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No Doctor Should Work 30 Hours Straight with No Sleep
- squozzer 10y agoWe shouldn't discount the possibility that the regimen is designed to break doctors down psychologically.
- djsumdog 10y agoI remember hearing about sleep deprivation in the medical field before; especially for people who work in the ER or as surgeons. The demand in the US for nurses and doctors is very high, and so are the education costs which can be prohibitive to people getting into medicine. There's a whole system of failures, from the cost of education to the student loan systems to medical insurance and billing, that has led directly to overworked doctors. Many med students today feel that they can't become GPs because they simply won't make enough to pay back their student loans.
- devoply 10y agoThe issue is that of management. The management profession has taken over hospitals and it runs those according to management practices. Overworked doctors are a result of (bad) management, and nothing else.
- dv_dt 10y agoExcept that management in hospitals are often doctors themselves (or influenced by the more senior doctors). One problem is that most doctors have gone through a residency with abusive hours - so it becomes hard to separate tradition from necessity. http://www.latimes.com/business/la-fi-medical-resident-hours-20161216-story.html http://www.latimes.com/business/la-fi-medical-resident-hours...
- devoply 10y agohttp://study.com/hospital_management_career.html http://study.com/hospital_management_career.html
- barry-cotter 10y agoI suggest you talk to some older doctors. If you did you'd discover that these insane schedules of work and training have been standard since before either of your parents were born.
- hx87 10y agoThe cost of education isn't a obstacle to people getting into medicine, except indirectly by slowing down the opening of new medical schools or expansion of existing ones--otherwise we'd be seeing lots of open spots in and reduce competition for admission to medical schools, which certainly isn't the case. Moreover, new medical schools with a total of 1000+ seats have opened in the past few years. The real bottleneck is in the number of residency slots, which hasn't changed in 20 years.
- jessriedel 10y ago> The real bottleneck is in the number of residency slots, which hasn't changed in 20 years. Aren't you just refering to the 20-year freeze on the number of medicare-financed residents? I believe the number of residents is still increasing through other funding. Or is there some other way to square your statement with this?: > Medical school seniors scored a record number of available first-year slots in this year’s Main Residency Match... Continuing a 4-year growth trend, the number of available post-graduate year 1 (PGY-1) positions rose to 27,860 in 2016, 567 more spots than in 2015, and a record 18,668 U.S. allopathic medical school seniors registered for the match, 221 more than in 2015, according to data from the National Resident Matching Program (NRMP). Family medicine residency programs offered 3,238 positions in 2016, up from 3,195 in the 2015 match. Internal medicine experienced similar increases, with residency programs offering 7,024 positions this year, up from 6,770 positions in 2015. http://www.mdedge.com/internalmedicinenews/article/107413/practice-management/match-day-2016-residency-spots-rise-growth http://www.mdedge.com/internalmedicinenews/article/107413/pr...
- user5994461 10y ago> There's a whole system of failures, from the cost of education to the student loan systems to medical insurance and billing, that has led directly to overworked doctors. There is a "shortage" of doctors and crazy hours in countries with free education, no student loan system and insurance is ensured by the country for all citizens. So, no, these issues are not the whole story (which doesn't mean they are not issues).
- themantalope 10y ago>Many med students today feel that they can't become GPs because they simply won't make enough to pay back their student loans. I'm at a private (but good) medical school and this is definitely a problem. My tuition (not including living expenses) is about $50,000 per year. And to be honest, there isn't a huge difference in tuition between most private and public medical schools. I'm from NYS, which does a pretty good job subsidizing its state schools. When I was applying to medical school, the in-state price was around $35,000 per year. However, just over the border in Pennsylvania the price at Pitt (which is public) was around $48,000 per year, for out of state students, and maybe 40 or 42k for in state students. I went to an in state school for undergrad, and I'm very fortunate to have no debt from that. However, many of my classmates who went to good private undergrad schools (Ivy league etc) will have (a lot) of debt from both undergrad and med school. They literally have no choice - they need to go into a high paying specialty if they ever want to pay their loans off.
- dnautics 10y agoDidn't they do a study and find that decreasing doctor hours caused an increase in patient mortality because of handoff errors? And that digitizing records didn't help because of a combination of inaccurate measurement by the staff and because of factors that can't be measured (intuitive observation, etc).
