5 ms·

Just an anecdote but on a subreddit I sometimes browse there's two MDs who boast of sleeping only 3 hours per day. And then on the financial incentives side of

Just an anecdote but on a subreddit I sometimes browse there's two MDs who boast of sleeping only 3 hours per day. And then on the financial incentives side of things, at this point practice insurance might be so robust that it might not be so risky any more to end up committing a medical error while working those extra 3 to 4 hours per day might mean you're making enough money to retire in your early 40s.

maaaats 10y ago
But would it be better for the patients if they didn't work that extra? Waiting months for surgery is not good either.
- TuringNYC 10y ago
  It is usually not because of doctor-shortages that doctors work long shifts -- it is because hand-offs create errors themselves. Think of it as a game of telephone. 8 hour shifts means 3 hand-offs. 12 hour shifts mean 2 hand-offs. One is 50% greater risk of mis-communication as the patient shifts from one doctor's shift to the other. During training, the long hours serve a double-purpose -- compressing more years of training into fewer. If residencies were 1.5x longer, more doctors would choose not to be doctors. Residents working 80 hours vs 40 helps compress the training time and let doctors get on with their lives and careers faster. Unlike in tech, medical residents get paid little for their training period. Shifting 3-6yr residencies into 6-12 year residencies would make residencies viable only for already-wealthy individuals who can withstand 4yrs undergrad + 4yrs med school + 6-12 yrs of low salaries in a captive residency. (btw, w/r/t/ shortages, it is probably due to the doctors themselves -- specialty boards such as the Board of Radiology essentially throttle the number of available training positions (residencies) per year creating artificial scarcity and keeping up their own pay.)
  - chimeracoder 10y ago
    You're correct that handoffs are a common point-of-failure, and also that residency programs are already near the tipping point of financial non-viability for the non-wealthy. However, to your last point: > (btw, w/r/t/ shortages, it is probably due to the doctors themselves -- specialty boards such as the Board of Radiology essentially throttle the number of available training positions (residencies) per year creating artificial scarcity and keeping up their own pay.) The actual bottleneck on residency positions is not artificially imposed by any external group - the bottleneck is the funding for residency positions themselves. Residency programs run at a loss, which is why Medicare has had to step in to fund GME. There are a very small number of non-Medicare funded residency slots, but they're also funded through external means.
  - albertTJames 10y ago
    > It is usually not because of doctor-shortages that doctors work long shifts -- it is because hand-offs create errors themselves. Think of it as a game of telephone. 8 hour shifts means 3 hand-offs. 12 hour shifts mean 2 hand-offs. One is 50% greater risk of mis-communication as the patient shifts from one doctor's shift to the other. So long shifts are due to errors ? I hardly see the logic in that... We work long shift because we are expected to work long shift, because nothing is done to prevent medical exhaustion, and because there is a strange societal archetype of the never-sleeping doctor that goes against any recent (or old) research on learning, stress management and work performance (among other). > During training, the long hours serve a double-purpose -- compressing more years of training into fewer. That is also incorrect. In every country except maybe Switzerland, residency programs last 3-5 years, whatever the number of hours worked per week, and medical errors are not the first, the second nor the 3rd cause of death in those countries... Cortisol is a brain cell killer, stress reduces our ability to learn and adapt, sleep deprivation reduces both encoding and storage of long term memory, and most research on attention shows that you cannot work more than 5 full hours per day with a NORMAL lifestyle and sleep cycle. BTW 80 hours is on small weeks in surgery, at least it was for me. > If residencies were 1.5x longer, more doctors would choose not to be doctors. I believe this also to be incorrect, there is no shortage of applicant to medical schools. Actually it would be a problem to finance residency programs..
    - TuringNYC 10y ago
