Dr. Gary D.V. Hankins shares his evidence-based best practices on the 10 Clinical Diamonds for Preventing Maternal Death and his 7 Habits of the Highly Successful Obstetrician.
St. David’s Healthcare CME program recognized the significance of ongoing clinical changes in medicine and how often new techniques and outcomes are introduced. We are proud to offer the library of courses available to you, however, cannot guarantee that all courses are presented with the most current information. The course shown above is no longer available for CME credit. DR HENKINS: So I'm going to go over seven habits of the highly successful obstetrician. Number one, read and study college publications. We get these compendiums, right? If you're a member of a college, you get the compendium. There is good and valuable information that's been well thought out by experts. The compendium is your friend. Whether you're a physician, nurse, midwife, nurse practitioner, the information in these, if you take care of babies, is important information. Now, I wish my team were doing better this year. We have the Houston Texans, and they have kind of floundered. But we know that they have playbooks, right? We know that the field is a certain dimension, and they stay within the confines of that. I would submit that for anybody practicing obstetrics, or gynecology for that matter, the compendium is our playbook. If we have done what is suggested in that, we have complied with standard of care. It doesn't mean that we can't have a bad outcome. But it does mean that we have complied with standard of care. It doesn't mean that there won't be some folks who will come forward and still opine you didn't do right. But the compendium is going to tell you that available evidence suggests the benefit of x for women with y. So there'll be the condition. And it's going to tell you that for that condition, this is recommended. Now, if they tell me that, I'm going to do x in women with y. So it's a good, good source. I think every labor and delivery unit should have one present. So read and study college publications. Then, change your practice if necessary to come into compliance. It may be that your practice really exceeds what the college is doing. And that's OK. There will be instances. But if you want to play it safe, go with what they are recommending. I'll give an example. ACOG Practice Bulletin, September 2008 was on fetal lung maturity. That bulletin reiterated a standard initially set 20 years earlier by both the American College and the American Academy of Pediatrics. But we were very, very slow to endorse it-- very slow to endorse it. Let's go to another publication-- neonatal and maternal outcomes associated with elective term delivery. I'm sure this being Austin, home of HHSC and DSHS, that you've heard a lot about the pre-39 week delivery, the non-indicated pre-39 week delivery. And this has not been a bandwagon. This became a juggernaut. It was jumped on by ACOG, Society of Maternal Fetal Medicine, March of Dimes, major insurers, the National Quality Foundation, Leapfrog, CMS, and, in the state of Texas, our legislative bodies. This is a quote from a The New York Times. "Insurers, policymakers, and regulatory groups have been piling onto the quality improvement wagon. But few of these quality enthusiasts are actually caring for patients." Now, there's a publication put out by NICHD and Society of Maternal Fetal Medicine jointly published in the Green Journal. And it has indications for delivery at less than 39 weeks. And they fall under all sorts of categories. This is another publication that I would submit to you should be handy for you to make reference to. And there's fetal issues. There's maternal issues. I'm not going to go through every line of this with you. There's issues about multiple gestations, congenital malformations. And they didn't miss much. Most of the things we encountered are going to be listed. Is it all-inclusive? No. You may have a totally valid reason to do a delivery that's not listed among these. It's probably going to be rare. And the purpose is not for you to fail to do that in those instances. But you need to document it-- need to document it. I'm going to speculate that within the next four to five years not just the state but the private insurers are going to say they're not going to reimburse if we don't have a criteria that we documented. I think in general the reasons are there. We just don't always do the best documentation of those reasons. Again, it's pretty extensive. They didn't miss very much. AUDIENCE: Is multiple C-section and obesity in there? We all have those patients who are 300 pounds, fifth C-section, and you're terrified to wait till 39 weeks, because you know she [INAUDIBLE] labor that C-section in the morning. DR HENKINS: Morbid obesity is not listed. Now, I'm going to share with you my first rule of life. I always get in trouble up here. My first rule of life is fear the large woman. Fear the large woman. There's nothing easy about a large woman. They're hard to monitor. They're hard to move. They're harder to section. And I can understand