Primum non nocere

According to the Agency for Healthcare Research and Quality, medical errors are now one of the leading causes of death in the United States, higher than motor vehicle accidents or breast cancer. A significant contributor to medical errors in hospitals is the medical residency program.

As an editorial in the June 28 issue of the New England Journal of Medicine attests, the 30 hour shifts and 80 hour workweeks medical residents are asked to endure does neither patient nor physician any service.

I remember a study that found that the standard amount of sleep deprivation required of medical residents was as impairing as these doctors having consumed three to four alcoholic drinks.

After many late nights in college and grad school, I have, on many occasions, experienced that loopy, intoxicated feeling that comes with sleeplessness after say, a 16 hour day. I can't imagine what I would be like after nearly twice that long. Probably something like this:




And perhaps it would be Ok for me or these blokes to confuse words or names of things, but if someone I loved were about to go under the knife, I sure as hell wouldn't want a physician to be confused as to a surgical procedure or medication regimen--or laugh uncontrollably as we discuss risks associated with surgery.

Of course, I should give physicians more credit. Every medical resident I've ever come in contact with, regardless of their lack of sleep has always treated me with the greatest respect and dignity possible. And so far, thank goodness, I have never suffered irreparable harm due to a medical error in the emergency room.

But medicine is a highly sophisticated and complicated art, that has significant room for error even under the best circumstances.

Last week, a contributor to Slate magazine published a story on what it was like to be a practice patient for medical students, calling herself a human guinea pig. These students were just beginning to apply the knowledge they have been learning to real people, although these real patients or actors are being paid to be examined and, in some cases, asked to pretend they have a specific illness.

Even for Emily Yoffe, a healthy patient undergoing a standard physical exam, the task required of these students was a complex one. These future doctors were being asked to juggle a patient-physician relationship (albeit a one-visit only deal) that involved the examination of 45 different aspects of the body, and apply to living tissue what they have only seen in textbooks or within bodies donated to science. Yoffe had a few students who well exceeded her expectations and others who floundered miserably.

But I can't help but thinking it's these poor students (with the exception of Dr. I) are the real ones being experimented upon.

Somehow, through the rigors of medical school, these future residents may get used to the fatigue and will undoubtedly save many lives. But why should we torture them so?

Despite the many reforms that have taken place to make the situation a little bit better, medical residency programs seem determined to ignore the problem, almost as ill-advisedly as Moliere's Imaginary Invalid employs several doctors to treat his made-up sicknesses.

One of my best friends, currently in her third year of medical school, says that because all the other doctors before them have had to suffer, things are unlikely to change. I imagine its also very difficult for hospitals with limited funds to afford additional placements to handle the extra work.

The financial constraints on staffing hospitals is probably even more serious in disproportionate share hospitals, or those that serve a much larger proportion of charity or Medicare/Medicaid cases than others in their geographic area.

Let's not even mention the fact that physicians, themselves, are putting their health at risk to keep up with this extremely taxing workload. To the extent that some may be even cutting their lives short because of it.

But something has got to give and until it does, the Accreditation Council for Graduate Medical Education is complicit in breaking the very oath that the students they oversee have been sworn to uphold--"First do no harm."