Blog

For too long, medicine has been a cult that deifies workaholism and mocks those who “fuss” about sleep, say Matt Morgan and Peter Brindley

Lauren Connelly was delighted when she landed her ideal job. After years of proving her mettle through hard study she stepped enthusiastically onto the medical ladder. She was now a doctor, and would hone her craft at a rural Scottish hospital. Fast forward a few weeks and Lauren was exhausted, both physically and mentally, after yet another 100 hour-week. Undaunted she readied herself for seven consecutive night shifts. This may have been her dream job, but the truth is that the rota rarely allowed for adequate sleep. Her death occurred on 17 September 2011 on Scotland’s busiest motorway, after falling asleep at the wheel. 

Following Lauren’s death, her dad, Brian [1], suffered his own insomnia, albeit for different reasons. Alongside grief, Brian Connelly was angry and in disbelief. After all, we—the supposedly sensible and all knowing medical profession—had blithely ignored decades of its own research. We know that lack of sleep kills. Data have consistently shown how it kills slowly and silently by increasing the likelihood of cancer, heart disease, immunosuppression, and weight gain. Poor sleep also kills suddenly and loudly through motor vehicle crashes and workplace trauma. If insomnia was a drug we would ban it immediately. If sleep was a drug we would prescribe it to all. Brian is right to speak up, is right to ask questions, and deserves our full support. The answer is seemingly simple: more and better sleep for all. The question remains: do we care enough to do the right thing? 

Speaking six years after his daughter’s death, you can still hear gritty determination mixed through his Scottish accent. He intends to wake up the government and the medical profession, and like all good parents, he just won’t quit. There is legislation to limit working hours, but Brian will tell you how it is commonly exploited and stretched. For example, we often tabulate average working hours. This sleight of hand allows 100 grueling hour weeks to be hidden within a rota, as long as that rota includes less hours over subsequent months. Brian is clearly smarter than the lot of us when he reminds us that: “Sleep cannot simply be banked and averaged over time.” We simply don’t believe that any doctor should be worked to death. 

For too long, medicine has been a cult that deifies workaholism and mocks those who “fuss” about sleep. Regardless of whether insomnia is limited to medicine or is, instead, a society wide issue, we can likely all agree that we need a cultural shift. This starts by senior folks speaking up and standing side by side with junior colleagues. 

We should not, cannot, and need not stand by as doctors work hours that we would never condone for pilots or bus drivers. Lessons must be heeded. Fortunately, these are lessons that we have known for decades, and lessons that Lauren and her dad are shouting on our behalf. Patient safety matters, and so does practitioner safety. 

Brian is a professional working in the information technology industry. As such, both his advocacy and his day job could save more lives than any single doctor. This is because many of the greatest patient safety initiatives have been spearheaded not by highly qualified doctors, but rather by remarkable and tenacious people who had to respond to tragedy and refused to wait for us to do the right thing. Brian’s campaign mirrors another magnificent non-medical professional, the airline pilot Martin Bromiley, whose wife Elaine died unexpectedly after a minor operation. Inability to manage her airway should not have ended her life, but it did. Elaine died because while the doctors and nurses had all of the individual skills they had insufficient team skills. She died because of her team’s spiral of indecision, deferred responsibility, and its collective failure to act. She died because a team of experts is not the same thing as an expert team. This death was no one person’s fault, instead it was everybody’s fault. Accordingly, making things better is everyone’s responsibility. [2]

Like Brian, Martin Bromiley threw his energy into improving the system even while battling grief. They simply could not just stand by and let it happen again. Using decades old lessons learnt from the aviation industry, Bromiley’s Clinical Human Factors Group may well save more lives than you and I ever will. We suspect Brian’s campaign to reduce deaths from medical tiredness will be equally revolutionary and necessary and therapeutic. We medical practitioners have a lot of work to do. We need to wake up, and this starts by ensuring everyone is properly rested. We owe it to Lauren, Brian, Martin and Elaine…and many many others.

Matt and Peter would like to thank Brian Connelly for his bravery and time.

Matt Morgan is an honorary senior research fellow at Cardiff University, a consultant in intensive care medicine and head of research and development at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter: @dr_mattmorgan
Competing interests: None declared

Peter Brindley is a professor of critical care medicine, medical ethics, anesthesiology at the University of Alberta, Canada. 
Twitter: @docpgb
Competing interests: None declared

References

[1]https://www.dailyrecord.co.uk/news/scottish-news/worked-to-death—exhausted-young-1084348

[2] https://qualitysafety.bmj.com/content/24/7/425

As I reach the top of the staircase a faded sign reads, “Block A, Tower 3, Wards 7F and 6G.” Nobody really knows what these characters mean or how they help to navigate the twists of an ever changing, expanding hospital. A patient looks up and down at a clutched paper letter, wondering if they’re going the right way. A hospital porter senses their disorientation and points them back towards the way they’ve already come.

