TGIF! Is it happy hour yet?

June 10, 2013 7:00 AM

Surgeries on Friday Are More Frequently Fatal. New research shows that "operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through Wednesdays."
posted by MisantropicPainforest (51 comments total)

Thursday doesn't even start.
posted by filthy light thief at 7:03 AM on June 10, 2013 [13 favorites]

"Hey nurse, how come you didn't make it to our "Thirsty-Thursday" happy hour last night?"
posted by The 10th Regiment of Foot at 7:05 AM on June 10, 2013 [2 favorites]

Thursday's child is full of surgical instruments.
posted by unSane at 7:06 AM on June 10, 2013 [18 favorites]

I'm surprised the article didn't address the possibility that cumulative sleep deprivation throughout the work week is contributing to this.

Also, the link under "research" is to a 2007 U.S. study; the article is about a new study in Britain.
posted by palliser at 7:11 AM on June 10, 2013 [5 favorites]

You are also 10% more likely to die in the ER on the weekends.

New residents start July 1st. Which means that your junior resident was a medical student last week, and his supervisor was a junior resident last week. The "july effect" is that fatal medication errors go up about 10%.
posted by cacofonie at 7:13 AM on June 10, 2013 [5 favorites]

It seems like this has more to do with the 48 hours following the Friday surgery than the surgery itself - the weekend nursing staff is more likely to be part-time and less likely to be as familiar with the patients and early signs of trouble.
posted by maryr at 7:13 AM on June 10, 2013 [8 favorites]

(I say that as someone whose sister is a part-time second-shift weekend nurse. I think she is an excellent nurse, every bit as good as the work week staff, but there's no way she can be as familiar with patients or surgeries as the staff that gets twice as much time on the floor.)
posted by maryr at 7:15 AM on June 10, 2013 [1 favorite]

I... had surgery on a Friday some years back. Maybe MetaFilter is just a peculiar dream i am having while dying after a botched surgery. Admit it, it would explain a few things....
posted by GenjiandProust at 7:17 AM on June 10, 2013 [3 favorites]

"Hey nurse, how come you didn't make it to our "Thirsty-Thursday" happy hour last night?"

If that were the case then Monday would be a bad day to have surgery
posted by TedW at 7:17 AM on June 10, 2013

The human factors in hospitals absolutely terrify me. Nearly every time I speak to a healthcare worker, their work stories are about how they have to work around incompetence and favoritism just to get the job done.
posted by gjc at 7:18 AM on June 10, 2013 [6 favorites]

You are also 10% more likely to die in the ER on the weekends.

Couldn't we also read this as "people do 10% stupider things on the weekends?"
posted by The 10th Regiment of Foot at 7:20 AM on June 10, 2013 [6 favorites]

Really, I have never been impressed by the level of competence in hospitals I've been in - luckily, almost always as a visitor.

I too attributed it to the culture of sleep deprivation. What I fail to understand is why the medical establishment has pushed back so hard against any attempt to regulate and control the issue.
posted by lupus_yonderboy at 7:21 AM on June 10, 2013 [7 favorites]

The thing that terrifies me about hospitals is the hours. I don't get how it's even legal to have 12 or more hours in a row of working for any job, let alone one where concentration and details are of literally the utmost importance.
posted by DU at 7:21 AM on June 10, 2013 [17 favorites]

If that were the case then Monday would be a bad day to have surgery

No way, Thisty-Sunday doesn't have the same alliterative ring to it.
posted by The 10th Regiment of Foot at 7:21 AM on June 10, 2013 [2 favorites]

See also: any restaurant on a Sunday night.
posted by KevinSkomsvold at 7:27 AM on June 10, 2013 [2 favorites]

This reminds me of the prickly bit of info that in the US, the majority of hospital births are induced by either 4pm or 10pm, because that's when doctors' shifts end.
posted by shakespeherian at 7:27 AM on June 10, 2013 [1 favorite]

People are more likely to die in restaurants on Sunday night?!
posted by maryr at 7:29 AM on June 10, 2013 [2 favorites]

Actual article here, may require institutional access.

It is worth noting that this was done in Britain, and extrapolating the results to other countries that may use different staffing strategies should be done with caution. Having said that, it makes sense that differences in postoperative care account for much, perhaps all of this effect.

As for the July effect, evidence is mixed as to whether this is real, but it is worth noting that the majority of hospitals in the US do not train residents (although they may have a few newly minted attending physicians joining their staff in July) and so would be relatively immune to the effect; the same observation applies to limiting duty hours for residents, which has widespread support outside of medcine but which some of us in the profession view with skepticism (at least in terms of it improving patient safety).
posted by TedW at 7:29 AM on June 10, 2013 [1 favorite]

People are more likely to die in restaurants on Sunday night?