wanting to move earlier if there's labor, if there's oligohydramnios, if you have a reason. But just because they're obese, no. Where I see people generally get in trouble there is rather than lowering the threshold to operate, they keep wanting it to happen from below. So I actually lower my titer for going for cesarean delivery before I get the catastrophe. So I will tell you there are days when I wish I got paid by the pound as opposed to the surgery. But-- and they're challenging. It's not uncommon for me to have, on any given day, two or three sections scheduled in women that weigh over 300 pounds, some of which are also vertically challenged. Standardized institutional practices for high risk situations-- I think that goes to, again, one of the points that you were just making. Now, these books came out from the Institute of Medicine-- To Err is Human and Crossing the Quality Chasm. And again, To Err is Human-- first, do no harm. They pointed out that hospitals are not the safest places to hang out. And there's truth to that. They make a lot of comparisons to the airline industries. And there's things we can learn from the airline industry and incorporate certainly. But again, if the weather's horrible, the plane's not going to leave Bergstrom Air Force Base. When my 500 pound lady comes in that's in labor, and the baby's having bad decelerations, we don't get that luxury. So we have to respond. The analogies and things that we can do better are there. But there's going to be instances where we obviously are forced to act under way less than optimal circumstances. Let's go to some though that could be standardized-- oxytocin guidelines. This is ACOG 2009-- any of the low or high dose oxytocin regiments outlined in table two are appropriate. They go from 0.5 to 6 milliunits per minute, increase anywhere from 15 to 40 minutes. They further say each hospital's OB/GYN department should develop guidelines for preparation and administration of oxytocin. It's clear that if you have several different strengths dripping that that's an opportunity for error. The uterine contractions and fetal heart rates should be monitored closely. What are the high error rate places where we live? We'll start with abnormal fetal heart rates and recognition and response to abnormal fetal heart rates. Second is oxytocin. Next is misoprostol. Do you all like misoprostol in Austin? Yes? AUDIENCE: [INAUDIBLE]. DR HENKINS: For postpartum hemorrhage, I like it, too. It's not my first line. But for postpartum hemorrhage, it's a good drug. The issue with the misoprostol that everybody is very aware of by now is you don't use it with a scarred uterus, right? It dissolves collagen. The scar is generally collagen. So you don't use it in somebody that's got a scarred uterus. VBACs-- another issue. Are they prevalent in the city now? Anybody doing VBACs, lots of people doing VBACs? We do VBACs. We have in-house physicians pretty much 24 hours a day-- in-house everything. Vacuum and forceps-- OK, who among you still does forceps? Man, proud to be in Austin. I use a vacuum at home. The vacuum I restrict to carpet. But forceps, those that grew up with forceps, are a magnificent injury that you can do a whole lot of things to extract a baby by virtue that most fair faculty are facile with them. There's an instance where an AFE occurred shortly after Hurricane Ike hit. And because Tony Wynn could do a mid-forceps delivery, the baby lived unimpaired and mom actually lived. If we had to get to her to the OR first, I think we'd have probably lost both of them. Shoulder dystocia, prolonged second stage of labor, and outpatient management of hypertension-- now, there may be many appropriate ways to treat a condition. But when using a team approach, I think we're best suited to picking one and deciding, this is how we're going to approach the problem. Again, there will be some variations. But if it's straightforward hemorrhage-- to know we're going to do the following for straightforward hemorrhage. If it's shoulder dystocia-- to know what we're going to do with a shoulder dystocia. The third of the seven habits of the highly successful obstetrician is integrate the 10 clinical diamonds for preventing maternal death into your practice. Again, I want to acknowledge Steve. Because we put this together looking back on years of experience, some of which had not been such great experience. So here are those 10 diamonds. The woman who is or was recently pregnant that has chest pain is deserving of a CT angiogram. Embolus, specifically pulmonary embolus, is the leading cause of maternal death in America. So chest pain should be paid attention to. Preeclampsia with dyspnea should get a chest x-ray and oxygen. Preeclampsian dyspnea, till proven otherwise, is pulmonary edema. A blood pressure greater than 160 systolic or greater than 110 diastolic is deserving of medication. I'm not trying to normalize the pressures when the baby is still in utero. But the higher the blood pressure, the greater the risk she's going to have lots of bad things happen, to include congestive heart failure, to include bleeding into the head if she is unlucky enough to have a berry aneurysm. Angiographic embolization is not for acute massive hemorrhage. That would make pretty good sense, right? For those of us that have practiced for a long time, we're certainly not going to take a woman that is profusely hemorrhaging down to radiology. If we can slow it down, we may get there. But that's not the treatment for acute massive hemorrhage. If there's maternal cardiac disease, a history of maternal cardiac disease, that is deserving of a consult with maternal fetal medicine. 