Split Thread Do Doctors cover for each other's misconduct? (Split from "Wakefield")

[blutoski]

Thank you for answering my question:



ETA: Which is more negligent? A sleepy airline pilot or no pilot at all?

I think that's an unfair comparison. Airlines can be told their flight is postponed until replacement staffing is obtained.

We don't have the power to 'postpone' a heart attack until staffing improves.

 

[Deetee]

I think that's an unfair comparison. Airlines can be told their flight is postponed until replacement staffing is obtained.

We don't have the power to 'postpone' a heart attack until staffing improves.

Nor do we have a back-up battery farm of rested, experienced cardiology specialists ready to leap into every staffing gap at a moment's notice.

 

[blutoski]

...which it is. Perhaps they believe doctors can't stack shelves or work on the checkout of a supermarket if they get struck off for being lethally incompetent physicians.

I think the quibbling might be about the word 'cover'. The evidence you've provided that *some* MDs are not disciplined enough is maybe not showing what you want, because the disciplinary bodies are publishing their rulings.

I'm as disappointed as anybody when a physician is given a slap on the wrist, but this is an example of inadequate punishment rather than an attempt to cover over the problem.

Typically, the victims get to participate in the hearings. They often bring their own expert witnesses and usually also engage media. The process is relatively transparent (at least it is here in Canada).

Here's a recent injustice (my opinion): [Doc gets 'slap on wrist' at misconduct hearing] - Eoghan O’Shea's barely token punishment is just the latest in the ongoing saga of [CCRG].

 

[blutoski]

Nor do we have a back-up battery farm of rested, experienced cardiology specialists ready to leap into every staffing gap at a moment's notice.

I'm going to grab CMAJ when I get home. I think there's evidence that the shorter shifts produce worse patient outcomes, and the explanation is staffing overwork.

The key is that 'on-call' is usually over-and-above an MD's regular job, so asking them to go on-call for 2 x 14hr shifts a week vs 1x24hr shifts a week on top of their regular 40hs translates into more fatigue errors, rather than fewer. It's two days of sleep deprivation instead of just one.

 

[Criticalist]

Nor do we have a back-up battery farm of rested, experienced cardiology specialists ready to leap into every staffing gap at a moment's notice.

Exactly my point. I was up till 10pm last night with a cardiologist doing an emergency angiogram on a critically ill patient. There are not enough cardiologists to roster on 12 hour overnight shifts and cover the extensive daylight work, and not enough urgent out of hour angiograms to justify it.

 

[Ivor the Engineer]

Exactly my point. I was up till 10pm last night with a cardiologist doing an emergency angiogram on a critically ill patient. There are not enough cardiologists to roster on 12 hour overnight shifts and cover the extensive daylight work, and not enough urgent out of hour angiograms to justify it.

Oh well, nothing can be done then. I guess we'll just have to put up with patients being injured and killed because of errors made by physicians when they are sleep deprived.

Obviously in the interests of informed consent physicians will be telling their patients and/or their relatives when they are sleep deprived and that this will vastly increase the probability of serious errors being made?

 

[Skwinty]

Here is an example relating to aviation:

The probable cause of the Colgan Air crash that killed 50 people near Buffalo, N.Y., a year ago was the captain's inappropriate response, characterized as "startle and confusion," after the stick shaker was activated, pulling back when he should have pushed forward, the NTSB reported in a hearing on Tuesday. Contributing factors included the crew's failure to monitor airspeed and their violation of the sterile-cockpit rule. In the daylong hearing, which ran past 7 p.m., the board split over the issue of whether or not fatigue was a contributing factor in the accident. Board chairman Deborah Hersman argued that several factors, including the crew's sleep deficits and the time of day the accident took place, indicated that fatigue was present, and should be counted as a contributing factor to the crew's performance. But the view of board member Robert Sumwalt prevailed -- he said just because the crew was fatigued, that doesn't mean it was a factor in their performance. More...

 

[Criticalist]

Oh well, nothing can be done then. I guess we'll just have to put up with patients being injured and killed because of errors made by physicians when they are sleep deprived.

Obviously in the interests of informed consent physicians will be telling their patients and/or their relatives when they are sleep deprived and that this will vastly increase the probability of serious errors being made?

And once again, I am not defending the performing of clinical duties when sleep deprived, I am opposing a facile and ill thought out opinion that doctors should be considered guilty of misconduct if they make an error when fatigued.

 

[Ivor the Engineer]

And once again, I am not defending the performing of clinical duties when sleep deprived

<snip>

Yes you are. You have just stated that nothing can be done and we just have to accept it.

Therefore it seems reasonable that patients and/or their relatives should be informed when a sleep deprived doctor is treating them or their relative and informed of the increased risk of error. Do you agree?

ETA: To not do so would be misconduct would it not?

 

[Deetee]

Oh well, nothing can be done then. I guess we'll just have to put up with patients being injured and killed because of errors made by physicians when they are sleep deprived.

Obviously in the interests of informed consent physicians will be telling their patients and/or their relatives when they are sleep deprived and that this will vastly increase the probability of serious errors being made?

I guess trainees who are now on reduced hours (as per the european working time directive just to ensure they are not tired or overworked) will also be telling all their patients that because of this they are getting less training and are less skilled and less experienced doctors and everyone will have to put up with patients being injured and killed as a result.