- deleted 10y ago[deleted]
- vorotato 10y agoWho is this they?
- jrowley 10y agoHere is a bit of survey on the topic from April of 2013: https://psnet.ahrq.gov/perspectives/perspective/140/are-residency-duty-hour-rules-improving-patient-safety https://psnet.ahrq.gov/perspectives/perspective/140/are-resi... Key finding: "In summary, the literature still does not definitively tell us whether limiting duty hours improves patient safety."
- mattkrause 10y agoI would argue that the literature is basically worthless here, because they're mostly looking at modulations around an absolutely ridiculous baseline. The 2003 changes dropped hours DOWN to 80/week and 16 or 28 per shift. As an analogy, imagine reducing your cheeseburger intake from 60 per week to 40 per week: it probably won't have a huge impact on physical fitness. The hand-off issue is also weird because it's at least theoretically improvable, whereas there's no real way (barring go-pills) to reduce sleep-related issues.
- TJSomething 10y agoThat would be Desai, et al. Though I can't access the paper right now, they say that the 2011 regulations have tripled handoffs, increasing handoff risk. It also turned out that the average amount of sleep per week was not increased by much after instituting the regulations. [1] https://www.sciencedaily.com/releases/2013/03/130325183819.htm https://www.sciencedaily.com/releases/2013/03/130325183819.h... [2] Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models on Sleep Duration, Trainee Education, and Continuity of Patient Care Among Internal Medicine House Staff: A Randomized Trial. JAMA Internal Medicine, 2013; DOI: 10.1001/jamainternmed.2013.2973
- prodmerc 10y agoThe medical system will disagree: all doctors should work 30 hours straight with no sleep, else they're not real doctors and slacking off.
- devoply 10y agoYou have people that have gone through the ringer to become doctors. These are the type of people that when you say jump, they ask how high. You can pretty much get them to do anything you want... because they are self-selected to be that sort of people otherwise they could have never become doctors. So when a manager comes to them and tells them they have to work so and so hours, they do it. And they suck it up, because that's who they are.
- squozzer 10y agoEven though I've suggested other motives in play elsewhere, you are probably on to something. Most doctors become doctors either as a childhood dream or to fulfill the expectations of others. Lots of pressure at an early age - and it only intensifies from there. Getting the grades, pre-med maybe, certainly biochem, then med school. Residency is the home stretch to a lifelong commitment, feet don't fail me know, brass ring almost within reach...
- acedinlowball 10y agoThis is not true. A doctor is a person who is extremely motivated by money but was too uncreative to come up with their own path for getting there. They suck it up because its going to allow them to buy their 3rd summer beach house. Not because they are genuinely better people.
- remh 10y agoDamn I feel sorry for you. Although I'm an engineer, I know many many doctors around me (admittedly not many in the US). Most of them (especially the new generation in their mid 30s) are curious, innovative, hard working and do the extra mile for their patients. They work long hours because: they love what they do and don't see themselves doing any other thing and because they care about the outcome of their patients. I agree that not all doctors are like that, but saying that all doctors are what you are describing is false and insulting.
- jseliger 10y agoThe culture of medicine, at least at the physician level, is completely insane; it's so insane that describing its insanity is part of the reason I wrote "Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school" (https://jakeseliger.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school/ https://jakeseliger.com/2012/10/20/why-you-should-become-a-n...). Residents in particular have no power, and even physicians themselves frequently feel they have no choice but to match the death-march pace set by administrators or their most deranged colleagues.
- finid 10y agoBut nurses are no different. We need to start addressing the leading cause of medical accidents - physicians/nurses sleep deprivation.
- mv 10y agothey are completely different. Where I work in cali nurses are full time working 3 or 4 twelve hour shifts a week. Overtime optional and highly compensated. medical residents will routinely do back to back 24 hour shifts with no sleep and even the ICU attendings will do a week of every other day 24 hour shifts. The 16 hour rule only applies to interns. Once you reach second year the rule is 80 hours a week averaged over four weeks. This means that 100 hour weeks still do happen.