      > So long shifts are due to errors ? I hardly see the logic in that... There is no logic in that, i'm not sure why you asserted that. I noted that long shifts reduce handoff errors. Consider two scenarios: Scenario 1: 8 hour shifts: Doctor 1 hands off to Doctor 2 at end of 8 hrs Doctor 2 hands off to Doctor 3 at end of 16 hrs Doctor 3 hands off to Doctor 4 (or perhaps 1) at end of 24hrs Each handoff is a game of telephone. In theory it should not be, but in reality it is. Details are missed, directions mangled, and risk accrued. Just like a technical design document going from a product manager to the development lead to the developer...things go wrong in the process. Just like with tech teams where each added person creates overhead and waste from communications overhead and mis-aligned understanding of requirements, hospitals face the same issue. Unlike technology, you dont just push a fix and rebuild -- an error such as forgetting to record a symptom on the binder/EMR could mean mis-diagnosis or death. Shifting to 12-hours shifts means just two handoffs instead of three. You dont eliminate errors, but you reduce them. In some sense, it may be better to have 4 days of 12-hour shifts than 5 days of 8 hour shifts. Of course, this is just one aspect of medical errors. There are others which may be brought on by increased shift lengths. We'd need to look at the total sum. Regarding your other point: > In every country except maybe Switzerland, residency programs last 3-5 years, whatever the number of hours worked per week, That makes no sense. If that were the case, residents would choose to work an hour a week and easily graduate in 3-5 years. But that would make for a poor doctor, as they need a certain # hours of training.
chimeracoder 10y ago
> working those extra 3 to 4 hours per day might mean you're making enough money to retire in your early 40s. The only way you could retire in your 40s as a doctor these days is if you were already independently wealthy before becoming a doctor. If you go into medical school today, you're looking at finishing off your student loan payments in your 40s (depending of course on which school you go to, where you do your residency, whether you do a fellowship, and what specialty you choose). The pre-tax, pre-insurance, pre-expenses, gross pay looks high on paper, but the lifetime ROI on going into medicine is nowhere near as good as what you describe, no matter how many hours you work.
- TuringNYC 10y ago
  That is a gross generalization. It is true in the US if you are a primary care physician or one of the lower-paid/lifestyle specialists. It is far from true if your are a higher-paid specialist or sub-specialist. Also consider that unlike tech, where you get paid more for working in higher-cost-of-living cities -- in medicine you get paid more for working in lower-cost-of-living cities. Also note that unlike tech, the peaks and valleys are much less pronounced.
  - chimeracoder 10y ago
    > Also note that unlike tech, the peaks and valleys are much less pronounced. The point is that, unlike tech, you have to take on massive amounts of debt before you can even begin to work[0]. And even after that, there's a really high latency before you're earning enough to make more than the minimum payments. Six-figure debt compounded over a decade or more really adds up. > That is a gross generalization. It is true in the US if you are a primary care physician or one of the lower-paid/lifestyle specialists. It is far from true if your are a higher-paid specialist or sub-specialist. It's actually more true if you're a specialist or subspecialist. People who don't practice medicine tend to overestimate what specialists get paid, and to underestimate what PCPs get paid. It also doesn't help that, in the last ten years, the relative reimbursement rates have changed dramatically, and to top it all off, private practices have been rapidly going the way of the dodo - so it's understandable that the public perception would be out-of-date. Overall, reimbursement rates for specialists have been slashed far faster than they have for primary care (with some specialties hit harder than others). Combine that with the fact that they have to spend even more time in training (during which time their debt compounds > Also note that unlike tech, the peaks and valleys are much less pronounced. Quite the opposite - tech salaries are relatively flat and stable compared to most other industries, and we get to take home pretty much 100% of our salary, less taxes. Yes, the industry as a whole has booms and busts, but so does literally every private industry. In medicine, unlike tech, even if you're salaried, you're oftentimes paying for a large chunk of your business expenses out of your "salary". This is one of the reasons why looking at listings of what doctors make is incredibly misleading. The insurance rates vary dramatically between fields of medicine (and practice locations), as does the necessary equipment and mandatory continuing medical education expenses (again, even salaried doctors will oftentimes have to cover these out-of-pocket). In tech, we don't have to worry about any of that. We have it pretty easy. > in medicine you get paid more for working in lower-cost-of-living cities. This used to be the case. It still is, for some fields like emergency medicine. It's a lot less the case in other fields, partly because of the consolidation of practice groups and the downward pressure on reimbursement rates across the board. [0] Unless, as I said in my previous comment, you're independently wealthy beforehand, in which case this whole discussion of early retirement is moot.
icegreentea 10y ago
Are they sleeping 3 hours a day every day? Or is that just their average when they get a shitty on-call rotation? I think both cases are ridiculous, but it's worth separating the two cases.

maaaats 10y ago

But would it be better for the patients if they didn't work that extra? Waiting months for surgery is not good either.

