THE BEST TIME TO HAVE A HEART ATTACK – WHEN DOCTORS ARE AWAY
by Dr Raj Persaud and Dr Peter Bruggen
Large medical conventions – where hundreds if not thousands of doctors converge on some luxury hotel in an exotic location – supposedly to read scientific papers to each other – often attract a well-worn joke – that such conferences are indeed the best place in the world for a member of the public to fall ill, like have a heart attack for example.
But a recent study has turned this prediction on its head, suggesting instead the safest place to have your acute cardiac event is in fact anywhere but where all the senior cardiologists have congregated for that week-end junket.
The paradoxical finding illustrates the reality that health and medicine remain stubbornly complex affairs, and defy easy solutions, such as simply throwing a lot of physicians at a problem is always best for patients.
Yet the British Government currently seems to fallen victim to this joke – they seem to believe that the more doctors you throw at a patient the longer they will live – not only might this not be true – it could even be positively bad for your health.
This is suddenly more relevant than ever as senior doctors appear pitted against junior colleagues over the wisdom of mounting strike action in an increasingly bitter dispute in the UK’s National Health Service. The debate includes the effects on patients of having a lot of senior or junior doctors around, or not, particularly at week-ends.
The Academy of Medical Royal Colleges in the United Kingdom is widely reported by the media, including the BBC News website, to be “disappointed” by the launch of a programme of a week of strikes by junior doctors later this month in England.
This industrial action by ‘younger’ physicians will be followed by three more five-day walkouts in October, November and December – actions some see as unprecedented in the history of the medical profession in the UK.
The Academy contends the proposed strikes are ‘disproportionate’ and this criticism of their ‘lower-ranking’ colleagues might represent the beginnings of a split between the more ‘senior’ members of the medical profession from their ‘junior’ colleagues.
After all, the British Government would hardly be the first to see the benefits of ‘divide and rule’ when dealing with as respected a profession as doctors.
It is currently being emphasised across the UK media that in contrast to senior Consultant physicians, it is the junior medics who appear to now be escalating what may be becoming the worst industrial relations dispute in the history of the British National Health Service.
The British Medical Association, otherwise known as the trades union in Britain for physicians, has declared that the government could end the strikes by calling off the imposition of a new contract, which is due to be rolled out from October, and which proposes significantly altering the working pattern of junior doctors, but which the Government has claimed is about creating a ‘seven-day’ National Health Service.
The new policy is supposed to be a response to controversial claims that mortality rates are significantly higher for patients admitted to hospital at week-ends. This, the government argues, highlights why more doctors are needed in hospitals on Saturdays and Sundays and so why the new contract is being imposed.
Health Secretary Jeremy Hunt meanwhile reportedly described this month’s strike as “devastating news”, predicting it would lead to the cancellation of 100,000 operations and one million appointments.
We have already reported on the surprising research finding that mortality rates in fact go down when doctors down tools in our article: ‘Why Do Patients Stop Dying When Doctors Go on Strike? Can psychology explain our surprise at mortality decreases when doctors’ strike?’ https://www.psychologytoday.com/blog/slightly-blighty/201510/why-do-pati…
We reported on the most comprehensive review of the medical impact of doctors’ strikes, published in the prestigious academic journal ‘Social Science and Medicine’. A team lead by Solveig Cunningham and Salim Yusuf at Emory and Georgetown Universities in the U.S. and McMaster University in Canada, analysed five physician strikes around the world, all between 1976 and 2003.
Doctors withdrew their labour, in the different strikes analysed, from between nine days and 17 weeks. Yet all the different studies report population mortality either stays the same, or even decreases, during medical strikes. Not a single study found death rates increased during the weeks of the strikes, compared to other times.
The investigation, entitled, “Doctors’ strikes and mortality: A review,” suggests that it’s the fact that elective, or non-emergency surgery, tends to stop during a doctors’ strike, which seems to be the key factor. It looks like a surprising amount of mortality occurs following this kind of procedure which disappears when elective surgery ceases due to doctors withdrawing their labour.
There are various other possible interpretations of these findings, but a key problem withunderstanding the data on doctors’ strikes is that in all medical industrial relations disputes studied so far, not all clinicians down tools, and emergency care often continues to be provided by various routes.
The split between senior and junior doctors in the UK becomes more significant because one wonders what would happen if senior doctors joined their junior colleagues and also took industrial action?
Surely this would be ‘game over’ for the Government?