- shams93 10y agoI was forced to do 100 hours a week for a company that had a sadistic culture of over work, you never get anything done, under those kind of hours unless you're doing stimulant drugs your brain just shuts down. I wonder how many doctors are also drug addicts just to make this kind of work intensity physically possible even?
- pdxandi 10y agoI'm surrounded by doctors and I don't know any that abuse drugs, other than alcohol and maybe weed. I believe they are just so busy and so overworked that they are constantly moving around / doing paperwork. The demands of the job keep them going.
- edblarney 10y agoYou wouldn't want your airline pilot to be sleep deprived so why would you want your doctor to be? Unless you're a field medic in the army or whatever. No thanks.
- AnimalMuppet 10y agoExactly. And it's not just airline pilots. Truck drivers have hours of service rules, too. So do railroad engineers.
- bigger_cheese 10y agoI work in a heavy industry in Australia. There is a 16 hour shift limit - after which you are required to take an 8 hour break before you are able to operate any heavy machinery again. We also have workplace drug and alcohol testing and there are requirements around disclosing any prescription medication you are on. Operating heavy machinery is no joke but then again neither is being a doctor.
- rileyteige 10y agoI'll mention the same thing here that I just did elsewhere in the thread to someone else: While I agree with you, I have to words: Doctor shortage. At least in the US, we need more doctors. Many of the doctors with whom my wife works all see dozens of patients every day, leaving them with mere minutes for each of them as it is. A 2-minute turnaround is very common, especially in the internal medicine / family medicine fields. Too many patients, not enough doctors.
- tspike 10y agoI wonder if part of the reason we have a doctor shortage is because people see the inhumane working conditions and decide not to pursue it as a career.
- rileyteige 10y agoWouldn't blame them!
- dirtyaura 10y agoI wonder why sleep monitoring is not used for pilots and doctors and other people working on mission critical jobs.
- GuiA 10y agoBecause nothing bad enough has happened yet.
- chewymouse 10y agoNo: https://en.wikipedia.org/wiki/Libby_Zion_Law https://en.wikipedia.org/wiki/Libby_Zion_Law
- throwaway2016a 10y agoI know what my code looks like after 30 hours of coding with no sleep (unfortunately)... it's not pretty and takes days to recover from. Thank goodness no one's health depend on my code.
- mpcadosch 10y agoHas anyone tried this service? http://circadienhealth.pagedemo.co/ http://circadienhealth.pagedemo.co/ It seems targeted towards nurses, but could be applicable to physicians as well.
- ceejayoz 10y agoMisspelling circadian isn't a great sign. The ICU my wife worked in resisted carrying emergency buttons around on privacy grounds because they included location tracking. One that tracks physiological data and presumably analyzes sleep outside of work would've probably had them striking.
- bb611 10y agoIt's an intentional mispelling, that's their brand name
- finid 10y ago30-hours of non-stop work is almost 4 days of work, assuming 8 hours per day. Next time you read that a surgeon left one of his/her tools inside a patient, now you know why.
- venomsnake 10y agoI would probably trust the worst student in a medical class when sober and well rested more than the even the best doctor after being awake for 30 hours. Mistakes will be made and people will die. After mission critical all nighter you also need 2 days at least to be able to recuperate.
- parenteral 10y agoI'm a doctor and I dispute this. I'm not advocating for long work hours or saying that it's healthy/OK. But the "worst students" in my assessment are people that I wouldn't trust to care for my loved ones at all and I would definitely take my weary-eyed trusted colleagues over the former any day. It's a very long discussion, but there are some really bad doctors out there who get by because most mistakes don't cause obvious harm. Also, the body that oversees residency programs is going to relax duty-hours restrictions since they've studied it now and there's no difference in outcomes or resident satisfaction when they eliminate the 80-hour restriction.
- trome 10y agoWorking over 80 hours in a 7 day period is just insane in and of itself, unless there is a major crisis you shouldn't be working more than 40hrs a week. People fought and died for an 8 hour workday, and here the AMA and hospitals are shitting all over it, putting everyone involved at risk. Should we bring back child labor while we're at it?
- zeroer 10y agoThere are basically no children with enough experience to be doctors.
- acedinlowball 10y agoDoctors should only have to work like 5 hours a day but should still get paid large amounts of money. It's important that the people responsible for our health are well rested and well-rewarded.