At least their food is.

Chef: "Order up! I've got two linguinis and a steak dying on the line here! Where the hell's that waiter?!?"
posted by The 10th Regiment of Foot at 7:34 AM on June 10, 2013

What I fail to understand is why the medical establishment has pushed back so hard against any attempt to regulate and control the issue.

There are simply not enough people and there is not the money to pay them so that medical professionals can all work eight hour (or whatever time is deemed appropriate) shifts and then have plenty of time for sleep before they return to work. Not only do concerns about sleep deprivation apply to physicians, but nurses, respiratory therapists, lab techs, even the guys who clean rooms beween patients can all make errors at work that lead to potentially fatal complications. Adding to the difficulty of ensuring adequate rest for healthcare workers is the unpredictable nature of the work. For example, I was on call all last weekend, which sounds like a long time but given the average number of cases we do on weekends it is not normally an excessive workload. There have been weekends where I didn't get a single call; other weekends I have been called a dozen times and spent most of that weekend in the hospital. That schedule also applies to the nurses, scrub techs and others who are needed to run an OR. It is hard to staff around that kind of variability without paying a lot of money to have an OR team sitting around doing nothing much of the time. This is even more true in this age of concerns about making health care more cost-effective.
posted by TedW at 7:38 AM on June 10, 2013 [3 favorites]

TedW,

The PubMed study looked at VA hospitals in the US.
posted by MisantropicPainforest at 7:39 AM on June 10, 2013 [1 favorite]

Ah, so it did; I just assumed it was a PubMed link to the BMJ study. That certainly makes the results more widely applicable.
posted by TedW at 7:42 AM on June 10, 2013 [1 favorite]

Theer are simply not enough people and there is not the money to pay them so that medical professionals can all work eight hour (or whatever time is deemed appropriate) shifts and then have plenty of time for sleep before they return to work.

This is especially obscene considering how much more money the US pours into its system than the rest of the developed world.
posted by Steely-eyed Missile Man at 7:51 AM on June 10, 2013 [6 favorites]

And apologies that I didn't make that clear in the FPP.
posted by MisantropicPainforest at 7:58 AM on June 10, 2013 [1 favorite]

I also wonder if weekend follow-up care has something to do with it. If the staff involved in the surgery is mostly present the next day, you may have several pairs of eyes that are already very familiar with the patient's case history. In contrast, there is probably a high staff turn-over from Friday-Saturday and fewer people have been thoroughly prepped to check from problem areas.
posted by fermezporte at 7:59 AM on June 10, 2013

> Theer are simply not enough people and there is not the money to pay them

Yes, that's the root of the issue. But where is the money going? The US spends more money per person on medical care than almost any other country.

My suspicion falls on the the fact that a fairly small number of doctors are taking disproportionately huge amounts of money out of the system (an NIH study seems to prove my point - even though, for some inexplicable reason, they arbitrarily capped reported salaries at $400K).

By the time you finish your residency and become a full-fledged doctor, you're probably $100K in debt and have spent the better part of a decade working under abysmal conditions. No wonder you feel it is your right to cash in.

In other countries like Canada, Scandinavia, or Germany, medical school is subsidized by the state, and the distribution of doctors' salaries is far more equitable - and they seem to get better results.

What makes me sad is that most US doctors simply see this problem as unavoidable. If pilots were falling asleep in the air and causing crashes, we'd fix it but we aren't doing anything with this issue - and preventable medical errors kill more Americans than car crashes, gun shootings and terrorism put together (source).
posted by lupus_yonderboy at 8:07 AM on June 10, 2013 [12 favorites]

I don't get how it's even legal to have 12 or more hours in a row of working for any job, let alone one where concentration and details are of literally the utmost importance.

As a point of reference in BC it is illegal for a mine worker to work more than 200 hours per month because it is considered unsafe though I don't know if healthcare workers have any restrictions.
posted by Mitheral at 8:11 AM on June 10, 2013 [1 favorite]

If I'm reading the article correctly, both the American and British studies use data from publicly-funded hospitals. The American study was done in VA hospitals, not all hospitals. I imagine it's a lot harder to get solid information -- not to mention directly comparable information -- from private medical providers.

I also suspect that private medicine is at least as bad if not worse on this stuff, given the poorer numbers on many outcomes in general health statistics in comparisons between private and public health care systems. (Sorry for the edit, something went wrong while typing.)
posted by kewb at 8:11 AM on June 10, 2013 [1 favorite]

Nearly every time I speak to a healthcare worker, their work stories are about how they have to work around incompetence and favoritism just to get the job done.

