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

[Rolfe]

Well, it would be nice to live in Utopia, where there was unlimited money to train doctors and pay them full whack for "shifts" during which most of the time they'd be sleeping or doing the gardening.

And in which some sort of enhanced teaching technology was available to compensate for the drastically reduced hands-on experience time this would result in.

However, in the world we actually live in, sometimes people have to push themselves when they're fatigued. Whether they're doctors or lifeboat men or mountain rescue. Sometimes the small number of actual adverse events that may result from this is way more than balanced by the number of successful rescues or operations carried out.

Rolfe.

 

[Darat]

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?

That wouldn't involve them in the patient's treatment would 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.

...snip...

Although not directed at me I don't see why a medical professional should be exempted from the law, and there is plenty of precedent in law for people being held responsible for harm caused to other people (at least in part) because they were fatigued. Why do you think medical professional should be treated differently?

...snip..

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.

And that may well be a valid defense in a particular case however as I'd said earlier the responses of medical professionals in this thread indicates that the idea that medical staff should be expected to work when we know their competency is diminished i.e. fatigued is embedded in the medical culture, so much so that when it is suggested they should not work when their competency is reduced it is reacted to as if it was akin to attacking medical professionals

The mortality rate for ruptured AAA is substantial. As many as 2 of 3 patients with ruptured AAA die before arriving at the hospital.[URL="javascript:showcontent('active','references');"]30 [/URL]Of those who reach the hospital, as many as one fifth of those who die do so before the operation, and the overall mortality rate still averages approximately 49%.

Given these statistics, the nurse can have a go as far as I'm concerned.

Total mortality rate for ruptured AAA without surgery is >98%...as opposed to 75-80% with surgery. I prefer the latter odds.

Me too, thats why I would let the nurse perform the op if a surgeon wasn't available for whatever reason.
I would rather die trying, than just roll over.

And perhaps that figure of 75-80% could be raised to 95-98% if the medical staff were not working when their competency is reduced?

__________________



This is an issue that should be decided by the cold light of the evidence, very sadly it would appear to be that the culture of the medical profession is very resistant to that idea and in fact actively works to prevent the evidence being collected in the first place.

 

[Darat]

Well, it would be nice to live in Utopia, where there was unlimited money to train doctors and pay them full whack for "shifts" during which most of the time they'd be sleeping or doing the gardening.

And in which some sort of enhanced teaching technology was available to compensate for the drastically reduced hands-on experience time this would result in.

However, in the world we actually live in, sometimes people have to push themselves when they're fatigued. Whether they're doctors or lifeboat men or mountain rescue. Sometimes the small number of actual adverse events that may result from this is way more than balanced by the number of successful rescues or operations carried out.

Rolfe.

There is a big difference between people working when their competency is reduced as an exception compared to a culture it which it is simply expected and almost seen as a "right of passage".

 

[Criticalist]

Well, I think there is a lack of understanding or appreciation of some aspects of medical care by the non doctors in the thread.

My point is that I believe it to be unfair to accuse medical professionals of misconduct when in some cases patient care forces them to work while fatigued. In the scenario i presented, Ivor thinks the surgeon cannot act ethically whatever she does.

Really?
Does anyone really think that there is an ethical and professional option not to perform life saving surgery when you are tired and you are the only one who can do it? Imagine a surgeon having that conversation with you as your family member lay dying. There is in reality no choice in that situation, and any comment on the doctors ethics or professionalism should recognise that.

Darat, from your comments you seem to think I am defending long hours as a necessary part of the medical culture. Thats not the case; certainly in the area where I work hours on call, for the trainees at least, are rigorously controlled. The "rite of passage" you describe is long gone. However, increasingly the specialists are the ones up in the middle of the night because the work still needs to be done. Some areas do use shift systems, but for the reasons already described they are extremely expensive and inefficient. In a world where resources are limited it is reasonable to ask if the money spent to make sure there is a rested vascular surgeon always on call, rather than the possibility of a tired one, could be better spent elsewhere. Especially when you may see only a few ruptured aneurysms a year.