40% of cardiac diseases that start as New York heart class one end up as four-- 40%. Now, what about a cardiologist? They'd be fine to consult, too. But maternal cardiac disease is deserving of having someone who's expert in this area evaluate the woman. Not only that, when you call them up when the woman has a lot of trouble, it's nice that they've already established a relationship with both you and the patient. Uterine atony that's required two medicines is deserving of the MD being present to help you manage it. So we've used pit and we've used methergine, or we've used pit and we've used something else, and we still have atony, the physician needs to be at the bedside. Postpartum hemorrhage is not a diagnosis. Uterine atony is a diagnosis. Retain products, uterine rupture, those are diagnoses. Postpartum hemorrhage is a sign. So it may not be atony. It may be a big laceration-- all the more reason that if she's continuing to bleed significantly, I need to present and evaluate it. OK, you've had hemorrhage, and now, they're not peeing. Lasix is not the cure. She's not peeing because she's not adequately profusing the kidneys. And you all are probably thinking, how dumb is this stuff? I mean, is Henkins out in-- not even in the ballpark? We come up with these because we have looked at bad outcomes. And these were the reasons the bad outcomes occurred over and over and over. So if she's hemorrhaging, and she's not peeing, she needs volume. She may need red blood cells. But she does not need to have her volume further reduced by trying to make the kidneys make some urine when she needs to retain that in her vascular system. Prior cesarean section plus a previa is deserving of being at a tertiary center. There is now not a month that goes by that I don't end up operating on an accreta, increta, or percreta. Section rate is high. They have low implantation. Oftentimes, we'll know from the ultrasound-- we'll have a high suspicion-- that something's going on, but not always. So be at a place that has a really good blood bank and where you can get help. Too fast there. AUDIENCE: [INAUDIBLE]? DR HENKINS: The question is, when do you admit them? And I admit them-- depending upon how high the index of suspicion is, we would admit them at 37 weeks for delivery, close to 37 weeks. If they've had bleeding already, it depends on how much bleeding. But 37 weeks-- we want to get them taken care of before they labor. Because that, very often, ends up being disastrous. If they come in, and they're in labor, depending upon whether I've truly assessed it as labor or not, then I'll move the delivery up earlier. Depending, again, upon what the history has been, if we really think they're going to end up delivering very remote from term, they would be people we would give steroids to, as well as magnesium for neural protection of the fetus. So it takes individualization. But what you don't want to do out at Podunk Hospital is you don't want to have that happen in the middle of the night from one of their referring facilities. Within the last two years, a doc operated unsuspecting. It had invaded all the way through. He delivers the baby, and mom's bleeding. He put her in mass trousers, sent her to us. Her hemoglobin was three on arrival, was three. And she actually was still mentating. And she lost the uterus. But she comes out OK. Now, there were folks that would want to criticize that guy who's way out in the middle of nowhere for sending that lady to us. She would have died if he had kept her. So when you're confronted with something like that, the best thing he could have ever done was get her shipped. He would have depleted his blood bank. Again, going to these-- and different places have different ways of managing them. At UTMB, the management is by maternal fetal medicine. We're the surgeons. We don't bring the oncologist in or the urologist or anybody else. We take care of it. And again, we probably have 20 to 30 of these that we do a year. So we get pretty good at it. But I'm not exaggerating. I've lost as much as three liters of blood in five minutes. So you need the experts with anaesthesia. You need the lines. While we're talking about that, we went through the phases of trying to put the catheters in, blow up the balloons. The fetus doesn't like it if it's still in if you blow up the balloons. I'm just kidding about-- fetus wouldn't like it, but don't do that. But the balloons we found didn't help us. So we no longer do that. And we had some significant complications from the balloons. You should have a massive transfusion protocol at