Doc around the clock

If you’ve ever spent a weekend in the hospital, you couldn’t fail to notice how quiet it was. No surgeries, other than those that are urgent. Fewer tests being scheduled. Fewer staff in the building. The underlying mood that we’ve-all-throttled-back-because-it’s-the-weekend-and-we’ll-get-back-to-normal-on-Monday.

But what if hospitals were ramped up around the clock, instead of concentrating most of their activity during traditional hours? This concept is the focus of an intriguing opinion piece that appeared this past week in the New York Times. The author, Peter Orszag, may be familiar to readers as the previous director of the White House Office of Management and Budget.

It’s been well established that weekends aren’t an optimal time for patients to receive care, Orszag writes:

It’s never good to be hospitalized, but you really don’t want to be hospitalized on a weekend. There are fewer doctors around, and people admitted on Saturdays and Sundays fare relatively poorly.

One study in 2007 found, for example, that for every 1,000 patients suffering heart attacks who were admitted to the hospital on a weekend, there were 9 to 10 more deaths than in a comparable group of patients admitted on a weekday. The weekend patients were less likely to quickly receive the invasive procedures they needed – like coronary artery bypass grafts or cardiac catheterization.

If patient safety is one of the weekend hazards, cost and efficiency are the others. Orszag calls it the “the economics of a $750 billion-a-year industry letting its capacity sit idle a quarter or more of the time.”

“If hospitals were in constant use, costs would fall as expensive assets like operating rooms and imaging equipment were used more fully,” he writes. “And if the workflow at existing hospitals was spread more evenly over the entire week, patients could more often enjoy the privacy of a single-bed room.”

This isn’t just idle speculation. Orszag describes what’s happening at one institution, New York University Langone Medical Center, to provide more care on weekends. At Langone, magnetic resonance imaging and elective cardiac surgery are now available on weekends. The facility’s radiologists read medical imaging studies seven days a week. The cancer center provides some treatments during the weekend. Women planning to undergo an elective Caesarean delivery can now schedule it on a Saturday.

Information being tracked at NYU Langone has uncovered some hitherto-unnoticed issues with how the hospital deploys its resources, Orszag writes.

The dashboard data revealed, for instance, that on any given day a disproportionately small number of eligible patients were discharged before noon, so that many people were kept in the hospital longer than necessary. Further analysis revealed a key reason: several routine procedures that some patients need before leaving, like the insertion of central catheters, were not performed in the morning. The medical center has since begun to offer the procedures earlier, and the percentage of discharges before noon has increased significantly.

Reaction around the blogosphere to Orszag’s column has been, uh, interesting. Many people have seized on Orszag’s opening comments, which in essence said doctors should suck it up and work more weekends, as the equivalent of endorsing involuntary servitude. The response, at least from more than a few health care professionals, could probably be summed up by a blog commenter who said, “My first thought was, yeah, good luck with that.”

I can feel a twinge of sympathy. I’ve worked evenings, weekends and holidays my entire adult life. In the news industry it just comes with the territory and I’ve learned to live with it. This doesn’t mean I always like it, though, and I suspect most people would rather not work evenings and weekends if they can possibly help it. I don’t think this was Orszag’s main point, however.

It’s true there’s idle capacity in health care, particularly among hospitals, and that the normal 8-to-5 schedule doesn’t always match patient need. How many of us have wished we could make a doctor’s appointment in the evening so we wouldn’t have to take time off work? There’s a certain irony in telling consumers to call their doctor for non-urgent problems rather than seek expensive emergency-room care – yet giving them no other option if something crops up when the doctor’s office is closed for the day or for the weekend. There’s a certain irony in advising people to try to avoid being hospitalized on a weekend, yet ignoring the fact that illnesses and injuries don’t happen solely during daytime hours Monday through Friday.

Whether this is enough to justify a shakeup of the industry model is a whole ‘nother question, though. Do hospitals and clinics have the wherewithal to expand their hours into the weekend? How feasible is it, in terms of both workforce and financial resources? Would patients use a weekend service? Would it actually improve patient care and outcomes?

On the other hand, it should be troubling to all of us that patients who are hospitalized on a weekend might not receive the same level of care as on a weekday. And the many little overlooked inefficiencies in the system – such as having no one available to insert central catheters until after lunchtime – are frustrating and frankly make little sense, either for patient care or for the financial bottom line.

Maybe some discussion on these issues has been long overdue. Access to care on evenings and weekends isn’t a new problem that only recently sprang up. There has been a long-standing gap in how care is provided outside traditional hours, and solutions such as urgent care clinics and nurse hotlines, even when they do fill some of the need, are not the total answer. Critics might not like what Peter Orszag is saying but he’s nailed an issue that seems to merit further consideration.

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