You may also want to check your sentence about mortality rates. I rather suspect that is not what you meant.

 

[Skwinty]

You may also want to check your sentence about mortality rates. I rather suspect that is not what you meant.

I would think the mortality rate with no intervention=100%
perhaps 99% mortality rate if the nurse does the op.

 

[paximperium]

Why do you think medical professional should be treated differently?

I don't.

The question of course is should a physician be held accountable for working tired? Yes.
Should they be held criminally negligent when there are no other alternatives? Don't know. The flip side is to provide no physician.

i.e. fatigued is embedded in the medical culture, so much so that when it is suggested they should not work when their competency is reduced it is reacted to as if it was akin to attacking medical professionals

Uh no. It is well accepted that working tired leads to mistakes and harm. That's a reason for the work hour rules.

The questions is of course should a physician work tired when their competancy is reduced when there are no others available?

This is an issue that should be decided by the cold light of the evidence, very sadly it would appear to be that the culture of the medical profession is very resistant to that idea and in fact actively works to prevent the evidence being collected in the first place.

Huh? There are large number of studies on this you know?

 

[paximperium]

There is a big difference between people working when their competency is reduced as an exception compared to a culture it which it is simply expected and almost seen as a "right of passage".

What "right of passage"?
It is against the ACGME rules for residents to work past their hours, highlighted by the fines and threats of removing credentials in placed like Duke University and Johns Hopkins Medicine and Surgery programs.

Physicians are expected to work for long hours. It is part of their life. It is part of their training. They need to learn to work while tired otherwise they'll never learn to do so when they are out of their own. Better to learn their limits while in residency when they have an attending and seniors watching over them as opposed to when they working on their own.

 

[Ivor the Engineer]

Well, it would be nice to live in Utopia, where there was unlimited money to train doctors and pay them full whack for "shifts" during which most of the time they'd be sleeping or doing the gardening.

I'm not sure where you're getting this from. While there will be additional expense because of a greater number of handover periods, why should someone on a shift where the expected workload is low be paid full whack?

Providing non-fatigued doctors requires a change to the rota so that no one individual is expected to work excessive hours without rest. In most cases it would not require any more doctors to implement, just a change to their working patterns to reduce the longest stretch anyone of them has to work before getting a break.

And in which some sort of enhanced teaching technology was available to compensate for the drastically reduced hands-on experience time this would result in.

<snip>

This is an excuse for the piss-poor organisation in most hospitals.

 

[Rolfe]

That wouldn't involve them in the patient's treatment would it?

I think the point was that if someone chose to attend a rare case as an observer while they were supposed to be resting, it might mean they were fatigued when they later came on duty.

There is a big difference between people working when their competency is reduced as an exception compared to a culture it which it is simply expected and almost seen as a "right of passage".

That is a highly relevant statement, and probably the most sensible thing that's been said on this subject. My impression was that Ivor was maintaining that a doctor who treated an emergency case while tired even in exceptional circumstances, was still guilty of malpractice.

As far as the rite of passage thing goes though, I agree with you. One of the main reasons I didn't apply to study medicine when I was leaving school was that I didn't want to deal with the sort of hell I knew junior doctors were put through in their pre-registration year. And yes, I didn't want to be responsible for someone's life in those circumstances. I don't deal well with lack of sleep, and I certainly knew that when I was 17.

ETA: It's quite a long time since I was 17, and I know that sort of rite-of-passage hell is a thing of the past. I might have made a different decision now, who knows?

Rolfe.

 

[Professor Yaffle]

Anyone have access to this? Looks pretty relevant.

