Monday, February 15, 2016

When doctors strike, deaths decline, but when nurses strike,,,

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.

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.

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.”

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.

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.


  1. Cunningham SA, Mitchell K, Narayan KM, Yusuf S. Doctors' strikes and mortality: a review. Soc Sci Med. 2008 Dec;67(11):1784-8.


    A paradoxical pattern has been suggested in the literature on doctors' strikes: when health workers go on strike, mortality stays level or decreases. We performed a review of the literature during the past forty years to assess this paradox. We used PubMed, EconLit and Jstor to locate all peer-reviewed English-language articles presenting data analysis on mortality associated with doctors' strikes. We identified 156 articles, seven of which met our search criteria. The articles analyzed five strikes around the world, all between 1976 and 2003. The strikes lasted between nine days and seventeen weeks. All reported that mortality either stayed the same or decreased during, and in some cases, after the strike. None found that mortality increased during the weeks of the strikes compared to other time periods. The paradoxical finding that physician strikes are associated with reduced mortality may be explained by several factors. Most importantly, elective surgeries are curtailed during strikes. Further, hospitals often re-assign scarce staff and emergency care was available during all of the strikes. Finally, none of the strikes may have lasted long enough to assess the effects of long-term reduced access to a physician. Nonetheless, the literature suggests that reductions in mortality may result from these strikes.

  2. Jena AB, Prasad V, Goldman DP, Romley J. Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Intern Med. 2015 Feb;175(2):237-44.



    Thousands of physicians attend scientific meetings annually. Although hospital physician staffing and composition may be affected by meetings, patient outcomes and treatment patterns during meeting dates are unknown.


    To analyze mortality and treatment differences among patients admitted with acute cardiovascular conditions during dates of national cardiology meetings compared with nonmeeting dates.


    Retrospective analysis of 30-day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure, or cardiac arrest from 2002 through 2011 during dates of 2 national cardiology meetings compared with identical nonmeeting days in the 3 weeks before and after conferences (AMI, 8570 hospitalizations during 82 meeting days and 57,471 during 492 nonmeeting days; heart failure, 19,282 during meeting days and 11,4591 during nonmeeting days; cardiac arrest, 1564 during meeting days and 9580 during nonmeeting days). Multivariable analyses were conducted separately for major teaching hospitals and nonteaching hospitals and for low- and high-risk patients. Differences in treatment utilization were assessed.


    Hospitalization during cardiology meeting dates.


    Thirty-day mortality, procedure rates, charges, length of stay.


    Patient characteristics were similar between meeting and nonmeeting dates. In teaching hospitals, adjusted 30-day mortality was lower among high-risk patients with heart failure or cardiac arrest admitted during meeting vs nonmeeting dates (heart failure, 17.5% [95% CI, 13.7%-21.2%] vs 24.8% [95% CI, 22.9%-26.6%]; P < .001; cardiac arrest, 59.1% [95% CI, 51.4%-66.8%] vs 69.4% [95% CI, 66.2%-72.6%]; P = .01). Adjusted mortality for high-risk AMI in teaching hospitals was similar between meeting and nonmeeting dates (39.2% [95% CI, 31.8%-46.6%] vs 38.5% [95% CI, 35.0%-42.0%]; P = .86), although adjusted percutaneous coronary intervention (PCI) rates were lower during meetings (20.8% vs 28.2%; P = .02). No mortality or utilization differences existed for low-risk patients in teaching hospitals or high- or low-risk patients in nonteaching hospitals. In sensitivity analyses, cardiac mortality was not affected by hospitalization during oncology, gastroenterology, and orthopedics meetings, nor was gastrointestinal hemorrhage or hip fracture mortality affected by hospitalization during cardiology meetings.


    High-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology meetings. High-risk patients with AMI admitted to teaching hospitals during meetings were less likely to receive PCI, without any mortality effect.

  3. Gruber, Jonathan, and Samuel A. Kleiner. 2012. "Do Strikes Kill? Evidence from New York State." American Economic Journal: Economic Policy, 4(1): 127-57.

    Hospitals now represent one of the largest union sectors of the US economy, and there is particular concern about the impact of strikes on patient welfare. We analyze the effects of nurses' strikes in hospitals on patient outcomes in New York State. Controlling for hospital specific heterogeneity, the results show that nurses' strikes increase in-hospital mortality by 18.3 percent and 30-day readmission by 5.7 percent for patients admitted during a strike, with little change in patient demographics, disease severity or treatment intensity. The results suggest that hospitals functioning during nurses' strikes do so at a lower quality of patient care.

    Yes, this is the Jonathan Gruber of, “Lack of transparency is a huge political advantage. And basically, call it the ‘stupidity of the American voter’ or whatever, but basically that was really, really critical to getting the thing to pass.”