asleep
when stopped at a light, vs 12.5% FAC (p < 0.001). 23% of HS had fallen
asleep while driving vs. 8% FAC (ns). A total of 49% of HS had fallen
asleep at the wheel; 90% of these events occurred post-call. In contrast,
only 13% of FAC had fallen asleep at the wheel (p < 0.001). HS had
received a total of 25 traffic citations for moving violations vs. 15 for
FAC and were involved in 20 motor vehicle accidents vs. 11 for FAC.  One
traffic citation clearly resulted from HS falling asleep at the wheel vs.
none for FAC. We conclude that HS frequently fall asleep when driving
post-call.  We speculate that current HS work schedules may place some HS
at risk for injury to themselves and others. Further study, using
prospectively objective measures is indicated.

PMID: 9085483

J Am Osteopath Assoc 1995 Oct;95(10):600-3

Residents' performance before and after night call as evaluated by an
indicator of creative thought.

Nelson CS, Dell'Angela K, Jellish WS, Brown IE, Skaredoff M

Department of Anesthesiology, Chicago Osteopathic Hospitals, Olympia Fields
Hospital and Medical Center, Olympia Fields, IL 60461, USA.

The effects of sleep deprivation on medical personnel have received much
attention. This study evaluates the effects of sleep loss on
divergent-thinking (creative or innovative) processes as measured by the
Torrance Test of Creative Thinking (TTCT). Anesthesia residents who had
approximately 30 minutes sleep while being on-call were evaluated. These
physicians had similar caffeine and nicotine consumption before and after
the test. The results reported here demonstrate that postcall residents
had TTCT scores that were appreciably below those scores of rested
residents. Postcall verbal fluency was less among the on-call group than
among the rested group (94.0 +/- 9.7 vs 101.8 +/- 9.8) as was figural
originality (89.9 +/- 22.1 vs 113.3 +/- 20.3). These study results
suggest that sleep deprivation affects divergent, or creative, thinking.
Divergent-thinking processes are usually innovative and are used during
complex problem-solving tasks. Further studies are needed on the effects
of sleep deprivation. This information can then be used to help improve
residents' working conditions and patient care.

PMID: 8557549

Surgery 1994 May;115(5):604-10

Influence of sleep deprivation on learning among surgical house staff and
medical students.

Browne BJ, Van Susteren T, Onsager DR, Simpson D, Salaymeh B, Condon RE

Department of Surgery, Medical College of Wisconsin, Milwaukee.

BACKGROUND. Sleep deprivation as a result of in-house night call may
alter capacity to learn. Surgical residents and medical students, in both
sleep-deprived and rested states, read surgical journal articles and
later answered questions regarding their content as a measure of ability
to learn while participating in scheduled night call. METHODS. Medical
students (n = 35) and residents (n = 21) rotating on surgical services
kept logs of hours slept during a 4-week study period. Subjects read six
selected articles at separate early morning sittings during weeks 1 and
3. A multiple choice test was given 1 week after each session to assess
short-term recall, and all tests were given again 3 months later to
assess retention of information over the longer term.  Scores were
compared with the sleep data. Subjective measures of fatigue and
motivation elicited from subjects also were evaluated. RESULTS. Sleep
deprivation (4 hours or less uninterrupted sleep per night) resulted in
increased fatigue and decreased motivation among medical students and
residents (p < 0.05, t test). Objective scores on tests administered 1
week and 3 months after reading did not show an effect attributable to
sleep deprivation (p > 0.05, t test). CONCLUSIONS. Sleep deprivation
leads to subjective feelings of increased fatigue and decreased
motivation. Residents and medical students, however, whether sleep
deprived or not, obtain comparable scores on objective tests measuring
both short-term and long-term retention of newly learned material. The
ability to learn medically relevant information does not appear to be
significantly altered by the degree of sleep deprivation associated with
clinical rotations on surgical services.

PMID: 8178259

From: "Steve Harris" <>
Subject: Re: long work hours for medical staff
Date: Sat, 5 May 2001 16:09:19 -0600

"big benz" <> wrote in message
> to the issue of long hours for residents i believe your argument was that
> shorter hours would increase the likelihood of medical errors because the
> replacing resident would not be as familiar with the patient in question.
> what i am saying is that there is a process, that being better
> documentation, which could ameliorate the problem that you identified.
> there are issues about whether there is the motivation and interest
> within the medical community to deploy such processes, but the problem
> that you identify is not "unsolvable" or evidence of some magical
> uniqueness that inheres in medicine.

CBI's argument doesn't just rely on the idea of some magical uniqueness that
inheres in medicine, but rather on some magical uniqueness that inheres in
hospital internal medicine or pediatrics vs. (say) emergency medicine where
patients are routinely handed off every shift. CBI thinks these are
different patients, but he's apparently not seen a large inner-city
Emergency Department recently. Furthermore, there are many cases here
standard housestaff-admitted patients are admitted to one team and need to
be handed off to another because of some problem, long before a standard
residency admitting shift is over. They go from medicine to surgery, or to
the ICU, or whatever. I don't hear CBI suggesting that all this is bad for
patients, and must be therefore be stopped (ie, that even if other doctors
are soon involved in a case, the original admitting team must continue to
function as the primary physicians for the first 36 hours after admission,
no matter what, so long as the patient still draws breath, because nobody
else can be safely trusted to read and understand an H&P during that sacred
span of time.).

Lastly, I want to bring up a separate issue, which is the fact that the
sleep deprivation of doctors in hospitals is most severely affected not by
how long they stay in-house, but by how many consecutive hours they are up
for new admissions or transfers. One can cut this number back without in any
way compromising patient care by anybody's criteria, even CBI's. The fact
that it hasn't happened until very recently, and still isn't optimal, is a
direct consequence of the abusive nature of the system. Slavery lasts longer
than it should in democracies because slaves don't get to vote. Housestaff
don't have an effective labor union, because they are disenfranchised by
licensing requirements. They are like illegal immigrant labor-- one can do
many nasty things to them because they have nowhere else to go.

There is a certain irony and justice in the fact that what has happened to
residents in the last century is now happening to all physicians in the US,
as they begin to be used by larger for-profit programs in much the same way
that they formerly used their own apprentices. And they find they don't have
any union, either, in the US. You're now hearing a lot of screaming and
yelling from people who figure that they paid their dues, and are now
entitled to be Top Dog. Except there's a little problem: they trained too
many new doctors in the process of using them, who now in turn are pefectly
willing to replace their seniors at the HMO as soon as the ink on their
licenses is dry, and none of whom have the slightest loyalty to a profession
which shows far less compassion to its own than it does to the ill (if you
can imagine that ;0). So here we are. I can hardly see a thing happening to
the American medical profession that it, as a profession, did not richly

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