A couple of weeks ago, I blogged about the divergent approaches that we have taken to addressing the public health problems of medical malpractice and auto accidents. We seem to have taken a “hands off” approach to medical malpractice (even though it kills 100,000 people a year), going so far as to enact “tort reform” that insulates insurance companies from having to pay out in medical malpractice lawsuits. On the other hand, we seem to have taken a “get tough” approach to car accidents, cracking down on texting and driving while intoxicated and insisting that car manufacturers offer new safety devices such as airbags.
In reading through two new journal articles touching on physician fatigue, it dawned on me that we also take a tougher approach to operator fatigue on our roadways and in our airways than we do in the operating room. We subject truck drivers to stringent “Hours of Service” requirements to insure that their fatigue doesn’t harm innocent people who share the roadway with them, but, aside from some lax regulation of the number of hours that medical residents can be forced to work, doctors have a great deal of autonomy in deciding whether they should keep on truckin’ or take a snooze.
New research, however, is calling into question whether this is such a good idea. A recent journal article in the Journal of the American College of Radiology (hat tip Dr. Bob Wachter) shows that, over the course of an eight-hour work day (8 a.m.-4 p.m.), radiologists suffered a statistically significant decline in their ability to evaluate x-rays. As the (eight-hour) day wore on, radiologists were more likely to miss a fracture on an x-ray and to see a fracture where there was none. By the time 4 p.m. rolled around, nearly 1 in 20 more x-rays were read incorrectly. The article should be troubling because very often radiologists are working more than an eight-hour shift and very often they’re doing something more demanding than reading an x-ray – such as reading an MRI or CT scan with dozens of images.
This study follows on the heels of a 2009 article published in the Journal of the American Medical Association showing that daytime surgery patients suffer an eighty-three percent increase in complications when their surgeon is working on less than six hours sleep. Citing the JAMA study and other recent work, an essay in last week’s New England Journal of Medicine recommended the implementation of policies that would minimize the risk of a patient being treated by a sleep-deprived surgeon. The essay suggested that how much sleep a surgeon had the night before surgery might implicate issues of informed consent (!) and that patients should be informed of their surgeon’s sleep schedule the night before, with the option of postponing their surgeries if their doctor hadn’t gotten enough sleep.
Hopefully, these recent developments signal a sea change in how the medical profession addresses the issue of fatigue. In his “Wachter’s World” post on the radiology study, Dr. Wachter related a telling anecdote about the late, legendary heart surgeon Michael DeBakey. While visiting Baylor College of Medicine, someone reverentially told Dr. Wachter of Dr. DeBakey’s feat of performing sixteen open-heart surgeries in a single day. Instead of being impressed, all Dr. Wachter could think was, “Boy, I wouldn’t want to be patient #16.”
When you are possessed of Dr. DeBakey’s singular talents, you must feel an immense burden. There are more patients who need your life-saving abilities than you could possibly ever treat and have time for rest and family. But there is a tipping point where you’d be better off with the next-best doctor than you would be with Dr. DeBakey and medicine is finding out that that tipping point might be reached earlier in the day than anyone had ever imagined.

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If you had to guess what hospitals, over the period of 2004-2008, billed Medicare for the most spinal fusion surgeries what hospitals would you name? Number one on the list – Johns Hopkins – probably would not surprise you. It’s a massive teaching hospital and one of the finest hospitals in the country. Number two on the list – UCSF Medical Center – wouldn’t raise many eyebrows either. Again, a massive teaching hospital.
But you might be taken aback a bit by who occupies the bronze medal space on this podium: Norton Hospital in Louisville, KY. The story of how a backwater hospital in Kentucky came to bill Medicare for $48 million in spinal fusion surgeries was recently told by Wall Street Journal reporters John Carreyrou and Tom McGinty in the latest article in the Journal’s “Secrets of the System” series (which uses publicly available Medicare data to uncover possible fraud and waste).
As the Journal article notes, spinal fusion is one of the most hotly debated surgeries in medicine. It involves fusing together two or more vertebrae in the hopes of alleviating a patient’s back pain. A number of orthopedic surgeons contend that fusion surgery is only indicated for a small number of patients with back pain. Other surgeons, such as the team at Norton Hospital, find spinal fusion to be useful in a much wider set of cases, including cases where the patient is suffering from disk degeneration due to aging.
The disagreement among surgeons about the usefulness of spinal fusion would only be an arcane medical debate if some surgeons weren’t being paid millions of dollars by medical device makers for promoting the use of their hardware. The hardware used in a single spinal fusion surgery runs into the tens of thousands of dollars (“You can easily put $30,000 of hardware in a person during a fusion surgery,” says one medical professor quoted in the piece). Last year a half-dozen surgeons at Norton Hospital earned more than one million dollars apiece from hardware manufacturer Medtronic.
The payments – which some characterize as “kickbacks” and some call “royalties” – are supposed to be for contributions that the Norton Hospital doctors made to the development of the hardware technology. But the innovations for which the doctors supposedly receive these payments are slight; in a day and age when virtually anything can be patented (a patent is meaningless; it’s whether the patent stands up to a challenge that’s important) some of the Norton Hospital doctors receiving millions aren’t named on any patents. Critics contend that the payments are really kickbacks paid to the doctors for getting their colleagues and others to use Medtronic products.
Thanks to pressure by Sen. Chuck Grassley, Medtronic now discloses “royalty” payments to doctors on its website. If you have a question about whether Medtronic is paying your doctor for his work with the company, you can discreetly check by using Medtronic’s Physican Registry, now available here.
Of course, if your spinal fusion surgeon receives payments from Medtronic, all that information will also be buried somewhere within the informed consent packet that the surgeon has you sign prior to surgery. That boilerplate, as one back fusion patient detailed in the Journal story learned, is a virtually ironclad defense in some cases where patients were injured by medically unnecessary surgeries. Assuming that a doctor, prior to performing an operation of dubious necessity, has disclosed all of his financial interests to the patient and his care in performing the surgery did not fall below that of the ordinary surgeon, you will have a very hard time with a medical malpractice lawsuit even if you were injured and only subsequently learn of the troubling conflict of interest raised by the doctor’s surgeries and the medical device payments.
Ultimately, the Journal story should not be a surprise to the readers of this blog. We’ve seen how doctors in McAllen, TX bilk Medicare for unnecessary tests and procedures, we’ve seen doctors bilk insurers for unnecessary cataract surgeries and we’ve seen dialysis centers who have developed techniques to squeeze every last penny out of Medicare. It’s all part of the fee-for-service model that is driving up our health care costs.

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