When a State severely limits access to safe and legal procedures, women in desperate circumstances may resort to unlicensed rogue practitioners, faute de mieux, at great risk to their health and safety,” she concluded. “So long as this Court adheres to Roe v. Wade and [Casey], Targeted Regulation of Abortion Providers laws like H.B. 2 that ‘do little or nothing for health, but rather strew impediments to abortion’ cannot survive judicial inspection.

That’s Justice Ruth Bader Ginsburg on today’s Supreme Court ruling that overturned a lower court’s upholding of Texas’ newest abortion restrictions. This WaPo infographic demonstrates how the ruling that these laws place an undue burden on women could change other states’ laws.

Regardless of your politics, I think most people can acknowledge that Texas state legislators don’t actually care about women’s health, and the true purpose of these laws was and remains completely unsubtle. A bunch of wholly unscientific white men making unevidenced claims about women’s health as a regulatory pretense is as disingenuous as it is politically expedient.

Not ready yet to extend the rule loosening, the ACGME is expanding and extending its study of the effects of longer shifts for surgeons. The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) has unsurprisingly shown that occasionally longer shifts and a less stringent rest period did not affect the rate of “surgical fatalities or serious complications.”

I say unsurprisingly because despite being tired making all of us drunkenly stupid, residents under supervision (like those in the OR) are unlikely to be able to make a significant number of extra disastrous mistakes when the additional time periods we’re talking about are usually an hour or two. Conveniently, classic fatigue-related personal disasters weren’t even covered: needle-sticks and post-shift car accidents. They also collected duty hours the normal way, meaning that the “control” group was probably lying on their duty hours just like programs do all the time, further eroding any possible real differences. Lying on duty hours is endemic to residencies nationwide, particularly surgeons. So yeah.

What else did FIRST show?

Residents working longer shifts indicated that their educational experience improved, but at the expense of time with friends and family, extracurricular activities, rest, and health. However, these residents generally were no more dissatisfied with their overall well-being than residents whose shifts conformed to the more lifestyle-friendly ACGME rules, the study shows.

This is what I love the most. What FIRST is studying is the effect of different shift length in the context of an 80-hour workweek. While long shifts can be miserable, the underlying issue affecting burnout, misery, and lack of personal well-being isn’t occasionally working 18 or 20 hours instead of 16 (or 32 instead of 30), it’s working 80 hours a week or more for extended periods of time. You can’t have a life working 80 hours a week. If a person wants to have something consistent and grounding outside of medicine, it’s probably not going to happen. And as the young professional demographic that competes against medicine involves more flexibility, better pay, less debt, more travel, etc, this dichotomy hurts young doctors. Every social metric measured was worse, but the study was promising enough to be expanded because overall dissatisfaction was similar. Of course the real bottom line is that residents—and general surgeons in particular—are burnt out.

You take a pie made out of….an unpalatable ingredient, and then tell someone that they have to eat one every week. They have the option to eat it in 5 big pieces or 6 slightly smaller ones. Do you think they’ll care that much? The bigger pieces are harder to eat, sure, but at the end of the day, it’s still a lot of pie. For most people of normal emotional reserve and professional eagerness, it’s probably too much. The FIRST results just tell us that the 80-hour work week trumps shift length—on the whole, both groups were equally miserable.

Duty hours restrictions may have initially started as a patient safety improvement mechanism, but both anecdotally and scientifically, it’s clear that the sacrifices made in the other direction wash away most if not all of those benefits. What duty hours really have the potential to do is make happier doctors who are less likely to suffer from compassion fatigue and other issues of burnout. But to do that, we either need more residents to make the same amount of work doable with less man hours per person, or we need to design systems that are resilient and flexible enough to not be built on the premise and foundation of overworked residents (or both).

David Silberswieg, Professor of psychiatry and Academic Dean at Harvard Medical School, writing in the Washington Post about the increasingly underfunded mission of academic medicine:

But while there is a need for oversight, in some political and journalistic quarters there are exaggerated senses of mistrust, attack, mixed messages (if not hypocrisy), and mis-aligned incentives…Ever-increasing regulation brings more and more unfunded mandates and documentation requirements, which while very important to a degree, require extensive amounts of organizational and personnel time, detracting from patient care and increasing professional burn out.

The IOM’s To Err is Human and the resultant quality improvement mandates have done some important things, but fetishizing quality improvement has resulted in countless ways to try to optimize some metrics at the expense of others (as well as other unintended externalities). When you tie reimbursement to a metric, you better be sure that metric is what you really care about. When it’s not, the system suffers (such as the issues that arise with optimizing patient satisfaction).

All of this has resulted in the corporatization of the culture at many teaching hospitals. Endless meetings and initiatives to make processes leaner and to remove waste may be imperative for the responsible, viable running of the teaching hospitals. But the relentless focus on these real concerns increasingly comes up against a point beyond which staffing and funding cuts endanger the academic mission, before endangering patient safety — the point no one wants to reach.

This has been become more and more of an issue during the past four years of my residency. In addition to more documentation, various best practice warnings, mandates, programs, and the unending growth in “vice-presidents” of various manufactured responsibilities, the GME funding dollars are simply getting tighter and tighter. Even our duty hours are now being scrutinized from both directions. A resident still can’t work too much (at least on paper), but the hospitals we work for also want to make sure each is getting their money’s worth for our salary as well. They’re even starting to compete within the system with each other for their share of the pie (if I’m working at hospital A, then why am I call on at hospital B?).

