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It’s 2 AM. Do you know where your doctor is?

It's practically a miracle that doctors don't make more mistakes due to lack of sleep
Doctors perform a liver transplant, April 7, 2003 (file photo: Flash90)
Doctors perform a liver transplant, April 7, 2003 (file photo: Flash90)

I would like to start with some simple math. There are a certain number of patients across the country, or even let’s say across the world, that need medical care. Simply put, there are not enough health care providers available 24/7 to provide all of this care.

Taking the number of doctors in a certain area and dividing it by the number of people who live in that area is often meaningless. You need to ask questions such as how many patients per hour each doctor can see, or is willing to see. You also need to know how qualified each doctor is in a given field. It doesn’t help the patients with an eye problem, if there are more surgeons in his or her area than another.

Let’s take this simple example of overnight care. I remember once a patient becoming  upset with me because I was yawning. Quite directly, the patient asked me if I was awake. I look back at the patient and said, it’s 2 AM, and no, I am not awake. But I am sufficiently alert to focus on your problem and provide your care.

There are many studies done on the productivity and accuracy of young physicians at odd hours of the night. Somehow, all of these studies seem to show that the quality of medical care is unaffected by the time of day. I am a big believer in evidence-based medicine. So when I see something like this, I say to myself that we must be asking the wrong question.

How can it be that in every other profession, the maximum allowed shifts are eight, 12, maybe 16 hours. In these other professions, like driving a large truck, there is a correlation between hours behind the wheel, lack of sleep and likelihood of an accident. So how can it be that doctors are immune to the effects of sleeplessness.

Perhaps, the question we should be asking is how can it be that the quality of care during the day is no better than the quality of care at 2 o’clock in the morning? It could well be that the quality of care at two in the afternoon is so poor, that even if you add major physician exhaustion, the results did not significantly change. Hundreds of thousands of people die every year just in the United States from medical errors. It could very well be that many of these errors are being committed by doctors who are totally awake, and “ready to go”.

It should actually be very simple to answer this question. It should be possible to give a number value to the quality of care being provided at any given hour of the day to any given patient in the hospital. You should then be able to correlate that back to the doctor who was caring for the patient, and the number of hours that the doctor was awake at the time that the doctor was caring for the patient.

We don’t have those numbers. There are definitely hospitals, which are trying to quantify quality of care for a variety of reasons, not only financial. But for every doctor who understands the importance of quantifying the way we treat people, there are many many doctors who argue that medicine is not quantifiable. If that is true, then there is no way to ever really answer the question, does wakefulness affect quality of care?

I want to say this in a clear and polite way so that any readers should be able to follow my logic.

Are you truly out of your minds? Do you think that doctors undergo special selection or training after selection to be less sensitive to the effects of loss of sleep? Do you think this is something that is tested for or that appears on an acceptance exam [how would you function after having not slept for 24 hours]? Does someone really need to do a study to show that doctors who have been running nonstop for 16 hours are tired?

Let’s put it this way. Let’s say that somehow, between the selection process for medical school and the training in medical school, doctors do become insensitive to the lack of sleep. Let’s say that even after 24 hours of straight work, a doctor is just as productive as the first hour of work.

Do you understand the implications of this? The medical community should be selling their training techniques to the American army [or any other army you wish]. The medical community should train Navy SEALs and Army Rangers in the art of being fully productive even after having not slept for over 24 hours. I have no doubt that this could be turned into a billion-dollar project, which could very well solve a great many of the issues with funding in the medical arena.

It is absolutely ridiculous to make the argument that the quality of care in medicine is unaffected by the level of wakefulness of the medical provider. The only way in which this is possible is, as I stated above, that the quality of care provided during the day is crap. So the conclusion is that since the quality of care around-the-clock, seven days a week, is so poor, with so many patients dying needlessly, it doesn’t make a difference if the doctor is totally awake or passed out. For anyone who does not like this conclusion, I am open to a different interpretation of the results.

The simple fact is that in teaching hospitals, residents [who are the least trained physicians on staff] are responsible for the welfare of the patients for most of the hours of the day and all of the hours of the weekends and holidays. One of the biggest perks to finishing your medical training and residency is that you get to be on call from home. The assumption is that the on-site doctors will only call you if absolutely necessary. But the same doctors are the least trained physicians on staff. What if they’re not sure?

The obvious answer to this, is that they should be calling the senior doctor who is at home. Now, what happens if the senior doctor at home receives a phone call from a hospital resident, at 2 AM, 3 AM, 3:30 AM, 4:15 AM, etc. How much sleep will the senior doctor at home get? When that senior doctor comes in to work the following day and is about to begin a 10 hour long surgical procedure that requires extreme focus, how will that work?

What’s the solution? I will tell you already that the solution does not lie in the use of human  staffing. As I have said countless times before, a combination of computerized medical management and involvement of all forms of health professionals [such as physician assistants and nurse practitioners] will make it possible for patients to receive good care 24/7. The “problem” with this system is that it reduces the position of the physician in the hierarchy of the medical system. The doctor in this structure, will no longer be at the upper tip of the pyramid. The doctor will definitely be part of the medical management process, but will by no means be the only person to be handling a floor of patients at 2 AM.

It’s time to wake up. It’s time to realize that the medical arguments demanding more medical students is not the solution. It’s time to recognize that a totally new system of healthcare management has to be established in order to provide quality health care 24/7. The doctors who continue to claim that computers interfere with health care,  are simply too shortsighted or too stubborn to recognize their own very serious limitations that are costing lives on a day-to-day basis.

Electronic medical record systems are not perfect. If there was a positive attitude towards them, I believe that they could be truly customized to the needs of physicians within a relatively short period of time. This is not happening because of mindless fear and shortsightedness.

I’m a doctor. And one of my greatest fears is ending up as a patient. I think that says it all.

Thanks for listening.

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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