Resident duty hours

Resident duty hours

Dr. Charles Lockwood’s recent editorial “Restricting resident duty hours: Where is the evidence?” (Contemporary Pediatrics, April 2013) was like a breath of fresh air. Finally someone is starting to see the damage that is being done.

I never thought that I would feel like a relic at the age of 43. As I see the shifting sands of medicine swirl around me, I grow very concerned over the future of health care delivery in areas of the United States that are not close to major metropolitan areas.

It seems that current health care policy decision making has centered around these population-dense areas, and although I understand the “more bang for your buck” rationale behind this, I and many others work and live in flyover country, that vast expanse of the country that policymakers jet across between the coasts and the Capitol. Those of us who practice pediatrics in these areas still take night/weekend/holiday call and round on our patients in the hospital. The hospitals with which we are privileged cannot afford to staff pediatric hospitalists 24/7 because of the seasonal nature of our patient population, so we take care of our patients. I feel that the shift in physician training to time limitations is not adequately preparing new physicians for the realities of practice in small communities.

Couple this with the dangerous assumption that “everything you need to know will be in the electronic health record” and you have a recipe for disaster. When the baton is constantly passed from shift to shift, no one takes control of the proper weeding of the overgrown backyard of problem lists and bloated notes that clog the potentially bountiful garden that is the electronic medical record.

Another dangerous assumption is the idea that everyone is proceeding with implementation of the various changes that are overwhelming small medical practices. I believe that many physicians close to retirement are just treading water until they can get out. The incredible loss of experience from physicians who would have potentially practiced for many more years will be very challenging to replace. As newer graduates leave residency with fewer hours of training and patient care exposure, who will mentor them?

On a closing note, I think that it is a dangerous plan to start assigning providers and facilities to tiers of quality. This will inevitably lead to cherry-picking, as it is not very hard to demonstrate good quality results when you are providing medical care to a population that is healthy! The safety-net facilities will enter into what I call the “death spiral.” They will never be able to demonstrate good quality results because they are caring for the sickest and least-desirable patients. I understand that a risk stratification scheme is proposed to account for this, but I honestly doubt that it could properly balance the equation. Many times patients make bad decisions regarding their health. Punishing providers for bad outcomes (or suboptimal quality measures) in unhealthy patient populations is like cutting the pay of law enforcement officers who are overwhelmed by an epidemic of crime in a gang-infested city that has already cut the police force down in size and training.

But, despite my concerns, I am optimistic! I believe that a large dose of reality is headed for everyone involved: policymakers, patients, providers, or payors. Maybe then someone will listen to those of us toiling in the trenches.

Ish Stevens, MD, MS, FAAP

Ashland Children’s Clinic

Ashland, Kentucky

Variolation not vaccination

Dr. Michael Brady, in his editorial “Alternate vaccine schedules are not safer and should be obsolete” (Contemporary Pediatrics, June 2013), makes important points about vaccine schedules with which I completely agree. He does, however, make an error. He states that Benjamin Franklin lamented not vaccinating his son against smallpox.

Franklin’s son died many decades before Edward Jenner developed the smallpox vaccine in 1796. What Franklin regretted was not trying the riskier procedure of variolation.

Variolation was the intentional infection of a vulnerable person with smallpox material from a person having less virulent disease to induce immunity. Variolation lessened the potential for severe disease but, in itself, was risky. This places Franklin’s lament in an interesting historical context.

Robert Brayden, MD

Professor of Pediatrics

University of Colorado School of Medicine

Denver, Colorado