The study finds that the different policy mechanisms employed in the two countries have had different degrees of success in reducing the work hours of junior doctors. The results also indicate, however, that even in settings in which hours have been reduced significantly, the regulations have only had limited effects on the quality of medical care, junior doctors’ well-being, and the quality of medical education.

http://www.sciencedirect.com/scienc...serid=10&md5=25d0771e47251855645413bad9d89487

ETA: also found this:

The Australian Medical Association argues that as fatigue depresses mood and decreases motivation, extended working hours reduces the effectiveness of learning on the job. Australian Medical Association. Effects of Work Hours on Learning - Volume I.. In Australia junior doctors typically work no more than 40 hours a week. It is often argued in the UK that such long hours are necessary for training; yet, there is no evidence either that long hours are necessary for training or that juniors' training in Australia is inferior to that of their UK counterparts.

http://www.bma.org.uk/healthcare_po...ofjuniordoctorsworkingarrangements.jsp?page=2

 

[paximperium]

Anyone have access to this? Looks pretty relevant.



http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-49M6M33-3&_user=10&_coverDate=06%2F30%2F2004&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1193531520&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=25d0771e47251855645413bad9d89487

I don't have access to the paper. It's from 2003, the mandatory ACGME workhour rules came into affect in 2002 so I don't know how relevant this paper really is. Several studies show contradictory results.

 

[sowellfan]

Well, I think the fatigue issue has been done to death at this point.

I'm curious, though, what Criticalist (and any other docs participating in this thread) think about the discipline process for doctors. Are significant numbers of bad docs getting a pass from disciplinary panels, or aren't even being reported to disciplinary panels? It seems like I've been hearing more and more in the past years about really sketchy behavior by doctors (not just 'honest mistake' type stuff), and in most of the stories that I've read, there doesn't seem to be much movement by the disciplinary board until maybe there's a lot of press.

OTOH, I'm an engineer here in Florida, and a few times every year I get a newsletter listing all of the disciplinary incidents for that time period. They come down on engineers quite hard, imho, even for some infractions that might not seem to some as a very big deal - and at least with us, it's engineers doing to the enforcement. Maybe a cultural difference in the professions?

 

[Darat]

...snip..

Huh? There are large number of studies on this you know?

See the link provided earlier in the thread, I know it is an anecdote but it was a doctor explaining how there was a culture of covering up mistakes fellow doctors made.

 

[paximperium]

Well, I think the fatigue issue has been done to death at this point.

I'm curious, though, what Criticalist (and any other docs participating in this thread) think about the discipline process for doctors. Are significant numbers of bad docs getting a pass from disciplinary panels, or aren't even being reported to disciplinary panels? It seems like I've been hearing more and more in the past years about really sketchy behavior by doctors (not just 'honest mistake' type stuff), and in most of the stories that I've read, there doesn't seem to be much movement by the disciplinary board until maybe there's a lot of press.

OTOH, I'm an engineer here in Florida, and a few times every year I get a newsletter listing all of the disciplinary incidents for that time period. They come down on engineers quite hard, imho, even for some infractions that might not seem to some as a very big deal - and at least with us, it's engineers doing to the enforcement. Maybe a cultural difference in the professions?

I did a rough count of about 70 cases completed by the Florida Medical Board in December 2009 alone with about 4 suspensions, 3 Emergency suspension, 6 voluntary license surrender, 3 probation and multiple agreed settlements. This does not include hospital disciplinary and review committees.
http://ww2.doh.state.fl.us/finalordernet/folist.aspx

You must not have read about these stories.

 

[Professor Yaffle]

See the link provided earlier in the thread, I know it is anecdote but it was a doctor explaining how their was a culture of covering up mistakes fellow doctors made.

Indeed, when they have a specific phrase to describe what they do "buffing the notes", you know it must be pretty widespread. The book/tv series he wrote (Bodies) is mainly about this issue, what happens when you encounter someone who is truly incompetant but still being covered up for, and what happens to anyone who might blow the whistle.

BTW, I don't have it in for doctors here. I think similar covering up is common in some other professions, eg the police.

