Wednesday, September 5, 2007

Reduction in residents' hours doesn't reduce death rates

One of the most ominous trends in medicine today is the ongoing trend away from being a respected sovereign profession with a high degree of authority and independence toward a more "team-based, cooperative" (i.e., subjugated to insurance companies, government, nurses, hospital administrators,etc.) one. There are many reasons for this, but in general, it fits perfectly with modern liberal society's view of anything smacking of authority, convention, or a traditional hierarchical social structure as bad, and non-judgemental, tolerant egalitarianism as good.

The call for more humble, less authoritarian doctors has manifested itself in many ways, not the least of which is an increasingly hostile attitude toward the tradition of intense residency training with its associated long work hours and frequent lack of sleep. As some may not know, the term "resident" comes from the fact that under the original system, these trainees actually lived in the hospital and basically never left. Though that requirement was abandoned long ago, for a long time interns (residents in their first year of training) were "on call" every other night, and residents every few nights, and call, especially for interns, typically involved being up virtually all night performing patient care duties, with seldom more than a chance to catch a few cat naps throughout the night.

Obviously, this system is unacceptable to liberals, because it is associated with producing authoritarian, "hardcore" doctors who think they know it all and can do it all, who have an air of confidence about their ability to handle any medical situation. Because this is non-egalitarian, it must be abolished. (The presence of liberals with this attitude within the medical profession has been greatly exacerbated by the presence of large numbers of women within the profession, who are concerned with "balancing" work and family life, a topic on which I have yet to write substantially about.) Liberals will bleat about how it's all about patient safety, but in reality I think they just can't stand the idea of doctors being so "hardcore," as they say, and, as I've learned as a new medical student, there are many liberal doctors and future doctors who feel this way too.

Starting with the famous Libby Zion case in 1984, there has been a movement to limit the number of hours residents can work, culminating in the Accreditation Council for Graduate Medical Education's enacting the 80-hour-limit workweek for residency programs in 2003. This is a private accreditation rule rather than a law, but the threat of congressional action was imminent, and the ACGME felt that the medical profession would be better off self-regulated than federally regulated. The rules made it difficult for some programs to meet what they felt were long-established standards of postgraduate medical education: for example, a surgery resident might have the opportunity to participate in a rare procedure thanks to an emergency, but would now have to be sent home because he had reached the 30-consecutive-hour limit on in-hospital time. Still, the thread of congressional action was due to alleged patient safety issues, so everyone has been waiting with bated breath to see if the work hour limitations resulted in fewer medical errors.

Well, surprise surprise, a new study has come out showing that they haven't:
"We can say conclusively that the duty-hour regulations did not worsen patient mortality. There was a lot of concern about that, and we can conclusively say that's not the case," said Dr. Kevin G. Volpp, staff physician and core faculty member at the Center for Health Equity, Research and Promotion at the Philadelphia Veterans Affairs Medical Center. "We can also say that there's some evidence of benefit in terms of mortality outcomes."
The only statistically significant difference the studies found was an improvement in mortality for medical (as opposed to surgical) patients at the VA. Meanwhile,

"The big question is how regulating work hours will affect the quality of training of the next generation of physicians who will be taking care of all of us for the next several decades," said Volpp, an assistant professor of medicine and health care systems at the University of Pennsylvania School of Medicine and Wharton School of Business. "That's the question no one really knows the answer to."
I don't know the answer either, but I have a prediction: it will make the quality of training worse.

Some may think that I, as not only a medical student who has yet to run this gauntlet, but an older one who will be running it in his mid-to-late thirties, am crazy for standing up for the old system. Certainly all of my fellow medical students whom I have heard voice an opinion on the matter have expressed disdain for the old system and support for the work hour restrictions, believing if anything that they're still not limited enough. But here's the rub: the disdain the express for the old system is of a piece with the disdain liberals express toward our society's traditional historical culture. Everything old, traditional, and Western European must go, because those old white males just didn't "get it." They were products of an ignorant and benighted time who didn't realize that people who strike a healthy balance between work and personal life make better doctors, instead believing that doctors have to be type-A macho jerks. They think that the younger generation has discovered the wonderful idea of shift work for the first time, which for some reason no one ever thought to apply to medicine before, but now that they have, the entire world is going to be filled with goodness and light. It doesn't occur to them that if doctors are shift-based, salaried employees, instead of independent professionals, they will continue to lose prestige, income, and the respect they traditionally as the final authority in the world of health care, until they are just yet another class of pencil-pushers overseen by middle managers.

This is a good example of what might be called the "positive feedback loop of liberalism," where once a liberal idea has infected a person or group, it begins to escalate, creating ever increasing and more fervent demands for even more liberalism. The work week rules were ostensibly established for safety reasons, but they soon created a shift-work mentality in new doctors; these new doctors forgot about the safety issues, and the idea of just plain not having to work as hard became the raison d'ĂȘtre for the restrictions. But since in an important job one will always have to work hard, someone looking for limits on hard work will never be satisfied; so the demands for ever more lenient standards--even more work-hour restrictions, part-time residencies and part-time attending/private practice positions (driven largely by women seeking to have families), and the transition of certain specialties, and in the ideals of some the entire profession, toward a shift-based salaried employment model rather than a sovereign independent professional model--never cease and grow ever more stringent.

There are certainly other reasons for this besides the ACGME work hour rules: for example, increasing numbers of women in the profession, a topic I really must address in its own entry, and the general immaturity of our society. The work hour restrictions, however, are a prime example of the law of unintended consequences, the deleterious effect of our society's obsession with "safety," and the way the medical profession, like our society in general, has become effectively suicidal due to liberalism.

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