- pmoriarty 10y agoDo doctors and nurses get paid by the hour? If not, they should be, with double or even triple pay for overtime. That would get penny pinching administrators to stop overworking their medical staff.
- Tobani 10y agoNurses, quite frequently yes. Physician reimbursement can be incredibly complicated depending on type of work.
- rileyteige 10y agoEspecially in the US with the Affordable Care Act.
- bb611 10y agoWhat did ACA change about reimbursement?
- rileyteige 10y agoMost of the changes pertain to Medicare/Medicaid. I haven't looked into it in several years, but this covers it in a nutshell as far as Medicare is concerned: https://www.medicare.gov/hospitalcompare/linking-quality-to-payment.html https://www.medicare.gov/hospitalcompare/linking-quality-to-... Pay-For-Performance is the key term there. And while it is certainly the more patient-friendly approach, the problem as I recall is that a lot of patients re-admit for issues that are their own fault due to them not following through on the prescribed treatment. The care provider, however, is the one that doesn't get paid, regardless of why the patient re-admitted.
- themantalope 10y agoYep, a big issue is the metrics that are used to determine performance. I'm at an upper tier medical school and the doctors here talk (complain) about this all the time. Not only are many within 30-day readmissions due to factors outside the control of the hospital, it also disincentivizes institutions to take on difficult and complicated cases. If you look at the top performing hospitals, many of them are obscure hospitals or ones that only offer expensive surgical care that most doctors would __never__ go to themselves or recommend to their friends/family: http://www.usnews.com/news/articles/2015/04/17/only-251-hospitals-score-five-stars-in-medicares-new-ratings http://www.usnews.com/news/articles/2015/04/17/only-251-hosp... I know the article is a bit old now, but if I recall correctly the rankings haven't changed much since the metrics are still calculated in the same way.
- deleted 10y ago[deleted]
- Rylinks 10y agoThis is only one side of the tradeoff. Both tiredness and shift hand-offs cause bad judgement, and both can kill people. An analysis that only looks at one is incomplete.
- pavel_lishin 10y agoDoesn't this level of overwork originate with one medical instructor, who was a habitual cocaine user and thought nothing of going without sleep? I remember reading this somewhere, but can't remember where.
- themantalope 10y agoI'm a medical student. According to legend, yes, William Osler (one of the founding physicians at Johns Hopkins Hospital) used cocaine to increase his energy and focus while working. https://en.wikipedia.org/wiki/William_Osler https://en.wikipedia.org/wiki/William_Osler
- deleted 10y ago[deleted]
- tnecniv 10y agoCocaine abuse was rampant around the turn of the 20th century, since it was used as an anesthetic.
- minimuffins 10y agoLearning about new ways that our medical industry is totally dysfunctional is baffling and infuriating. It seems to be an inexhaustible well of misery for workers and patients alike. These conditions are like something out of a 19th century factory town. One more way the US healthcare system is a ridiculous anachronism. My first questions are 1) Is sleep deprivation and the generally toxic work culture for doctors and healthcare workers a uniquely American thing? Like does a doctor in Denmark or the UK or Mexico have such a brutal work regime? 2) What's the solution to this? I'm inclined to think healthcare workers have to organize themselves to oppose it and demand new policies because who else will? It seems no one in hospital administrations, regulatory bodies or government has any incentive to push for change here, in fact they're doing the opposite by expanding allowed hours worked.
- user5994461 10y ago1) It seems pretty bad in France too, judging from the few friends I have in medicine. 2) Like everywhere else. Do your hours and leave. If the business fails, too bad for it.
- trowawee 10y agoThe problem is that doctors are never going to organize against this, because A) most have been thoroughly inculcated in a culture that worships that kind of work ethic and B) the limited number of physicians is the reason they make absurd amounts of money. The median ER doc in SF makes $328,047[1], and ER's a relatively low-paying specialty. The solution is regulation with teeth, similar to the rules governing pilots. [1]: http://www1.salary.com/CA/San-Francisco/ER-Doctor-Salary.html http://www1.salary.com/CA/San-Francisco/ER-Doctor-Salary.htm...