As I approach the door of the ward, I see a line of relatives huddled around a buzzer with “ONLY PRESS ONCE” taped over its scratched buttons. Once a minute, once an hour, once a day? A busy nurse, looking after patients and supporting families, hears the buzzer’s call but can’t answer it. As I open the door with my access card, the opportunity is seized and families flow in. Through that one door come meals, x ray machines, dirty linen, nurses, doctors, patients, and dead bodies.

On the ward the relatives peer into different wings, looking for “bed 9 in the 4 bedder,” without knowing what that means. As an overflowing catheter bag is quickly carried to the sluice, the dinner trolley is manoeuvred to make room. The height of the desk at the nurses’ station is an awkward compromise—too low for my knees to fit underneath and too narrow to house a set of paper notes. As I squeeze in, the computer mouse falls to the floor, hanging helplessly by the wire and swinging like a pendulum. I feel the same.

I want to speak to the patient and her family. I think that the patient is going to die. The cloth curtains around the bed are too thin to contain this news from the well wishers next door, so I look for a more private area. (“Just use the office, it should be empty.”) I don’t want to use the office. This is a hospital ward. It should be the perfect environment to do all of this—for conversations to be spoken, for food to be eaten, for patient care to happen, and for medicine to work.

Yet the many hospital wards I’ve visited all over the world have a design that’s changed little since the late 18th century. It’s time to reimagine it. The general ward should have as much consideration as a shiny new operating theatre or boardroom.

Wards need separate entrances for utilities and families—even a circular design with dividing walls. Natural light and noise reduction technology would aid sleep, and communal areas would encourage socialising, rather than eating in a chair next to the bed. We need separate areas where intimate examinations, treatments, and even difficult conversations can happen. These should be large enough to house a hospital bed and a supportive family. We should replace faded signs and use floor maps, with directions to toilets and exits, that are shown to nudge human behaviour.

Think too about staff. Central workspaces should encourage thoughtful work with additional areas close to patients, for individualised care. Zoned areas could indicate different levels of need and safe “wander paths,” allowing movement even when patients are unwell. And ageing posters that fail to change behaviour could be replaced with art that encourages reflection and has been shown to aid recovery. Hospital needs to be a place that promotes healing, not one that simply delivers it.

Read the full article here.

It had been a tough weekend for our colleagues. They had to deal with a complex patient in cardiac arrest. Yet the response team took days to get to them. This decline was hardly a surprise, the warning signs were there in the notes months before. Chronic ill health, previous missed opportunities to intervene with a failure to engage with difficult palliative care conversations. Had the case been examined in detail, a DNAR decision would probably have been in their best interests. Yet instead, there was a mad scramble to treat all reversible causes while the team tried to keep blood flowing through the system at short notice.

This may sound a sadly familiar story, but we are not talking about a patient. We are not even talking about a human. We are talking about a sudden break in the critical physical infrastructure of a hospital that was predictable, should have been prevented and responded to without the necessary skills nor urgency. As the NHS creaks into its 71st year, hospitals up and down the country will echo these events. Cables will break, pipes will burst, and lifts will stop. These are all predictable events. The important thing is that prevention can work and a rapid response should be rehearsed. The day of the week, the time of night or the hospital manager on duty should not matter just as it does not for patients when they are sick. A sick hospital means that all patients are at risk and a proportionate response should be elicited.

In 2009 the NHS implemented a “never events” policy to improve patient safety. The list of never events included wrong site surgery, in-patient suicide, and wrong route medications. It was hoped that this list would allow focus on detection, investigation and action with reports shared with care commissioners. It has long been taught that before offering help, you should first “check the scene is safe”. The physical structure of a system is a core component of safety for both patients and staff. It is about time that never events are extended to organisational events and non-clinical staff. 

We propose that the never events list should include:

• Malfunctioning safety systems during an event such as fire detectors, sprinklers and circuit breakers.
• An inadequate or untimely response to critical infrastructure systems failure including water, electricity and transport.
• Serious injury to staff from known, predictable risks including asbestos exposure, non-compliant building regulations or structural damage.
• Failure to address staffing gaps that are known about that result in patient or staffing harm.

If it is right to call proximal patient harms events that should never happen, then surely it is right to apply these same standards to the wider hospital structures that endanger the many as well as the few.

Tom Holmes, Consultant in Intensive Care Medicine.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan. Matt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.

