The Weekend Effect

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Feel bad on a Friday night? Worried about how you feel? Well, there’s more than your medical condition to feel bad and to worry about. It’s called, “The Weekend Effect”. It’s the only exception to the rule, TGIF. Over the years there have been dozens of studies that demonstrate the dangers of weekend admissions.

Author, Chuck Palahniuk said, “The only reason why we ask other people how their weekend was is so we can tell them about our own weekend.” Not so, if you have a heart attack, an ICU admission, a stroke, acute kidney injury, a gastrointestinal bleed, and a variety of nonelective operations. For your baby’s sake, even childbirth is best experienced during the week.

 

The Weekend Effect in Action
In the ICU, weekend admissions offer an 8-13% greater chance to join the Invisible Choir than a weekday arrival.

During a gastrointestinal bleed, (ulcers, diverticulosis etc) most patients will get an endoscopy to assess and treat the problem at hand. On weekends, only a third get this potentially lifesaving interventionAs a result, 22% more die than if they presented during a weekday.

A British study showed that giving birth outside the typical 9-to-5 workday — as most women do — was associated with a greater chance of the baby dying within the first four weeks of life. Death rates for neonates are up to 37% higher on weekends.

For strokes, a weekend admission means you face a 5-12% higher chance for death. Friday night to Monday morning admissions for stroke are an independent risk factor for an unfavorable outcome. If you suffer traumatic kidney damage, you are 22% more likely not to need them ever again (uh, you’re dead) than if you hurt them during the week.

No day is a good day for a cardiac arrest or heart attack. Nights and weekends are particularly bad days for these events. Multiple studies demonstrate higher mortality rates for these emergencies. In 15 of 26 major diagnostic categories, a weekend admission spells trouble. For certain leukemias, 50% more will die on a weekend day. In one study, the only problem for which patients don’t suffer their fates on Saturday and Sundays are for mental health disorders.

Why?
There  is a host of potential issues that characterize weekend care that alone, or more likely in combination, produce unhappy clinical results. And note, I have only mentioned deaths. It is impossible to exclude higher rates for non-fatal events like infections, medication errors and other dangers that plague hospital life without even mentioning hospital deaths. Surveillance levels are lower; there is less availability of trained medical staff and allied employees. Important medical services are not routinely available, and common, urgent procedures require time to dragoon elusive on-call doctors. Some cite psychophysical performance deficits on those who must endure their weekends in hospital. When it comes to nursing even small differences in staffing levels produce big differences in survival. In one study, each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission.

The presence of intensivists in the ICU do improve weekend stats. They are a full time cadre of medical specialists who could proudly wear Seal Team 6 or Green Beret patches on their lab coats. They are devoted to the most critically ill. Unlike hospitalists, they bring special talents to the bedsides of the most grievously stricken.

 

And The On-Call Doctors? AWOL!
I hated being on-call. I devoted a chapter of my book to my experiences during this thankless, unhealthy, non-reimbursed, family compromising demand. But that’s the point. I viewed it as a demand.

This is not the case any longer, as doctors run from what used to be their duty to safe havens that don’t or can’t demand their presence during weekends and evenings. The remaining doctors who will venture out on weekends is a diminishing doctor demographic. Such is the demand the psychological and physical tolls on these, the few and the proud, it may affect their performance. They often don’t get a chance to make it back to their homes. And don’t forget the looming doctor shortage. Fewer docs, less care.

In light of this, it’s time to sit back and reflect a bit about what this all means. A doctor’s availability off-hours is no longer assured. Your doctor’s availability is highly unlikely on any given night or weekend due to larger coverage groups and hospitalists. Not only are there fewer doctors to care for you, most are guest stars who meet you when you can least afford a ‘Stranger in the Night’.

Some physicians and surgeons hire others to perform on call duties, but per diems fill in no better than round pegs in square holes. They know nothing about the communities and hospitals in which they bivouac. Some groups will hire junior members at night and on weekends. Others may hire trainees to provide a first line of defense.

 

Tricks of the Trade
Some doctors are Great Debaters. They use the phone as their podiums to engage in debating society tactics and long practiced polemics to avoid a weekend-busting journey.

Other doctors become off-hour charitable institutions. They will do the unthinkable, requesting that a competing same-specialty group be consulted or magnanimously spread the wealth by recommending that alternative specialty consultants be sought first. My favorites are, what I call in my book, the ‘Reverse Cinderellas’.

Rather than leaving home they leave lists. Lists of tests to be performed– some inevitably unnecessary, and others done simply to run the clock. When the clock strikes seven am, they are now off call and nowhere to be seen. When that critical hour strikes their pumpkins turn into Porsches.

The last group I identify in my chapter are the ‘Suddenly Stupid’. These docs suddenly and uncharacteristically demean their own clinical skills as ‘not up’ to the level of care needed when it comes time to perform a requested on-call duty.

What To Do?
First and foremost don’t avoid the trip because you wish to avoid the Weekend Effect. Although real, it’s still a small, although tragic phenomenon. When choosing a hospital give extra credit points to those that are level I or II Trauma Centers. In 2010, there were 129 trauma level I centers in the United States, most of which have twenty-four-hour, in-house surgery and anesthesiology. About half of them have continuous in-house availability for neurosurgery and orthopedic surgery. Prompt access to radiology and internal medicine specialties are also required to obtain this imprimatur. Not only are these Level I centers the best candidates for treating trauma patients in their emergency rooms, they are usually larger, university-affiliated members of the Counsel of Teaching Hospitals and, therefore, best suited to treat a range of emergency conditions for patients who have multiple comorbidities. Level II centers are just as good. They only lack research and training services.

Make sure your candidate hospital has intensivists in their ICUs.

Irrational Rationalizations
If you are sick during the day, don’t wait for the sun to set for your anxieties to rise. Act while your doctor is available. Act when your medical records are available. Act so that your tactics will lead to the best results. When you are facing an emergency act like it.

No, there is no one more deserving of help than you. No, you can’t wish it away or hope that it will go away. Don’t try to rationalize it away.

 

And Now That You Know…
Choose your hospital wisely. In the ‘good old days’, five years ago, it used to be up to your doctor. Now, in the age of hospitalists, your old friend, the family doctor, needs a GPS to even find the hospital.

Place a high value on the nearest certified Trauma Center. Read a new book that just came out that has a section entitled ‘Choosing A Hospital’.

If you land up in the hospital on a weekend, maybe it’s a good idea to think about a private duty nurse. Maybe it’s time to say ‘No!’ to the hospitalist and call in the sub-specialist who has been part of your care over time. These subspecialists know you and are, by ethical norms, required to see you. The on-call cardiologist will find it harder to pass the buck, if her group has cared for you over the years. The same is true for gastroenterologists, neurologists and the rest of the ‘ologists.

And finally just come out and say it. “Doctor I know it’s a weekend and I’m aware of the weekend effect. I don’t want to be rude but I will not tolerate any slackening in my care. Do you anticipate any problems?”

Remember to make a fuss when you think that your care is being influenced by the weekend rather than your ‘weakend’ condition.

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