- arikrak 10y agoI wonder what would happen if instead of adding more regulations, they took away some of the power that medical schools have in restricting people from practicing medicine. E.g. nurse practitioners and physician assistants sound like a step in the right direction.
- chirau 10y agoGenerally, no one should work 30 hours straight with no sleep. No?
- finid 10y agoThe interesting part of this is that truck drivers are heavily regulated, as they should. They are forced to take breaks after driving a certain number of hours. Not sure exactly, but I think it's about 8 hours. The same treatment for doctors won't be a bad idea.
- maxerickson 10y agoIt's 11 out of 14 hours, then a 10 hour break. https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Drivers%20Guide%20to%20HOS%202015_508.pdf https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Dri... There's some additional rules about how many hours can accumulate over a certain period of days (the period is rolling, it doesn't reset).
- rileyteige 10y agoWhile I agree with you, I have two words: Doctor shortage.
- Mz 10y agoYes, and preventing health problems by preventing medical errors would go a long way towards easing up the demand for medical care.
- finid 10y agoIf that ever becomes a direct result of regulating doctors in that way, then I don't see why we can't solve that problem the same way we solved the shortage of nurses decades ago. In this case instead of importing filipino nurses, we'll just import doctors from wherever. Who know, India or China might have a surplus of doctors too. Or maybe that's the kind of problem that telemedicine will solve.
- seanwilson 10y agoNobody should work 30 hours straight without sleep whether you're a doctor or not.
- matryoshka4811 10y agoIt's hard to comprehend how many hours a doctor can keep going unless you see them everyday. My mother is an OBGYN. I remember growing up surrounded by MCAT and medical school books and the residency nights when she wasn't home when I went to sleep and when I woke up. I don't really remember when the doctor lifestyle wasn't a dominant part of how my immediately family functioned. (She had both of my siblings during her residency.) And now, after she's been in practice for almost two decades, it really isn't much different. She's the head OB at a hospital/clinic that is the only one for several counties. She gets multiple cases a year when women show up in labor that she's never seen before. She's had to report multiple births to child services because the mother is an addict. On a personal level, it means that she never makes it to both Thanksgiving and Christmas, sometimes neither, and she's on call pretty much all the time. All of this to say that she's inspiring really. I've never known someone who works harder or more tirelessly. I worry though that she'll work herself to death. Even then, I know she won't regret any of it.
- diimdeep 10y agoIn the US alone, the Association of American Medical Colleges (AAMC) estimates a shortage of 91,500 physicians by 2020 and up to 130,600 by the year 2025. https://en.wikipedia.org/wiki/Physician_supply#Global_View https://en.wikipedia.org/wiki/Physician_supply#Global_View
- tjic 10y agoNote that the AMA, run by doctors, is required by US law to give their approval before a new medical school may open, or an existing medical school can expand its program. The doctors who would see their salaries fall if supply increased have complete control over supply. This is complete regulatory capture, and it's terrible.
- themantalope 10y agoWhile this is true, the real bottleneck is the availability of training positions. Other commenters have pointed out that these positions are generally increasing in number, but not nearly at a rate large enough to make up for the shortfall. One positive argument to having a body like the AMA leverage some control over medical schools is that it helps to ensure that schools only open/expand if the AMA thinks that their students will have reasonably good chances of getting residency positions. It helps to avoid the sort of situation that is currently going on in law school and PhD programs where there are no where near enough positions available for all the students who are graduating from those programs. And I do generally agree with you that there are some significant regulatory problems regarding training and residency positions, especially since residents have basically zero leverage at all.
- mattkrause 10y agoIt's confusing to me that there are not more programs that "convert" biomedical PhDs/postdocs into MDs. The PhDs and postdocs have some relevant background and are clearly fairly clever and motivated. However, I looked into this after grad school and other than a new program at Columbia, there's not much. In fact, one person told me that since it was more than 5(?) years after I took intro bio, I would need to retake those classes--despite doing bio research for the entire intervening time. It's baffling that a PhD would quality one to teach a class to medical students, but not attend it.
- wenbert 10y agoJesus. 30 hours straight. I know I wouldn't work 30 hours straight in IT - I think everybody is bound to make expensive mistakes when they're tired. And how much more for doctors? When what's at risk isn't just money but someone else's life.