 

[paximperium]

I'm curious, though, what Criticalist (and any other docs participating in this thread) think about the discipline process for doctors. Are significant numbers of bad docs getting a pass from disciplinary panels, or aren't even being reported to disciplinary panels?

I think it needs to be better. The problem with most disciplinary processes is that is informal. Only the worst cases reach a formal review or is passed on to a state licensing authority.

A "problem" physician who makes mistakes/sloppy/idiotic/lazy but is not formally reprimanded will seldom show up on any formal review. Many of these docs will just be told to leave or not have their contract renewed unless there is a formal complaint from a patient or staff member. So they just float around from job to job.

Unless they make a serious mistake, the only way to find out about their prior problems is for a hiring medical group or hospital to run a stringent credentialing process. Many big city hospitals are very strict but smaller hospitals or places that are desperate for anyone to work there are just sloppy. This is where many really bad docs drain down to. This is compounded by looser standards of care in some states and in some rural areas.

 

[kmortis]

A non-existent doctor can't kill me by her non-actions!

What if it's a homeopathic doctor?

 

[Criticalist]

If anyone is still interested I found a good balanced editorial on this subject:

Duty hours.
DeMarco DM.
Medical Care. 47(12):1189-90, 2009 Dec.

It gives an overview of the changes in medical hours over the last few years and summarises the evidence for their results; interestingly they are both positive and negative. It doesn’t really come down on one side or the other, but I think does contradict the assertions that the medical profession has a culture of long hours and has not studied the problem.

There is also an interesting and sometimes entertaining exchange in a BMJ rapid response thread:

http://www.bmj.com/cgi/eletters/339/nov05_1/b4260#224721

I particularly liked this comment: “One of my wisest trainers told my some 20 years ago that he could teach me to do an operation in a few months, teach me when to do an operation in a year, but to teach me when not to do an operation would take many years.”

Again I don’t think there are any magical answers in there, but I think it serves to show that the profession does care about the issues we have been discussing, and that the solutions may not be quite as simple as they appear at first sight. Mind you, there are clearly some James Robertson Justice “I worked 100 hours a week as a trainee and it didn’t do me any harm” types in there as well, which hardly helps my case.

By the way, the editorial may not be free access; if anyone especially wishes to read it you can pm me and I may be able to help.

 

[Ivor the Engineer]

I suppose it's only to be expected that doctors and surgeons in particular want to believe more extensive experience results in better judgement or performance. This is not always the case. Being cognitive misers, we develop heuristics as we become more experienced to avoid having to put time consuming mental effort into solving problems. From a patient's point of view this is great if he or she has a common condition which a well-honed heuristic can identify reliably, but dangerous if not fatal if the condition is unusual and gets misdiagnosed.

On the subject of doctors / hospitals covering up medical errors, I have an anecdote about my cousin's wife, who because of negligence ended up having her son dragged out of her so roughly it severely and permanently damaged the nerves to the muscles in one of his shoulders and left her needing a colostomy bag for the rest of her life.

There were two nurses who were initially prepared to testify that things had gone wrong that should not have, but after a while both decided to retract their offers to testify.

I assume that hospitals are dangerous places and despite a pretence of concern for their patients' wellbeing, most medical professionals will quickly go into '**** you, it's my ass on the line now pal' mode when they screw up while treating a patient and try to cover up their mistake(s) with the help of their colleagues.

 

[Darat]

What "right of passage"?
It is against the ACGME rules for residents to work past their hours, highlighted by the fines and threats of removing credentials in placed like Duke University and Johns Hopkins Medicine and Surgery programs.

Physicians are expected to work for long hours. It is part of their life. It is part of their training. They need to learn to work while tired otherwise they'll never learn to do so when they are out of their own. Better to learn their limits while in residency when they have an attending and seniors watching over them as opposed to when they working on their own.

That rite of passage!