Knockin’ on Hospital Doors – But Is Anyone Listening?

It is June, and the temperature in Delhi has breached 44º C. Scores of patients are braving the searing heat as they line up outside a hospital’s doors. As the Sun gets stronger, they huddle together in the small patches of shade under the few trees nearby. The elderly sit on the footpath, on sheets made of recycled plastic. By the time the doors open, the queue is nearly a kilometre long. Unfortunately, this means some of them won’t be able to see a doctor before the end of the day and will have to wait until the next day for their turns. All this for a two-minute consultation.

On the other hand, the doctors on the other side of the hospital’s doors will have been working nonstop for a period of 36 hours before the day ends. A single doctor will have done the work of three, as well as have skipped meals and survived on a couple of hours of sleep – all while struggling to improvise some sort of a therapeutic outcome for underprivileged patients beset by extreme resource and time constraints. Such resident doctors are the backbone of government hospitals; without their efforts, the entire hospital machinery would sputter and come to a grinding halt within days.

But their isolated efforts are not sufficient to stave off the decay of the public healthcare system, which has suffered historically from administrative neglect and poor management, exacerbated by a shortage of human and material resources. Instead of working towards real, sustainable solutions, those at the top of the medical hierarchy espouse ineffectual solutions to cover up doctor shortage by making the junior-most resident doctors work more than 100 hours every week, including pull 36-hour continuous shifts in a state of chronic sleep deprivation, and at the expense of quality of patient care and resident well-being.

Sleep deprivation occurs after being awake for more than 24 hours. It impairs neurocognitive and motor performance, causing significant decrements in the quality of routine clinical tasks that junior residents are expected to perform. There is a reason that first-year residents make 36% more serious medical errors when working frequent shifts of 24 hours or more compared to shorter shifts.

Studies have also shown that after 24 hours of being on call, surgical residents make twice as many technical errors on simulated laparoscopic surgical skills as after shorter shifts. Even going up to 19 hours sans sleep can impair motor performance equivalent to a blood alcohol concentration of 0.05% – but surgery residents are frequently expected to operate in this condition. The legal inebriation limit for driving in India is 0.03%.

Apart from an enormous patient load, another contributing factor is the strict hierarchy that operates within the hospital. Seniority is sacred, and the junior-most doctors bear the brunt of keeping the hospital running. Work – instead of being evenly distributed across all levels of seniority – becomes magnified as it percolates down and eventually falls on the newest member of the team.

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Working 36-hour shifts without sleep or food is considered a rite of passage for these young doctors, who barely have any experience practising medicine to begin with. They are often clueless about managing patients in the ward during their long shifts. Guidance from senior doctors is not always available. Dr M, currently a senior resident in one of the most respected medical institutions of India, said:

“There were too many instances to enumerate in my medicine training where I felt unguided. We were given too much responsibility without sufficient training. Some of our consultants did not care about teaching at all. We used to read [by] ourselves and plan management. Naturally, the quality of care wouldn’t be great.”

(M wished to remain anonymous as they were speaking against their seniors.)

Exhaustion and inexperience are the perfect recipe for medical errors – but the proponents of the current system in India conveniently ignore this. Senior doctors and professors, entrenched in the tradition, insist that long hours are the ‘only way to learn medicine’. They openly disregard the mandates laid down by the Supreme Court in 1992 through the Uniform Central Residency Scheme, which stipulates that continuous active duty for resident doctors should not normally exceed 12 hours per day, in order to prevent blunders that endanger human life.

As the lawyer Sidney Zion wrote in the New York Times in 1989, “You don’t need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgement call—forget about life-and-death.” His daughter Libby died as a result of a medical error by overworked resident doctors.

How many deaths will it take before we realise that too many people have died? Talk to any first year medical resident in India and you will hear stories about how they made preventable errors and endangered lives simply because they were forced to work at the limit of their physical and mental capacities. Unlike Libby Zion, whose unexpected death led to nationwide reforms and a limit on the consecutive number of hours doctors were allowed to work in the US, these cases are rarely publicised. There are no journalists and lawyers waiting in the wings to ensure a fair and just outcome for the underprivileged patients who reap too many tragic outcomes.

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Yet the answer to this pressing problem may already be blowing in the wind. Rather than wait indefinitely for the government to increase healthcare budget and build infrastructure (government spending on healthcare is pitiful – a mere 1.3 % of the GDP, one of the lowest in the world), we can make simple changes in policy. Dividing the traditional 36-hour shifts into two and implementing standardised measures to minimise errors during handoffs from one shift to the next can help reduce the number of serious medical errors by 36%.

In addition to implementing the ‘Uniform Central Residency Scheme’, delegating routine clerical work, blood-sampling and other simple ward procedures to other professionals will give residents more time to focus on providing actual care to patients. As Dr M said, “I feel we need to reach a more balanced approach. We should put responsibility on our residents in a more graded manner – gradually increasing every semester. Senior residents and doctors should be held more responsible for patient care and resident training.”

In the face of critical shortages of human resources, the solution is not to provide suboptimal care to patients and endanger resident well being, but to figure out ways to deploy people more efficiently.

Dr Gurasis Boparai did his MBBS from AIIMS, New Delhi. He enjoys reading, playing the guitar and exploring the city around him.

Featured image: A health worker rests before the burial of a woman who died due to COVID-19, at a graveyard in New Delhi, August 7, 2020. Photo: Reuters/Adnan Abidi

This article was first published on The Wire Science.