your hospital. And if you call the blood bank, and you tell them you need it, just like when trauma surgeons call and say you need it, they know you need it, and they start sending it. This is one example-- some of you heard Louis Pacheco earlier today. Louis is one of my partners. And this is one example of a massive transfusion protocol. You may have one that's slightly different. It doesn't matter. What matters is when you say, I have to activate it, nobody's arguing with you about it, that it occurs. OK, the fourth habit-- remember, your goal is a healthy mother and a healthy baby. This is some data that Steve Clark put together. Steve is the quality director for the HCA group. And he looked at the cesarean delivery rate primary as well as total. And just about everywhere the rates-- I'm not sure they've plateaued yet in America. I think they may edge a little bit higher. What's the rate here in Austin? AUDIENCE: [INAUDIBLE]. DR HENKINS: So similar to what he reported from the HCA system. The more primaries we have, the more repeats we're going to get-- no question about it. Now, I mentioned that we allow the VBACs. But again, there's almost never a week that goes by that I don't have a VBAC or a woman that doesn't want it where I find a huge window when I go in to deliver the baby at section-- I mean huge windows. So the OBs need to be good surgeons. So every woman deserves an easy vaginal birth or an easy cesarean birth. Any of you ever had one of the sections after a three or four or five hour second stage? AUDIENCE: [INAUDIBLE]. DR HENKINS: That's a good response. The response is, what's the five hour second stage? Well, we see them, believe it or not. And the head is wedged down in the pelvis. And it's not an easy cesarean section. And I've gotten lacerations that I think sometimes stopped just short of the labia from trying to get that baby up. They're not easy. So the point would be, as you bring up, what is a five hour-- my bias, you should not get to a five hour second stage. That's not good for anybody. It's not good for the baby. It's not good for the doctors. It's not good for the hospital. OK, what's wrong with this picture? Treat the nurses with respect. I would have never made it out of internship but for the nurses taking pity on me. Now, I had a colleague that went on to be a reproductive endocrinologist. And he started as an electrical engineer. And he was totally devoid of personality. And he ticked off the nurses, almost all of them. And boy, did he have a miserable residency. So the nurses are my best friend and my best ally. They're treated with respect. They're always listened to. Oftentimes, my pager will go off if they don't like something another faculty is doing, and they want me to please walk by and see what's going on. And I'm happy to do it. Never, never refuse to come by if the nurse asks you to come by. Nurses, if you want me, tell me. Don't make me guess. Say, Dr. Henkins, I would like you to come over here please, or, you need to come see this patient, or, I'm concerned, would you come here? No need to be ambiguous-- tell me what you want. Deal responsibly with sleep deprivation. Rats deprived of sleep die sooner than rats deprived of food. Now, I'm not saying we're rats. So let's look at this and compare it to serum alcohol levels. At 17 to 19 hours, it's equivalent to a 0.05 blood alcohol. At 19 to 21 hours without sleep, it's equivalent to 0.08. What's DWI or DUI in Texas? AUDIENCE: 0.08. DR HENKINS: 0.08-- 19 to 21 hours, we're functioning as if we could be arrested for driving a car. So sleep deprivation is bad stuff. Greater than 24 hours-- equivalent to a 0.10. I'm sure that the majority of physicians in this room have experienced sleep deprivation, and perhaps lots of it. They didn't have an 80 hour work week when most of us went through. And I marvel that I didn't hurt others or myself because of it. But sleep deprivation is very real. Additionally, following 24 hours of sleep deprivation, it takes three nights of uninterrupted eight hour sleep to recover cognitive function. Ongoing accrual of sleep debt is unavoidable. You can't get used to it. You just can't get used to sleep deprivation. Now, I wanted to show you this. This, again, is Steve Clark's data from the HCA system. And it looks at standardizing and doing the things we just talked about and its effects on reported claims per 10,000 births. So by doing these relatively simple things-- like there's only one concentration of mag sulfate, only one concentration of pit-- they have drastically reduced claims in the system, the entire system. And they have a half million births a year in their system. So the power is there to say, yes, it actually does work. AUDIENCE: Do you know from that chart where certain things were spliced in their protocol? DR HENKINS: I cannot tell you off top of my head. But drop me an email, and I can get it. One of the first things we put in play was the oxytocin standardized protocol, and that there's one protocol. Another one was mag sulfate. They were knocking off several women a year with mag overdoses-- I mean deaths. Because there