I'm pretty sure that's a common refrain in every profession.
posted by ghharr at 8:19 AM on June 10, 2013 [2 favorites]

Ghat, nothing the favoritism and incompetence remarks! That startsreally earlier on. In the class-room.
posted by Katjusa Roquette at 8:31 AM on June 10, 2013

+* gharr. Stupid AutoCorrect!
posted by Katjusa Roquette at 8:32 AM on June 10, 2013

the weekend nursing staff is more likely to be part-time and less likely to be as familiar with the patients and early signs of trouble

I don't know about this. I was in the neurology ICU for the weekend, and the staff were very pleasant and competent. I also had a weekend in the Neurology ward, and they were good too. The only hospital where I have been for a weekend was one that other problems as well (one of my Doctors said "I know you were unconscious, but, if I were you, I wouldn't have gone there").

While I was in the ICU, a nurse I had not met before was coming on for the evening shift and stopped to say hello and check my vitals. She said "sorry if my hands are cold; alcohol always does that." I looked at her and said "do you always belt down a few before coming to work?: She said "I knew that was going to sound bad; I meant using alcohol wipers on my hands." We had a nice laugh, and she refrained from sedating me.
posted by GenjiandProust at 8:37 AM on June 10, 2013 [2 favorites]

TedW, isn't "not enough people" a direct result of bad policies set up by medical assocations...limiting the available number of medical degree slots? I run across that statement often, that the AMA or other groups deliberately hold down the number of doctors to be able to keep competition low/prices high, and also attempt to prevent importing too many docs from overseas. I don't know if it's true, though.

I am told by my nurse mother-in-law that nursing school slots are actually harder to find than they should be, at least partially because teaching nursing is much less renumerative than being a nurse, so there aren't enough professors, thus not enough classes/student slots. But I also don't know if that's the whole picture either.
posted by emjaybee at 8:44 AM on June 10, 2013

The human factors in hospitals the world at large absolutely terrify me. Nearly every time I speak to a healthcare worker anyone in any major industry, their work stories are about how they have to work around incompetence and favoritism just to get the job done.

I realize health care is directly and critically related to the lives of people, but most industries are littered with petty individuals and power-plays. The world would run so smoothly and happily if it were not for personalities and emotions.
posted by filthy light thief at 8:47 AM on June 10, 2013 [1 favorite]

Hmm.. I remember long ago seeing research about surgical complications in teaching hospitals. They discovered that until a doctor has performed a specific procedure 7 times, the outcomes are pretty random with high rates of complications and death. But after 7 times, outcomes pretty much snap into line with the general rate of complications for that specific procedure.
It would be really great if doctors could find a way to become proficient without inflicting harm on people, but alas, that is how the whole field is structured. That's why I dropped out of the pre-med track in college, I was horrified at the whole scenario.
posted by charlie don't surf at 8:50 AM on June 10, 2013

The U.S. medical system has the worst training conditions in the developed world. They complain about it all the time and yet they throw up their hands as if nothing can be done about it.

I refer to this as the Fraternity Hazing Syndrome. Fraternity pledges are treated horribly and made to do all sorts of humiliating and stressful things. At the time, pledges all agree they would never inflict this on others, but as soon as they become full members, they turn around and eagerly do the same things to the next pledge class. They've survived it, they've paid their dues and by golly everyone following them better suffer as well. They rationalize that they are better people for having gone through it.
posted by JackFlash at 8:54 AM on June 10, 2013 [4 favorites]

This reminds me of the prickly bit of info that in the US, the majority of hospital births are induced by either 4pm or 10pm, because that's when doctors' shifts end.

It's an induction, why shouldn't you time it for when you're at work?

Given that this post is basically about how adverse events increase after hours, it sounds ideal.
posted by chiquitita at 8:59 AM on June 10, 2013

This reminds me of the prickly bit of info that in the US, the majority of hospital births are induced by either 4pm or 10pm, because that's when doctors' shifts end.

It's an induction, why shouldn't you time it for when you're at work?

Given that this post is basically about how adverse events increase after hours, it sounds ideal.

The issue is that births shouldn't be induced unless there is a serious medical reason, and doctors will induce births because it is easier for them, not because it is best for the mother or child.
posted by MisantropicPainforest at 9:13 AM on June 10, 2013 [2 favorites]

TedW, isn't "not enough people" a direct result of bad policies set up by medical assocations...limiting the available number of medical degree slots?

