A couple of weeks ago, a study appeared in the New England Journal of Medicine showing that patients admitted to hospitals with heart attacks on weekends had higher mortality than similar patients admitted on weekdays. The investigators' analysis demonstrated that the main reason for this was a decreased rate of invasive intervention--namely, cardiac catheterization and angioplasty--on weekend admissions compared to weekday admissions.
This is perhaps not the surprise of the century: interventional cardiologists like their weekends off, just like normal people do. And although any hospital with an interventional cardiology service has someone on call at all times, that someone is rarely in-house. In order to get a procedure done on a patient having a heart attack on the weekend, two things need to happen:
- someone needs to interrupt a cardiologist's meal/show/lovemaking, and
- a cardiologist needs to set down her fork/step on his seatmate/put on her pants, then get on the road and into the hospital.
There are improbabilities in both scenarios, but the improbabilities are not what this study studied.
We understand the impact of delaying angioplasty for patients who need it. National guidelines governing the use of angioplasty suggest that when treating people with demonstrated death of heart tissue (ST-elevation myocardial infarctions, for you medical types), we shoot for a goal interval of ninety minutes and a maximum of twelve hours between the first medical contact and the time the balloon hits the coronary artery.
There's a little more room for judgment in people without demonstrated tissue death, or with other indictations for angioplasty. However, this study adjusted for one of the major diagnostic determinants of severity in heart attack (acute Q-waves) and found no difference in its results, suggesting that the severity of the heart attack was unrelated to the difference in outcomes. (Which, taken a step further, means that the difference in outcomes on weekends wasn't just due to weekend patients having more severe heart attacks.)
The investigators adjusted for several other patient characteristics, like demographics, comorbidities, and complications, and found no significant differences in their results, reassuring readers that it's unlikely to be patient characteristics that shape their findings. But oddly, they included very little analysis of or adjustment for hospital or provider characteristics.
It's possible this omission is political--perhaps results in this area cast certain entities in an unflattering light--or just pending publication. Or perhaps it's a litte touchy to ask institutions to grade the unapproachability of its interventional cardiology service, or to admit that less experienced junior staff get stuck with most of the weekend call, or to get into whatever kinds of things result in these kinds of findings.
Still, the question remains: why do fewer heart attack patients get angioplasties over the weekend? That's the question I asked a cardiologist shortly after the paper was first published. He replied, "I don't want to talk about it."
I think I'm on to something.
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The problem is not just getting the cardiologist out of bed... it's getting the rest of the team there, the techs and such who set everything up. They are the ones who are on the 8-5 work day schedule and get paid overtime if they come in at different times, making the hospital in general less likely to push for more aggressive treatments in those off time hours.
I think it is a sign that there are no "generic" cardiologists (or "generic" anything). That skill matters, and the ad hoc teams put together on the weekend are not as skilled as those during the week. There probably is a larger difference between hospitals and between individual clinicians than within a single hospital.
The problem no one wants to talk about is that half the doctors are below average and who wants their doctor to be below average? But if you get rid of the bottom half, half of those that remain are below the average of those that remain.
But these difference are microscopic compared to the differences in mortality caused by the lifestyle choices that people make for themselves. The crappiest doc at CABG would save more patients by getting them all to lose weight, stop smoking, and exercising before a heart attack than by improved technique afterward.
While i don't smoke, pay attention to diet, and exercise regularly, i'm still planning my first heart attack. Everyone in my family who's old enough to have had one has had one, and many who weren't old enough. So, i'll avoid the weekend. Simple enough. Is Tuesday better than Monday? Hey, many men, it seems, wait for the end of the current sports event on TV before going to the ER... Last time i went, i waited over six hours so child care could be arranged.
I'd always thought that Christian doctors should take Saturdays, and Jewish doctors Sundays, or something like that. And not just doctors, but everyone who provides services to the public. Athiests, one supposes, could take the whole weekend. If it was totally common, then it wouldn't be so hard to socialize on Tuesdays and Wednesdays, or whatever your days off are. It's gonna be hard to jump start this, though. We enjoy Saturday mall traffic too much. Then, those that need training could get training any day of the week.
Half of doctors perform below the median. But it just doesn't have the ring of "are below average", and it's often close. In my profession, performance of a few has been measured as seven times anyone else - which screws up your averages. The set 1, 1, 1, 7 has an average of 2.5, but the median is 1. Obsessive compulsiveness is a plus in this profession, naturally.
Start that broccoli today... and oh, don't forget the berries...
Mom
I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.
in the end, the blame was placed squarely on my shoulders in a very public venue - i would have felt better if the chair had just called me in and reprimanded me, but for it to have been done in that fashion in front of the ORL team present to witness it, to boot! i was in my 3rd year of residency, but a part of me was very, very close to quitting.