were many different concentrations. So in standardizing them-- but we can get some arrows. That's a good suggestion to add to the slide. The bottom line is OB litigation for the HCA system currently ranks behind accidents on hospital grounds in terms of dollar cost to the HCA system. That's an improvement worth paying attention to. So deal responsibly with sleep deprivation. OK, don't peek ahead. What do you think number seven is? Oh, you peaked. I saw that. I live on Galveston Island. And this is a photograph that my wife shot. And those are snowy egrets or white egrets. They're pretty, aren't they? And it's mating season, so they're in their beautiful plumage. This is a roseate spoonbill. I had been in San Antonio for my residence and military time, and I thought the damn things were flamingos. But I got educated. It's actually a roseate spoonbill. And they're pretty. And this is where I sit and drink wine after coming home in the evening. Barbara and I sit out on the back deck at our house. We watch the colors of the sky. And we have a glass of wine. There goes the sunset. This is not Galveston. [LAUGHING] But the point is-- this is Galveston. The point is, you have to refresh yourself. And you have to have time for yourself and your family. That's really, really another important habit. And it's one that early in my career I was very neglectful of. The other thing I'd add is you know that you only get one shot at the kids. So be there with the kids. They'll grow up, and they'll leave, and you don't get that shot over again. I really appreciate the opportunity to be here with you today and the interactiveness that we've had. I'll take questions or comments. Yes ma'am. AUDIENCE: So A1 recommends waiting for 40 weeks for induction now. Do you think ACOG will get there? DR HENKINS: I don't know. The question was, A1 recommends waiting till 40 weeks for an induction. I don't know. I'm skeptical that ACOG will embrace and endorse that from the standpoint that there may be a lot of valid indications to go before 40 weeks. For instance, you're my patient, and you're 39 weeks, and I have great dates, and you've told me, my baby's not moving very much. It's still moving, but it's changed its behavior state significantly, and you have a favorable cervix. In that circumstance, I'm going to listen to what you're telling me, and I'm probably going to offer you an induction. I won't demand it. But I'll certainly offer it. And I'm going to tell you, you really need to keep close attention to the movements of your baby. So I, in fact, have my patients, all 100%, high risk, low risk, doesn't matter, do kick counts. Do you all like kick counts? And I do a real simple version. I do, count to five. So lay down at roughly the same time, put your hands on your abdomen, and I want you to count. And when you get to five, if it's in three minutes, you're finished. I don't care if I get five in three minutes or 10 or 15 minutes. I'm happy. That baby's moving. On the other hand, if we go 20 minutes, and she has to go another 20 minutes, and if at that point she's not got the movements, she needs to come in and go on a monitor. So I think the latitude that we've got right now with 39 weeks allows individualization and judgment. And I think that's a good thing still in the practice of obstetrics. Yes sir. AUDIENCE: I know that you mentioned before you had a patient walk into the delivery, and you had [INAUDIBLE]. DR HENKINS: The last part-- I'm sorry. AUDIENCE: Is it a legal decision or a medical decision? [INAUDIBLE]. DR HENKINS: It's both. It's both. The primary reason I do it is I want to figure out the state of the baby so I can talk to the family and prepare them. So if I do that by physical profile-- and again, if the baby had a sub-lethal cord event, the AFI is not going to instantly go down. So I may score a two for the AFI and another two. If I score a four or less on a biophysical profile, my recommendation to her is, if she wants to be sure I don't cause additional injury, to go forward and deliver it by cesarean section with my neonatal team present to resuscitate the baby if the baby's depressed. If she doesn't want that, then I'm going to try to perk the baby up with oxygen and fluids and rest for several hours, reassess it with a biophysical. I'm not going to move instantly for a delivery. Because in that circumstance, I don't want to precipitate a series of late decelerations or a bradycardia. So I don't want to turn what's already bad into an emergency with a worse outcome. Yes. AUDIENCE: You're talking about a non-laboring patient? DR HENKINS: Any patient-- again, any patient that comes in with a strip like that, unless it's markedly premature. Now, premature babies may do that. But even there, the biophysical profile should let us sort out which is just flat verses which is a baby that something has potentially happened to. AUDIENCE: [INAUDIBLE] premature patient in labor or not in labor with a flat strip? DR HENKINS: The flat strip concerns me period, labor or not. And oftentimes, they are not laboring when they come in. Or if they are laboring, there'll be very subtle light decelerations present. But a totally flat strip that stays that way is always concerning. Now, could it be the mom has taken a narcotic or drug or something? Certainly it can be. AUDIENCE: So my question is, you said you go about this with profiles. Do you do biophysical profile at bedside? Because I know at our hospital, if we don't do it at bedside, it's probably not going to get done for a while. DR HENKINS: I do it right then. And I do it at the bedside. It's not a test to wait till morning. AUDIENCE: If they're laboring, is scalp stem [INAUDIBLE]? DR HENKINS: If their scalp stem-- from the studies that have been done, if it is positive, it has a 90% accuracy in telling you the baby's non-acidemic. 