What would Mickey do?

I'm taking a lot of flak --some deserved, most not-- for yesterday's post about my recent ER experience. When I have a moment I'll address some of the comments. Meanwhile I asked Mickey (who's a pediatrician) for his perspective. Here it is:

If you suspect a fracture outside of regular office hours and a doctor can't rule it out over the phone you should go to an ER.  The solution is to make the ER faster.

When I was a resident our chief of service told us that families should not be kept up after 10 PM for scheduled admissions.  This is reasonable, but often 5 families come in for scheduled admissions after 6 PM and one resident can't admit them all and take care of other priorities (such as the ER) without some people waiting a long time.  We decided amongst ourselves to create an overflow system in which we'd ask other residents on the team to stay late to do some of the admissions.  We needed to invoke this backup system only about 10% of the time, but it made things run more smoothly, and everyone got more sleep.  One of my most memorable nights on call began with my diagnosing a tumor that I noticed incidentally on a skull X-ray of a kid hit by a car while bicycling.  After that, one after another fascinating patient showed up, and each got great care because I got two other residents involved, people who are today among the top clinicians in the field.  We did a great job and no one waited around for 5 hours.

Hospitals should use similar backup systems to cope with peak load problems.  Ironically, measures taken to reduce doctors' working hours have limited this flexibility by banning the others on the team from staying around.  Yet, using such a flexible system, everyone got more sleep.

Two of us from that memorable night wrote a letter to the NYT that appeared on June  8, 1987 arguing for such a backup system instead of heavy-handed regulation of doctors' work hours.  The WSJ got me to expand this as an Op-Ed, run on 18 June.