What Do We Really Know?

By

Leonard Zwelling

The March 7, 2019 issue of The New England Journal Of Medicine makes it quite clear that we, as humans, can act before we know what the heck we are doing.

The first issue the journal touched upon is the need for sleep in young doctors or perhaps it’s about the rigidity of house officer on-call schedules. It was the death of Libby Zion that began the push to more closely regulate the hours that house officers work. Training programs mandated shortened work hours and more sleep for house officers. This necessitated more hand-offs as interns and residents were sent home at the end of very regimented work shifts. Hand-offs are also opportunities for errors and clearly generated a lack of continuity of care.

In a well-performed study from the University of Pennsylvania, some internal medicine training programs were granted waivers from the strict regulations for work hours so that the performance of the young physicians could be quantified and compared with the performance of residents in the rigid hour programs. What a surprise! No difference was found in the two programs in patient mortality or total sleep of the doctors. More importantly, as noted by Lisa Rosenbaum in her accompanying editorial, the new systems of in-patient care with rotating doctors and hospitalists surely serve to confuse patients as to who their doctor really is.

This has been my argument about the new schedule rules from the beginning. They abbreviate clinical experience, interfere with a young doctor’s understanding of a disease’s natural history (e.g., diabetic ketoacidosis), disrupt care continuity, and confuse patients. As a graduate of one of the most brutal training programs in America, I certainly felt many times that I could use a little bit more sleep. It’s good to know that it probably wouldn’t have made me less effective to be up with a GI bleeder all night and it certainly broadened my education. Libby Zion and her poor care is no reason to upend a system that served the country well for years. In light of these new findings, perhaps leaders of training programs should be granted a lot more flexibility to determine the work schedules of their trainees. Just say for me, I want my doctor to be the one who learned how to function while staying up all night. That pulmonary embolus I got in the middle of the night at St. Luke’s could have used someone besides me making the diagnosis–like someone who could write orders for heparin and who actually knew who I was and why I was in the hospital.

The second topic addressed widely in this issue is that of genetic alteration of the human germ cell line in the wake of the Chinese scientist who did just that in late 2018. This led to the birth of twins with altered genomes that will be with them forever and with their off-spring as well.

Is this ethically tenable?

Fortunately, the answer seems to be a combination of NO and IT DEPENDS. The use of the CRISPR system to edit the DNA of human embryos would seem like an awful idea fraught with Brave New World implications. But consider the possibility of parents wishing children who both have a known genetic defect in a single gene—like Sickle Cell Anemia, or Huntington’s Disease, or Tay-Sachs Disease. You get the drift. In the case from China, a thoroughly unnecessary change was made in the embryos to prevent them from contracting HIV. There are easier ways to do this. But there may be times when such technology may be of benefit.

Once again Dr. Rosenbaum writes a lucid editorial based on her reporting and conversation with many experts that suggests this is not all that simple and the technology clearly progressed faster than the ethics have.

In the end this is going to come down to many difficult judgments best left to groups of people from many fields and not just scientists. This is changing the essence of what it means to be human and cannot be taken lightly. As CRISPR discoverer Jennifer Doudna says in her book A Crack In Creation, “That we are unprepared for such colossal responsibility, I have no doubt. But we cannot avoid it.”

This issue of the NEJM is not to be missed. Everyone has a vested interest in how we resolve the issues of training hours for doctors (after all we all we be patients soon enough) and what CRISPR should be allowed to be used to do.

The Journal once again fulfills its role as the premier forum for medical insight. It also provides lots of questions, but no certain answers. But in these two realms, as widely separate as they are, humans moved too soon, before they knew what they were doing. And in both cases, thoughtful experimentation and discussion might have headed off human error.

And also, my latest letter to The NY Times:

https://www.nytimes.com/2019/03/23/opinion/letters/college-experiences.html

Leonard Zwelling