90%-- that's pretty good. AUDIENCE: I'm just trying to figure out the fastest way to evaluate-- because I don't think that [INAUDIBLE] profile on someone in labor that's ruptured, because it takes too long, and I can get further information from scalp stem. And I'm just making sure that that's still reasonable to do. DR HENKINS: Scalp stem would be fine in that circumstance. AUDIENCE: In the same line, just making that point [INAUDIBLE]. And if you have a patient [INAUDIBLE]. DR HENKINS: There's a big difference between a contraction stress test in a baby that comes in looking reasonable versus one totally flat. I've seen CSTs over and over in a strip that's totally flat have three or four lights and then go into a bradycardia. And I've seen that happen where the doc's not at bedside, not in the hospital, and there's a significant delay in getting their baby delivered. That's a bad place to put yourself, the hospital, the patient, everybody. Again, CST is a provocative test. CST is doing something that's very different than looking with a biophysical or scratching a baby's head. And I would never-- I mean, I just will not-- do that. Because-- not in the totally flat strip. I will not put pit on until I've otherwise evaluated it. Putting pit on is still within standard of care. But it, I think, exposes you to a lot more risk than doing non-provocative testing. Yes sir. AUDIENCE: Do you believe there's an imaging study to rule out accreta in a case of abnormal [INAUDIBLE] just de novo, that you would feel comfortable saying, well, yeah, she's had a section, she's got accreta, but it's not an accreta based on the imaging study? DR HENKINS: No, none of them are going to hit. All of them have false negatives. Even with the very best imagers, they won't always show it. Now, I would venture a guess that you pick up probably 80% with a high degree. So that's good. Most of our tests aren't even 80%. But if you miss it, even if it's 90 and you've missed it, you're in a bad place when you get there. Now, you deliver here? AUDIENCE: No. DR HENKINS: If you deliver at a place that has all sorts of resources, and I've got it-- I mean, low index of suspicion like you're talking about, I don't have an anesthesia put in multiple lines and all those things up front. I have them prepared. I have them do an assessment. And then, if I open up, and I see that I'm getting into some real bad stuff in a few minutes, I stop. I stop and say to anesthesia, we're going to have a lot of hemorrhage here in a minute. You need to get more lines in before I precipitate that hemorrhage. And I think that's perfectly acceptable to do. Because we get there and we see it, particularly-- most of us, if it's really down there, the blood vessels under the bladder are the size of your fingers. If I see that, I'm going to ask anaesthesia, put in additional lines, large bore-- not 20 gauge, but large bore-- IV so that we can volume resuscitate if need be. Yes sir. AUDIENCE: And as far as sleep deprivation goes, what's your advice or comments to physicians in private practices who find themselves on call every third or fifth night? And that often happens that you have sleep deprivation. What's your advice? DR HENKINS: I've always had the luxury, except for a couple of manning assist in the Air Force, of being at a center where we didn't have that rigorous of a call schedule. If there's a hospitalist, which there may or may not be, or if practices can combine and cross cover, that would be my suggestion. And again, it depends on what is the volume that you're handling. Because if you know every third night you're going to be up all night long, you're going to get sleep deprived. So were it me, I would say, OK, is there another good group that I can associate with, and we can cross cover? AUDIENCE: So your advice would be, simply don't put yourself in that position. DR HENKINS: Try not to. And it may not be an easy solution, or there may not be a solution. But if you can work one, it behooves us to so do. This data is becoming well known to the trial lawyers as well. So very often, they're going to delve into, how many hours were you at the hospital? How many babies? They're going to get the records and see, so the data is out there. It appears to be real. They can redo the experiments and show that it holds up. Try to find a solution. AUDIENCE: I just have to point out-- here we have hospitalists who