That may be part of it, but even if you could have enough physicans to do their jobs in a minimum amount of time, there still need to be nurses and a whole host of other personnel, who also need to be trained and paid. This is especially true in a labor-intensive environment such as the OR or labor & delivery. The problem is compounded by the fact that the workload is not predictable; if you staff for the busiest day of the year, then you will be paying a lot of money to people sitting around doing nothing on all the other days. On top of that there is the fact that there is a lot of maldistribution in the system; more well-paid, trained professionals are going to want to work and live in major metropolitan areas than underserved rural communities for a number of reasons.
posted by TedW at 9:38 AM on June 10, 2013

I am fairly thankful that this thread didn't exist when I was going in to have my elbow put back together on Sunday morning a couple of months ago. I certainly assume my surgeon hadn't come in straight from a kegger. Of course, this was in Canada, so I also didn't have to go bankrupt for the privilege. I have a (different) surgery scheduled for a Monday, and then two more coming up on possibly varying weekdays after that; I should ask them to spread them throughout the week so I can compare my complications and mortality rate. Science! (Actually, my only conclusion is really that turning 28 means you suddenly need to have all the surgeries, so my recommendation is not to do that.)
posted by ilana at 9:45 AM on June 10, 2013 [1 favorite]

It's like the Boy Scouts; you start collecting surgeries/badges as you get older: "Here's my ACL badge, my hernia badge, my sterilization badge, my carpal tunnel badge, my ..."
posted by Mitheral at 10:23 AM on June 10, 2013

I get really tired of medical studies that don't address any sort of cause. "This is happening and we have no idea what's causing it, or how to fix it. Everyone panic!"
posted by MadMadam at 10:29 AM on June 10, 2013

Thank God (in person) It's Friday.
I've had the unfortunate experience of going to the hospital emergency room twice in my life: both on Thanksgiving Day. Don't think of getting sick on a holiday.
posted by dances_with_sneetches at 10:40 AM on June 10, 2013

Can't find the reference, but I've heard more than once that your chances of being pushed to get a C-section rise in the evenings and on Fridays, supposedly because doctors want to get it done and go home.
posted by gottabefunky at 11:10 AM on June 10, 2013

TedW, isn't "not enough people" a direct result of bad policies set up by medical assocations...limiting the available number of medical degree slots? I run across that statement often, that the AMA or other groups deliberately hold down the number of doctors to be able to keep competition low/prices high, and also attempt to prevent importing too many docs from overseas. I don't know if it's true, though.

They're not necessarily bad policies; it's just a really tough balancing act. The AMA/med schools need to graduate enough students to supply demand, but they can't graduate so many that they'll have trouble getting jobs.

For comparison, look at the ABA/law schools. They've been cranking out too many graduates for years, and now there's a problem of unemployed lawyers with 130k in student debt.
posted by cosmic.osmo at 11:21 AM on June 10, 2013

I can't imagine a scenario where it was easier for my doctor than simply doing a C-section.

Its not, but it is easier from their perspective than not inducing.
posted by MisantropicPainforest at 1:33 PM on June 10, 2013

I'm so glad I put off the next day surgery suggested by the doctor when I met with him on a Thursday. Went in on Monday and survived just fine.
posted by _paegan_ at 1:42 PM on June 10, 2013

The issue is that births shouldn't be induced unless there is a serious medical reason, and doctors will induce births because it is easier for them, not because it is best for the mother or child.

This is not correct. If doctors did not induce, the rates of stillbirth, meconium aspiration, and shoulder dystocia would all go up.

From the Medscape overview of postterm pregnancy

In summary, routine induction at 41 weeks of gestation does not increase the cesarean delivery rate and may decrease it without negatively affecting perinatal morbidity or mortality. In fact, both the woman and the neonate benefit from a policy of routine induction of labor in well-dated, low-risk pregnancies at 41 weeks' gestation. Because it is associated with a lower rate of adverse outcomes, including shoulder dystocia and meconium aspiration syndrome, this policy may also prove to be more cost-effective.[54]

A policy of routine induction at 40 weeks' has few benefits, and there are multiple reasons not to allow a pregnancy to progress beyond 42 weeks.

posted by purpleclover at 1:47 PM on June 10, 2013

The issue isn't that induction is dangerous, the issue is that doctors are making a medical decision based on their own schedule rather than on what is best for their patient.
posted by shakespeherian at 1:50 PM on June 10, 2013

I'm curious about the source of that 4 pm or 10 pm statistic.
posted by purpleclover at 1:59 PM on June 10, 2013

Couldn't have posted this a week ago before I scheduled shoulder surgery, huh?
posted by yerfatma at 4:01 PM on June 10, 2013 [1 favorite]