- noskillz 10y agoMy wife was a surgery resident when we had our first child. It was tough with her working 30 hour on-call shifts. Plus the normal 80+ hour (sometimes it would be as much as 130) work weeks. She eventually decided that instead of killing herself for a job she would stop being a doctor and focus on the kids. This worked out for us but it took some guts to call it quits after 10 years of training to get where she was at. We have a ton of debt because of it as well. Besides the tough work schedules I find it kind of crazy we require 20-something year olds to choose a speciality and stick with it. Very few people can do this and not have some regrets. On top of the insane work hours they also put up with people dying on them and delivering the bad news to family members (at least for surgeons this happens a decent amount).
- KVFinn 10y agoUsually this discussion is around residents' performing worse while deprived. A big problem no doubt. But I wonder why people don't bring up another aspect: sleep is essential for actually retaining and making any learning from practice permanent. Anyone who has trained or studied anything knows this well and it's clear in the literature. How can we expect these doctors in training to be actually learning and improving if they are so often sleep deprived?
- intrasight 10y agoNo Doctor Should Work 30 Hours Straight with No Sleep - unless it is some major emergency. Never say never
- snowwrestler 10y agoA friend of mine is a PA who works in emergency medicine, which means he pulls 30 hour shifts sometimes. I challenged him about how, with what we now know about sleep deprivation, he could defend that schedule. He pointed out that much of medicine, especially emergency medicine, requires deep complex analysis of a wide variety of symptoms, some of which might seem unimportant or unrelated at first. We've all seen shows like House where it takes a genius to diagnose the root cause of a set of weird symptoms. While that is obviously exaggerated, the reality is that diagnosis is often difficult and in an ER, happens continuously with treatment. He said there is no way that a doctor or PA can fully hand that mental flow state off to another one. So the scariest thing to him is handoff--what if he forgets to document or mention some seemingly minor detail that ends up being crucial?? Long shifts give medical personnel more continuous time with each patient, reducing the chance that handoff will come too early in treatment, when mistakes or misses have a greater impact. It also permits long periods of overlap between shifts. "Being sleep deprived is bad for care," he admitted, "but so are handoffs." He feels that as long as the total time per week does not exceed too many hours, long shifts are good for care.
- michaelmachine 10y agoYeah there is lots of literature on this issue and some ongoing studies trying to determine how to reduce medical error during the hand-off. For example: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015016108 http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD...
- amorphid 10y agoThat's a really interesting point. I wonder if it'd be practical to address the handoff problem with rolling start times. So if average ER patient takes 3 hours to treat from start to finish, for an 8 hour shift, you stop taking new patients at the 5 or 6 hour mark. That being said, if an ER doc is in the "graceful shutdown" part of their shift, and a spike in patients rolls in the door, it'd be hard to say no to helping out.
- mjevans 10y agoI had similar thoughts, except with 4s. For the first 4 hours they take patients (and shadow some of the persisting cases from other doctors). For the next 4 hours, they're purely cleanup/handoff... EXCEPT in the case that a major crisis happens. Things extend 4 hours at a time in that case. This would, however, mean staggering the doctors in 6 different shifts that could each handle the ingress load for their ramp up period. Naturally doctors that are 'morning' or 'evening' people should be binned in to shifts compatible with their biological schedules.
- tn13 10y agoAs a rule of thumb I would not recommend anyone working that long without sleep. A truck driver with lack of sleep can kill more people than a driver. Even a coder returning home driving might kill someone if he has not slept in 30 hours straight. For doctor unless he is doign surgeries chances of his mistake resulting into death might be lower.
- walrus01 10y agoI barely trust myself to do anything with 'sudo' on a production system after 24 hours without sleep, 30 hours without sleep and making life or death medical decisions is scary as shit.
- travisty 10y agoThanks for posting this...I think up until this article was posted, everyone on earth assumed it was perfectly fine for Doctors to work 30 hours straight. Thank god you posted this.
- ghufran_syed 10y agoShould any parent be "allowed" to care for a newborn baby for 30 hours straight witg no sleep? Perhaps we should ensure that parents do not care for their children for more than 8 hours in a row, to ensure an appropriate quality of care.... :)