TuringNYC 10y ago
It is usually not because of doctor-shortages that doctors work long shifts -- it is because hand-offs create errors themselves. Think of it as a game of telephone. 8 hour shifts means 3 hand-offs. 12 hour shifts mean 2 hand-offs. One is 50% greater risk of mis-communication as the patient shifts from one doctor's shift to the other. During training, the long hours serve a double-purpose -- compressing more years of training into fewer. If residencies were 1.5x longer, more doctors would choose not to be doctors. Residents working 80 hours vs 40 helps compress the training time and let doctors get on with their lives and careers faster. Unlike in tech, medical residents get paid little for their training period. Shifting 3-6yr residencies into 6-12 year residencies would make residencies viable only for already-wealthy individuals who can withstand 4yrs undergrad + 4yrs med school + 6-12 yrs of low salaries in a captive residency. (btw, w/r/t/ shortages, it is probably due to the doctors themselves -- specialty boards such as the Board of Radiology essentially throttle the number of available training positions (residencies) per year creating artificial scarcity and keeping up their own pay.)
- chimeracoder 10y ago
  You're correct that handoffs are a common point-of-failure, and also that residency programs are already near the tipping point of financial non-viability for the non-wealthy. However, to your last point: > (btw, w/r/t/ shortages, it is probably due to the doctors themselves -- specialty boards such as the Board of Radiology essentially throttle the number of available training positions (residencies) per year creating artificial scarcity and keeping up their own pay.) The actual bottleneck on residency positions is not artificially imposed by any external group - the bottleneck is the funding for residency positions themselves. Residency programs run at a loss, which is why Medicare has had to step in to fund GME. There are a very small number of non-Medicare funded residency slots, but they're also funded through external means.
- albertTJames 10y ago
  > It is usually not because of doctor-shortages that doctors work long shifts -- it is because hand-offs create errors themselves. Think of it as a game of telephone. 8 hour shifts means 3 hand-offs. 12 hour shifts mean 2 hand-offs. One is 50% greater risk of mis-communication as the patient shifts from one doctor's shift to the other. So long shifts are due to errors ? I hardly see the logic in that... We work long shift because we are expected to work long shift, because nothing is done to prevent medical exhaustion, and because there is a strange societal archetype of the never-sleeping doctor that goes against any recent (or old) research on learning, stress management and work performance (among other). > During training, the long hours serve a double-purpose -- compressing more years of training into fewer. That is also incorrect. In every country except maybe Switzerland, residency programs last 3-5 years, whatever the number of hours worked per week, and medical errors are not the first, the second nor the 3rd cause of death in those countries... Cortisol is a brain cell killer, stress reduces our ability to learn and adapt, sleep deprivation reduces both encoding and storage of long term memory, and most research on attention shows that you cannot work more than 5 full hours per day with a NORMAL lifestyle and sleep cycle. BTW 80 hours is on small weeks in surgery, at least it was for me. > If residencies were 1.5x longer, more doctors would choose not to be doctors. I believe this also to be incorrect, there is no shortage of applicant to medical schools. Actually it would be a problem to finance residency programs..
  - TuringNYC 10y ago
    > So long shifts are due to errors ? I hardly see the logic in that... There is no logic in that, i'm not sure why you asserted that. I noted that long shifts reduce handoff errors. Consider two scenarios: Scenario 1: 8 hour shifts: Doctor 1 hands off to Doctor 2 at end of 8 hrs Doctor 2 hands off to Doctor 3 at end of 16 hrs Doctor 3 hands off to Doctor 4 (or perhaps 1) at end of 24hrs Each handoff is a game of telephone. In theory it should not be, but in reality it is. Details are missed, directions mangled, and risk accrued. Just like a technical design document going from a product manager to the development lead to the developer...things go wrong in the process. Just like with tech teams where each added person creates overhead and waste from communications overhead and mis-aligned understanding of requirements, hospitals face the same issue. Unlike technology, you dont just push a fix and rebuild -- an error such as forgetting to record a symptom on the binder/EMR could mean mis-diagnosis or death. Shifting to 12-hours shifts means just two handoffs instead of three. You dont eliminate errors, but you reduce them. In some sense, it may be better to have 4 days of 12-hour shifts than 5 days of 8 hour shifts. Of course, this is just one aspect of medical errors. There are others which may be brought on by increased shift lengths. We'd need to look at the total sum. Regarding your other point: > In every country except maybe Switzerland, residency programs last 3-5 years, whatever the number of hours worked per week, That makes no sense. If that were the case, residents would choose to work an hour a week and easily graduate in 3-5 years. But that would make for a poor doctor, as they need a certain # hours of training.