The solidarity issue also raises the question about who needs who more – do juniors need seniors more to enable them to do their jobs or is it in fact vice versa? Who could health systems do least well without – junior or senior medics? Senior doctors are being relied on increasingly by the Government in the UK to cover for absent junior doctors, particularly during days of industrial action by the younger medics. Junior doctors have historically found themselves frequently covering for absent senior physicians as part of an increasingly difficult work environment.
A possible intriguing answer to this question comes from a recent study published in the prestigious medical journal ‘JAMA Internal Medicine’, which found that high-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology professional or scientific meetings – when cardiologists are more likely to be out of town attending those conferences.
The authors of the study, Anupam Jena, Vinay Prasad, Dana Goldman, and John Romley, point out that in 2006 for example, nearly 19 000 cardiologists and other health care professionals attended the American Heart Association (AHA) annual meeting, while a similar number of cardiologists and other professionals attend the American College of Cardiology (ACC) annual meetings.
During such conferences, physician staffing in hospitals are likely to be lower than on non-meeting dates, and the composition of physicians who remain to treat patients—rather than those who attend the meetings—may be different. These factors, one would have predicted, given it’s likely that more senior doctors attend the prestigious conferences, may affect treatment practices and outcomes for hospitalized patients.
Indeed, it is not an unusual gripe amongst junior colleagues that they feel they are forever ‘covering’ for senior physicians as they ‘swan around’ attending ‘junkets’ while the more junior members of the team are left back at home manning the fort.
The study entitled, ‘Mortality and Treatment Patterns Among Patients Hospitalized With Acute Cardiovascular Conditions During Dates of National Cardiology Meetings’, was particularly interested in teaching hospitals because the authors hypothesized that mortality would be higher and treatment lower during cardiology meeting dates, and that these differences in outcomes would be largest in teaching hospitals, where a disproportionately larger fraction of cardiologists may attend cardiology conferences.
The authors of the study conclude that mortality is actually lower among patients with high-risk heart failure or cardiac arrest admitted to major teaching hospitals during the dates of national cardiology meetings. One explanation for these findings is that the intensity of care provided during meeting dates is ‘lesser’ and that for high-risk patients with cardiovascular disease, the harms of ‘more’ care may unexpectedly outweigh the benefits.
Another possible explanation, suggested by Ezekiel Emanuel writing in The New York Times about this study, is that while senior cardiologists are better researchers or academics, the junior physicians, more recently and fresher out of training, may actually be more proficient clinically.
And yet another potential explanation, suggested by Ezekiel Emanuel, from the data, is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest, for example, were significantly more likely to get intercessions, like stents, to open up their coronary blood vessels.
This study illuminates an uncomfortable possibility – that sometimes having a more senior doctor meddle in your care may be worse for your health.
Just in case some are tempted to dismiss this study of 10 years of data involving tens of thousands of hospital admissions, there has been another similar investigation this time in Japan with not dissimilar results.
This study entitled, ‘Is Survival After Out-of-Hospital Cardiac Arrests Worse During Days of National Academic Meetings in Japan? A Population-Based Study’, and was conducted by academics based at Osaka University.
The study published in 2016 in the ‘Journal of Epidemiology’, looked at 1-month survival with a neurologically favorable outcome after out-of-hospital cardiac arrests, which ought to be worse during days of national academic medical meetings because many medical professionals are then absent from clinics.
Calendar days at three national meetings (Japanese Society of Intensive Care Medicine, Japanese Association for Acute Medicine, and Japanese Circulation Society) were obtained for each year during the study period, because medical professionals who belong to these academic societies play an important role in treating Out-of-Hospital Cardiac Arrest patients after hospital admission.
The authors of the study conclude that the proportion of patients with favorable neurologic outcomes after cardiac arrests did not differ during academic medical meeting and non-meeting days. Indeed there was a very, very, small marginal benefit, which did not reach statistical significance, to having your cardiac arrest during the dates of these medical conferences when theoretically the top specialists would have been out of town.
While the debate will continue to rage over what this data means, one possible recurring theme is that medicine and health are too complicated to be reduced to simple solutions, like having more doctors around the more superior the care, or more senior physicians are always better for patients.
Good health care is about a lot more than just numbers of doctors or even their seniority. It requires a deeper analysis than that.
Yet this more simplistic approach is precisely how the debate about doctors striking, and what they are in dispute over, has been framed by the British media.
And this is also increasingly how the UK National Health Service is run.
Which may be precisely why so many doctors could now be getting fed up with the way they are being managed.