If a patient gets admitted to an emergency ward on a weekend in the British hospitals s/he is worse off, as senior consultants do not go for ward-rounds, to see the new admissions. So, many short-term cross-sectional studies were carried out to sort this out; but, recently, the editor of the British Medical Journal (BMJ) chose to write an editorial about the subject wherein she was non-committal in deciding which way the wind is blowing.
Disease is an accident and it cannot be programmed to hit only on working days. The hospitals are adequately staffed by junior doctors even on weekends. This was so even when I was an SHO (senior house officer), registrar and SR (specialty registrar) in England decades ago. Most of the work is done by the junior doctors anyway even on weekdays. The consultants were there just to guide and help when we got stuck. They were on call even during the weekends, if needed. I am told that now the consultants will have to work harder as there are fewer junior doctors. All said and done, the brunt of hospital disease management depends on the junior doctors. Under these circumstances, what is our problem during the weekends?
What about the impact of fewer doctors on patients? A 14-country study showed that where there were more doctors per capita in the US and Europe, but mortality was higher, health of the population worse and longevity lower compared to countries with very few doctors per capita like in Japan. (Journal of the American Medical Association 2000; 284: 483) In addition, Japan had the best health indices with least mortality and morbidity with less healthcare costs. Japan also had one more advantage: the majority of doctors there were family physicians.
If we extrapolate those data here, weekend patients must be the luckiest! When doctors went on strike in Israel a few years ago (2 BMJ 2000;320:1561), Bogota in Columbia and Saskatchewan in Canada, mortality and morbidity did fall precipitously only to climb back to normal when doctors came back to work in full strength! The five-star ICU almost next door to the War theatre in Vietnam vis-à-vis almost nil medical facility in Falklands War where the seriously injured soldiers, at times, were left on the snow for hours to be airlifted to England, showed no statistically significant difference in overall mortality with marginally better results in Falklands cases.
We need a good audit on what we do to patients in an emergency. Nature has in-built mechanisms to keep a person alive after severe injury like auto-transfusion, auto-infusion, autonomic system mediated redistribution of the circulation, clotting cascade and supply of extra energy through neo-glucogenesis and many other changes that we are yet to comprehend. As pointed out by Mary Tinnetti, in her article End of Disease Era, “The time has come to abandon disease as the focus of medical care. (American Journal of Medicine 2004; 116: 179) The changed spectrum of health, the complex interplay of biological and non-biological factors, the aging population, and the inter-individual variability in health priorities, render medical care that is centred on the diagnosis and treatment of individual diseases, at best, out-of-date and, at worst, harmful. A primary focus on disease may inadvertently lead to under-treatment, overtreatment, or mistreatment... Clinical decision making for all patients should be predicated on the attainment of individual goals and the identification and treatment of all modifiable biological and non-biological factors, rather than solely on the diagnosis, treatment, or prevention of individual diseases.” I couldn’t agree more.
Our reductionist method of looking at weekend syndrome does not give you clear answers adding to my argument that all is not well in our knowledge base about human physiology, pathology and worse than them both our faulty management strategies. Junior doctors are, in some ways, better equipped to manage acute illness compared to specialists who are needed to think deeply about vexing problems which need many bright heads to solve. Otherwise, a specialist could complicate matters further. Let us get out of the weekend mind-set to whole week problems in disease management!