chimeracoder 10y ago

> working those extra 3 to 4 hours per day might mean you're making enough money to retire in your early 40s. The only way you could retire in your 40s as a doctor these days is if you were already independently wealthy before becoming a doctor. If you go into medical school today, you're looking at finishing off your student loan payments in your 40s (depending of course on which school you go to, where you do your residency, whether you do a fellowship, and what specialty you choose). The pre-tax, pre-insurance, pre-expenses, gross pay looks high on paper, but the lifetime ROI on going into medicine is nowhere near as good as what you describe, no matter how many hours you work.

TuringNYC 10y ago
That is a gross generalization. It is true in the US if you are a primary care physician or one of the lower-paid/lifestyle specialists. It is far from true if your are a higher-paid specialist or sub-specialist. Also consider that unlike tech, where you get paid more for working in higher-cost-of-living cities -- in medicine you get paid more for working in lower-cost-of-living cities. Also note that unlike tech, the peaks and valleys are much less pronounced.
- chimeracoder 10y ago
  > Also note that unlike tech, the peaks and valleys are much less pronounced. The point is that, unlike tech, you have to take on massive amounts of debt before you can even begin to work[0]. And even after that, there's a really high latency before you're earning enough to make more than the minimum payments. Six-figure debt compounded over a decade or more really adds up. > That is a gross generalization. It is true in the US if you are a primary care physician or one of the lower-paid/lifestyle specialists. It is far from true if your are a higher-paid specialist or sub-specialist. It's actually more true if you're a specialist or subspecialist. People who don't practice medicine tend to overestimate what specialists get paid, and to underestimate what PCPs get paid. It also doesn't help that, in the last ten years, the relative reimbursement rates have changed dramatically, and to top it all off, private practices have been rapidly going the way of the dodo - so it's understandable that the public perception would be out-of-date. Overall, reimbursement rates for specialists have been slashed far faster than they have for primary care (with some specialties hit harder than others). Combine that with the fact that they have to spend even more time in training (during which time their debt compounds > Also note that unlike tech, the peaks and valleys are much less pronounced. Quite the opposite - tech salaries are relatively flat and stable compared to most other industries, and we get to take home pretty much 100% of our salary, less taxes. Yes, the industry as a whole has booms and busts, but so does literally every private industry. In medicine, unlike tech, even if you're salaried, you're oftentimes paying for a large chunk of your business expenses out of your "salary". This is one of the reasons why looking at listings of what doctors make is incredibly misleading. The insurance rates vary dramatically between fields of medicine (and practice locations), as does the necessary equipment and mandatory continuing medical education expenses (again, even salaried doctors will oftentimes have to cover these out-of-pocket). In tech, we don't have to worry about any of that. We have it pretty easy. > in medicine you get paid more for working in lower-cost-of-living cities. This used to be the case. It still is, for some fields like emergency medicine. It's a lot less the case in other fields, partly because of the consolidation of practice groups and the downward pressure on reimbursement rates across the board. [0] Unless, as I said in my previous comment, you're independently wealthy beforehand, in which case this whole discussion of early retirement is moot.

icegreentea 10y ago

Are they sleeping 3 hours a day every day? Or is that just their average when they get a shitty on-call rotation? I think both cases are ridiculous, but it's worth separating the two cases.