Competing interests: None declared

If you missed it, have a listen to this BBC Radio London interview with the lovely Jo Good https://www.bbc.co.uk/sounds/play/p07bhgym.

Doctors constantly strive towards what is best for patients. Good doctors try to make accountable decisions based on integration of clinical experience, medical evidence and patient preferences – a stable three legged stool that is safe to sit on. Great doctors do the same but realise that such decisions can only ever be based on the best evidence at that time. Ultimately such decisions may in the future be shown to have been wrong.

With less than one in ten interventions in critical care being based upon high quality evidence(1), we must be honest with ourselves and our patients. Although public awareness programs and quality improvement initiatives are common, these should be based upon best evidence driving knowledge translation for patient benefit. It may come as a surprise that these uncertain treatments include even simple concepts such as how much oxygen we should use when people are critically ill(2). Admitting this uncertainty about fundamental treatments can be hard.

In order to improve the care of our patients, we need to advance the evidential basis for our own practice. This involves addressing the remaining nine out of ten interventions that lack evidence head-on, challenging assumed, potentially outdated, or frankly wrong knowledge. This comes from a position of equipoise.

Even when trials are based on acknowledged evidence gaps, then funded, designed and delivered, we stumble against a new barrier – equipoise. Whilst the trial committees, funders, ethical committees and collaborators all maintain equipoise, individual treating doctors will sometimes prevent trials from being conducted in their own institutions. Their reasons are noble – they want to do what they feel is right for patients and be early adopters. The problem is that feelings do not save lives

Things that we have felt to be right in the past have a regular habit of actually causing harm(3-5). Some people feel best in the safe, understandable and predictable world of demonstrable physiology at the bedside as an end in itself. Understand and correct the physiology and you can deliver treatments that feel right. However, whilst physiology is important, adaptive physiology in critical illness is complex and instead we need to strive towards meaningful patient outcomes as the stick by which to judge our feelings.

Getting the right balance is hard. How should “equipoise” be decided (5)? Should it be by country, by hospital, by department or by an individual? We worry that an individual’s feelings about what works and what doesn’t may negatively impact on clinical trials. They may restrict sites from contributing towards important research, reduce recruitment rates, increases the costs of research, waste public money and ultimately be bad for patients. More than 30 years ago Benjamin Freedman writing on ‘equipoise and the ethics of clinical research’ suggested that the concept of ‘clinical equipoise’ should refer to genuine uncertainty in the expert medical community rather than on the part of individual investigators(5). Despite the passage of time researchers still find themselves encountering the same issues today.

As most trials in critical care are funded from the public purse, we need an agreed solution. There should be a social responsibility for equipoise as we strive to create new evidence for patient benefit. Too often the lack of generalisable medical evidence means that complex decisions are based only on clinical experience and patient preference. The original stable, three legged stool becomes too unsteady to safely sit upon. The development of clinical research networks both in the UK and internationally can help, outsourcing difficult evidential challenges to those best placed to balance them. This allows individual clinicians to focus on the job of integrating their outputs with clinical experience and patient preference whilst allowing equipoise to answer the questions for which uncertainty presides.

Matt Morgan is an Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead for critical care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan. His first book “Critical – Science and stories from the brink of life” published in May 2019.

Matt Wise is a Consultant in Intensive Care Medicine and Research and Development lead for Specialist Services at University Hospital of Wales.

Paul Dark,Consultant in Critical Care Medicine, NIHR Clinical Research Network National Specialty Lead for Critical Care and Chair in Critical Care Medicine, University of Manchester. He is on twitter: @DarkNatter

Disclosures/conflicts: none. This work is original.

1. Zhang Z, Hong Y, Liu N. Scientific evidence underlying the recommendations of critical care clinical practice guidelines: a lack of high level evidence. Intensive Care Med. Springer Berlin Heidelberg; 2018 Jul;44(7):1189–91.
2. Schjørring OL, Perner A, Wetterslev J, Lange T, Keus F, Laake JH, et al. Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU)-Protocol for a randomised clinical trial comparing a lower vs a higher oxygenation target in adults with acute hypoxaemic respiratory failure. Acta Anaesthesiologica Scandinavica. 2019 Mar 18;18(15):711.
3. Chohan SS, McArdle F, McClelland DBL, Mackenzie SJ, Walsh TS. Red cell transfusion practice following the transfusion requirements in critical care (TRICC) study: prospective observational cohort study in a large UK intensive care unit. Vox Sang. 2003 Apr;84(3):211–8.
4. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, et al. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med. 2011 Apr 21;364(16):1493–502.
5. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med. 1987 Jul 16;317(3):141–5.