help us with emergencies. Not to be disrespectful, but the hospitalists do 24 hour service shifts. And they may be up for 20 of the 24 hour service shifts. So the hospitalists are no better off per se. Again, sorry to be disrespectful, but I think we just have to lay it out there-- we've done a horrible job traditionally in OB of recognizing that we can't work 48 hours in a row, or 24 hours in a row, and still do everything right. And yet, we do that every single day. I would ask, is there anybody in this room who's an OB doctor who does not work 24 hours in a row and have to be up 24 hours in a row sometimes? I see it all around me. I do it all the time. And it's not because you want to put yourself in that position. But I think the answer is going to have to be really looking at solutions like pilots implemented, and trying to be more cooperative. DR HENKINS: Well yeah, they won't let you drive a truck or fly an airplane or a bus if you've been up that long for that kind of a stretch. And again, when I was young, maybe I was better than I am today. But I know my functioning falls off, cognitive at least, as I get towards 24 hours. Now, I can still operate pretty well. I can do mechanical stuff OK. But if I have to do a whole bunch of thinking at that point, I'm actually impaired. And I know I'm impaired. Did you have a comment? AUDIENCE: Well, I'm in academic medicine. And we do 36 hour shifts. And our residents have limited hours. They cannot take more than a 24 hour shift and have 12 hours time in between, or they have to have 12 hour shifts and 12 hours off. And then, the interns only can work 60 hours a week. And the other second, third, and fourth can only work 80 hours. And they're strict. Our program gets sanctioned if we make our residents work. So then, they don't pursue their job with the attention [INAUDIBLE]. DR HENKINS: Well, they're going to be shocked when they leave-- AUDIENCE: And there's no government regulation on attendants. And yet, we're twice the age. DR HENKINS: I wish I were twice the age. AUDIENCE: So if there's any injustice, it's not just the private. It's in academics, too. AUDIENCE: But there are studies now that are coming out in academia showing that with the residents, interns, there are more errors being made because of these short shifts, because of poor communication and hand-off of patients from one physician to another. It's a whole different area that is having to be looked at. And some changes are coming. AUDIENCE: Do you think the 80-hour work week should make the residency programs longer than four years now? People are wasting a lot of time working those really long hours. AUDIENCE: I can comment on that. The OB that the residents get is usually overwhelming. They come out very well-trained in OB. They see things that we probably never saw 30 or 40 years ago. But the GYN is where they're lacking, so their experience as surgeons and their experience in doing any kind of gynecology. They're trying to do simulation programs and have different kinds of high-tech computer programs. But I don't think [INAUDIBLE]. I don't think we're graduating good residents. DR HENKINS: I'm going to reflect back to when I came through and echo a comment that was made from the back of the room. When we came through, we got to see the disease process from inception-- preeclampsia, for instance, all the way through. So at this point in time, our residents across the board, I think, have been produced to piecemeal workers. They seldom ever get to see the full spectrum of the disease process. And I think that that ultimately makes it more difficult for them to see and grasp some of the things that those of us that are older did experience, see, and grasp. And the trade-off is obviously coming down to an issue of safety. And this whole issue of the hours worked had nothing to do with the surgical specialty, right? It started in New York, and it was internal medicine. The sleep deprivation data shows what it does. It's pretty solid data. I didn't particularly enjoy that I had 40 hour stints without any sleep as a resident. But there were benefits to it that I got to see things through to their fruition. Now, what does the future hold for training? I think we're only a few years away from their doing tracks. And I think those tracks will be, OK, do you want to be an obstetrician? And if you do, you're in an obstetrical track. Are you going to do office practice? And if so, you're in that track. If you're going to do surgery, there'll be that track. I think it's going to come in that direction. Because I don't think most people are going to be willing to do six or seven year residency training. And I think the scope of what the ones I'm training today, the amount of information they need to grasp compared to how much information I had, and the technology that I had going through-- it's grown exponentially. So I'm not sure that 10 years from now we'll be graduating people that are trained across the board like most of us were. But sometimes, my crystal ball is all fuzzy, so I could be completely wrong. Well, thank you all very, very much. [APPLAUSE]