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    Ideas | Ryan Hoskins

    When doctors strike, fewer patients die

    A doctor wore her stethoscope during a strike in central London on Jan. 12, 2016. English doctors staged their first strike in 40 years over government plans to reform pay and working conditions.
    Stefan Wermuth/REUTERS
    A doctor wore her stethoscope during a strike in central London on Jan. 12, 2016. English doctors staged their first strike in 40 years over government plans to reform pay and working conditions.

    Junior doctors across the United Kingdom traded their stethoscopes for picket signs last month in a 24-hour strike against changes to the National Health Service, the first labor disruption of its kind in nearly 40 years. And unless the British government makes concessions, the 37,000 doctors say they will strike again on Feb. 10 — this time withholding even emergency services.

    The thought of physicians shutting down operating theaters and emergency rooms has understandably provoked concern among some Britons. NHS managers, seeking to win public sympathy for their side, have stoked this alarm, stating they “fear patient deaths” resulting from the strikes.

    But politics and histrionics can be set aside — it turns out medical researchers have applied the cold, hard tools of science to explore the consequences of striking physicians. And what they have found is an apparent paradox: Not only is there no harm to patients when doctors strike, there nearly always seems to be a decrease in patient deaths.

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    Investigating physicians strikes is not an easy thing to do because among high-income countries, they are exceedingly rare. Physicians are less frequently unionized than other workers, many countries have imposed barriers on the abilities of physicians to strike, and physicians have tended to regard this organizing tool as unavailable to them.

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    Yet a 2008 analysis led by Solveig Cunningham of Emory University attempted to bring together existing research on physician strikes to see whether patterns existed on patient impact. Five strikes — lasting from nine days to five weeks in places as varied as Los Angeles, Jerusalem (twice), Spain, and Croatia — yielded sufficient data to study. Researchers found that mortality in all cases either stayed the same or substantially declined when physicians walked out. In the case of the first Israeli strike of 1973, patient deaths dropped by 50 percent.

    The authors acknowledge a number of potential flaws in the review. The first is that in none of these strikes did medical care cease completely — emergency services were always made available. What’s more, some high-risk patients may have sought care elsewhere during the work stoppages, relieving the system of cases more likely to end up dying.

    Nonetheless, the results seem to describe a pattern that repeats itself consistently from California to Croatia, and from 1973 to 2003: Fewer doctors on the job results in better health outcomes.

    Cunningham has been chewing on this phenomenon ever since writing the 2008 paper. She believes there is something important in the findings for policy makers to consider. “Elective procedures are really what are driving this,” Cunningham explained. “There are a lot of procedures that are not actually life saving that have small risks associated with them. These small risks — including infections from hospitalization — are potentially leading to the results we see.”

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    When physicians who provide non-urgent care are away, elective procedures are canceled. These elective procedures may actually have greater risks than benefits; when they are nixed, the death rate declines. It is a counterintuitive idea, but it is a reasonable conclusion to draw — that what the strike data actually illustrate is that, at least for certain procedures, less is more in health care.

    A 2015 study led by Harvard’s Dr. Anupam Jena echoes this observation. It is a large investigation looking at deaths in hospitals across the United States when the American Heart Association and the American College of Cardiologists are in session — measuring patient health when most of America’s cardiologists are away from their home institutions. In the outcomes it considers, the study finds that patient death rates either stayed the same or significantly improved when doctors were away at the conferences.

    One finding in particular from Jena’s study sticks out: Angioplasty — where a catheter is floated through the vascular system to open up blocked arteries of the heart — occurred less often when the heart doctors were away. But levels of patient deaths remained unchanged, i.e. the absence of physicians doing modern procedures did not harm patient outcomes. Disagreement exists among doctors as to when the benefits outweigh the risks of angioplasty. This research may be more direct evidence that some physicians tend to pursue the more invasive of treatment options, and that this behavior may worsen patient outcomes.

    These studies do not definitively confirm a less-is-more approach is always better — there are plenty of confounding variables that would require more research to clarify relationships between absent doctors and better outcomes. But perhaps too many angioplasties, as well as bypass surgeries, cesarean sections, and tonsillectomies, are being performed when they are not really indicated.

    Interestingly, studies of nurses going on strike show a negative effect on patient health. A 2012 study by MIT’s Jonathan Gruber examined nursing walkouts in New York State from 1984 to 2004. He found that patients admitted on days of labor actions had death rates 18.3 percent above the normal. It’s a reassuring indicator that nurses — more involved in bedside care and less involved in treatment plans — actually improve patient outcomes when staffed appropriately.

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    A refrain sometimes heard by senior physicians to doctors in training is “don’t just do something, stand there.” Rather than reflexively order a diagnostic test or recommend a surgery to alleviate a patient woe, it is often better to watch and wait.

    In fact, doctors stepping back more often may be exactly the prescription that the health care system needs.

    Ryan Hoskins is an emergency room physician and health policy analyst based in Canada. He is currently a Fellow in Global Journalism with the Munk School of Global Affairs at the University of Toronto.