How, then, can we save our academic medical centers, cutting costs and improving efficiency, without compromising the high caliber of care, patient safety, workforce development and discovery? How can we attract, educate, retain and develop our best medical talent, who have spent many years training while incurring crushing debt, and allow them to do their best work on behalf of society?

I’m not sure you can without big changes in the structure and length of medical training from college through residency. With trainees caught within the ever-grinding gears of the bureaucratic machine, the clinical and regulatory missions will absolutely try to kill the academic mission. How can the average trainee learn over a reasonable timespan in an environment of relentless oversight and pseudo-clinical distractors? How can we continue to attract driven and smart people to medicine when the journey and even the destination are becoming more unpalatable? More young physicians want “part time” work (which would often still be considered full time outside of medicine) in order to match the non-medicine lifestyles of their peers. Meanwhile student debt grows unabated. Big things change slowly, and the GME is no exception. But we’re slowly approaching a crossroads.

From the NYTimes piece about a new synthetic polymer that could be used medically to keep topical medications on the skin, maintain moisture in conditions like eczema, and—of course—to temporarily reduce wrinkles:

A Harvard colleague, Dr. Mathew Avram, who was not associated with the company or its product, said he had tried second skin, putting it under his eyes.

“It does work,” he said.

“But it was a little depressing,” he added. “I didn’t realize I had those bags.”

Is this going to replace some surgeries, make us all feel worse about the superficial effects of aging, or both?

If you’ve seen the headlines, then you know that this open letter to the CDC from three medical students and Martin Makary at Johns Hopkins has gained a lot of media attention. In it, they argue that the CDC should allow doctors to list medical error as a cause of death. So far so good.

Then they argue, through the power of contrivance, that medical error is the third leading cause of death after heart disease and cancer but above COPD (emphasis mine):

We define death due to medical error as death due to 1) an error in judgment, skill, or coordination of care, 2) a diagnostic error, 3) a system defect resulting in death or a failure to rescue a patient from death, or 4) a preventable adverse event. The prevalence of death due to medical error leading to patient deaths has been established in the literature. From studies that analyzed documented health records, we calculated a pooled incidence rate of 251,454 deaths per year.(1) If we project this quantity into the total number of deaths in the year 2013 (2,596,993 deaths), they would account for 9.7% of all deaths in the nation.

Wait, what? All of the medical error data is slightly bullshitty, and doubling down on it to “calculate a pooled incidence rate” for this purpose is no different. Medical errors that occur before death do not necessary cause that death (correlation and causation). Some patients who die “due” to medical error are so sick that the medical error is not the prime (or even secondary) culprit. Perhaps being on death’s door and requiring high level and Herculean care is a risk factor to experiencing medical error. Not all bad surgical outcomes, hospital acquired or postoperative infections are “errors” even if someone labels them as “preventable.”

The accompanying article in BMJ is longer but doesn’t help with the underlying math (emphasis mine):

A literature review by James estimated preventable adverse events using a weighted analysis and described an incidence range of 210 000-400 000 deaths a year associated with medical errors among hospital patients.16 We calculated a mean rate of death from medical error of 251 454 a year using the studies reported since the 1999 IOM report and extrapolating to the total number of US hospital admissions in 2013.

Associated. I have to imagine that this “analysis” is for dramatic effect, to spur popular outrage and official (re)action. It’s like projecting the cancer risk of CT scans based on the atomic bomb survivors exposures, dividing to estimate the risk of a single CT, and then multiplying to get the total risk of all CTs. Sure, it could be right by coincidence, but it’s certainly not rigorous or even definitely based in reality.

The premise that we should actually know if we kill someone is important and makes sense (though telling people to actually put down “medical error” on a death certificate for their patients given the malpractice climate might be a tough sell and means that I imagine in real life it would often be reserved for egregious cases). I personally think that while this sort of presentation may generate discussion, it actually cheapens an important topic within medicine. Medical error is important and we must do more to track it, but tying a number to it in this manner is almost arbitrary.

Fresh from JAMA:

In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

If 1 in 3 seems low to you (and it certainly does to me), that’s because it almost certainly is. The data were acquired from normal ambulatory care visits with physicians. Not included? Midlevels and urgent care centers (as well as dentists and over-the-phone call-ins). I bet it’s at least half taking all things into account.

The study’s lead author, Katherine Fleming-Dutra, quoted in the Washington Post (emphasis mine):

Clinicians are concerned about patient satisfaction and the patient demand for antibiotics. But the majority of individuals do trust their doctors to make the right diagnosis, and better communication by doctors about the dangers of antibiotic overuse can lead to more appropriate prescribing.

This is an important statement, but I’m not sure it’s true. For acute complaints, many people seek medical attention precisely because they want/feel/think they need antibiotics. Anything else they can get over the counter. Even if they are aware of the likelihood of a viral illness, many still want an antibiotic due to the possibility/notion of a superimposed infection or because they’re miserable and/or not getting better quickly. Even if the majority of individuals do trust their doctors, I would love to see data on the percentage of inappropriate antibiotic receivers that do!

Happy patients are good for business but often terrible for healthcare, and patient satisfaction is a dangerous quality metric.