As you know the [Royal] College and the vast majority of surgeons believe that a 48 hour week for surgeons in the NHS is a major threat to safe patient care which will result in very thin medical cover with multiple handovers, and will devastate standards of training.

http://www.rcseng.ac.uk/news/surgeons-the-european-working-time-directive-and-august-1st-2009

 

[Darat]

Here is an example relating to aviation:

The probable cause of the Colgan Air crash that killed 50 people near Buffalo, N.Y., a year ago was the captain's inappropriate response, characterized as "startle and confusion," after the stick shaker was activated, pulling back when he should have pushed forward, the NTSB reported in a hearing on Tuesday. Contributing factors included the crew's failure to monitor airspeed and their violation of the sterile-cockpit rule. In the daylong hearing, which ran past 7 p.m., the board split over the issue of whether or not fatigue was a contributing factor in the accident. Board chairman Deborah Hersman argued that several factors, including the crew's sleep deficits and the time of day the accident took place, indicated that fatigue was present, and should be counted as a contributing factor to the crew's performance. But the view of board member Robert Sumwalt prevailed -- he said just because the crew was fatigued, that doesn't mean it was a factor in their performance. More...

I don't think anyone is arguing that fatigue is the only reason medical staff make mistakes, but we know beyond doubt that fatigue does affect someone's ability to make complex judgements, that is why in aviation, as in many, many other professions it is taken into account.

The issue appears to be twofold to me, one is understanding to what degree fatigue contributes to medical mistakes, after all it may well be that statistically speaking the likelihood of a medical professional making a mistake is only slightly increased by them working fatigued. (I admit I find that very unlikely given what we know about fatigue contributing to mistakes in so many other areas of life, but it may well be that the system medical professionals work within already has compensationary mechanisms to help alleviate the additional risk fatigue adds.) The second point is dealing with what appears to be an ingrained cultural acceptance that medical staff have to work when fatigued.

 

[paximperium]

I'm going to grab CMAJ when I get home. I think there's evidence that the shorter shifts produce worse patient outcomes, and the explanation is staffing overwork.

The key is that 'on-call' is usually over-and-above an MD's regular job, so asking them to go on-call for 2 x 14hr shifts a week vs 1x24hr shifts a week on top of their regular 40hs translates into more fatigue errors, rather than fewer. It's two days of sleep deprivation instead of just one.

I'm not familiar with that study.
I did read a study among orthopedics that show increased morbidity in hip replacements after the work hour rules were implemented. But it was not a well designed study and was just based on a national review of case complication rates.

 

[Deetee]

Here's a recent injustice (my opinion): [Doc gets 'slap on wrist' at misconduct hearing] - Eoghan O’Shea's barely token punishment is just the latest in the ongoing saga of [CCRG].

Hard to tell what is going on here from that link. Seems he prescribed "supplements" to patients which cost them lots of money. That may have been unecessary or futile, but what was the actual misconduct about?
Should everyone offering patients CAM/spplements/vitamins etc be similarly censured?

 

[paximperium]

I guess trainees who are now on reduced hours (as per the european working time directive just to ensure they are not tired or overworked) will also be telling all their patients that because of this they are getting less training and are less skilled and less experienced doctors and everyone will have to put up with patients being injured and killed as a result.

http://www.rcseng.ac.uk/news/surgeons-the-european-working-time-directive-and-august-1st-2009

I don't have any problems with Ivor's "reasoning". He and everyone just has find the money that will be spent to keep all the oncall docs sleeping and well rested and ready to go...if they get called at all.

I'm actually all for it.

 

[Deetee]

How about having cards printed like this to give to all patients:

Medical disclaimer:

I am a trainee doctor.

In order to function efficiently and safely, I must not be tired as this may render my performance suboptimal and increase the likelihood of medical errors. I therefore maintain the right to refuse to treat you, cancel my operating lists, cancel my clinics and refuse to see emergencies if I do feel tired.

In order to minimise my chances of becoming tired, I am now required to do less training and work shorter shifts. This may reduce the chances of my becoming tired, but not necessarily so. It will however significantly reduce the clinical experience and training I get, and increase the chances of medical error.

I guess we all want the best for patients. In an ideal world there would be more money for medical staffing, better training etc.

 

[Darat]

How about having cards printed like this to give to all patients:

And perhaps the second issue I mention is the one that really does need to addressed....

...snip... The second point is dealing with what appears to be an ingrained cultural acceptance that medical staff have to work when fatigued.

 

[Skwinty]

When a doctor is on call, I would imagine that he is at home waiting for his pager to go off. It would, IMO, be irresponsible for the doctor not to have a sleep during that period.

As for the late night/early morning emergencies, are there not sufficient on duty doctors at the hospital to deal with these emergencies?

I don't expect the top specialists to be there at all times, but surely the on duty doctors can deal with the initial diagnosis and treatment.

 

[paximperium]

And perhaps the second issue I mention is the one that really does need to addressed....

It's a good point. But then it continues to be a training issue.

If a trainee surgeon sees a disease that is rarely ever seen or a special procedure that they have never done before, do you think they'll pass on the oppurtunity to be in the OR for this case? Do you think it is fair or good for their training to miss such a rare opportunity?

 

[Ivor the Engineer]

It's a good point. But then it continues to be a training issue.

If a trainee surgeon sees a disease that is rarely ever seen or a special procedure that they have never done before, do you think they'll pass on the oppurtunity to be in the OR for this case? Do you think it is fair or good for their training to miss such a rare opportunity?

Why is it important for so many doctors to have experience of rare diseases or procedures? Someone will be there to benefit from the experience. If you're lucky they'll shake your hand and save your life.

 

[Criticalist]

Yes you are. You have just stated that nothing can be done and we just have to accept it.

No I am not. Your position appears to be that a doctor who makes an error whilst they are fatigued is guilty of misconduct; not because of the error per se, but because they allowed themselves to work while fatigued which presumably contributed to the error in the first place. Your comment :

"While the excuse 'I was just following orders' is understandable, it is not a valid defence."

seems to bear this out. I am saying that is inappropriate to censure a doctor for performing when fatigued when a number of factors outside of their control, including clinical urgency, lack of staffing, funding etc, force them to do so.