5 ms·

First-year doctors will be allowed to work 24-hour shifts starting in July

39 points by finid 10y ago

pmarreck 10y ago
Cruel and unusual punishment? Sleep deprivation has some pretty serious negative side effects
- walshemj 10y ago
  And will lead to mistakes with fatal consequences
  - deleted 10y ago
    [deleted]
  - pmarreck 10y ago
    "First, do no harm... but fuck your sleep, that can't possibly harm you or anyone you work on, duh"
- Arizhel 10y ago
  What's really bad is that the American medical establishment, including these doctors, seem to be defending this practice. It'd be really interesting to see a good study comparing the rate of medical errors and resultant patient deaths/injuries in hospitals in the US and in other industrialized nations, and to also compare the hours worked between them. Another thing that came up in the article is the problem of hand-over between doctors and medical teams, and that having ridiculously-long hours seems to be a patch to avoid all the problems that come from that. That sounds like an organizational and procedural problem: doctors and nurses aren't properly writing things down, or if they are, they're not writing them in a legible way. I had a recent experience where I had to accompany a friend on an ER trip. Different doctors and nurses kept asking her, over and over throughout the lengthy visit, what she was there for, and to describe the symptoms. It was eerie; there seemed to be absolutely no information recording and usage by these people, it was like everything was all-new every time some new person came on the scene. It was also really strange how they kept telling her totally different and contradictory things: one nurse says she's not allowed to have any food or water (despite being parched), another nurse says this is wrong, etc. (She ended up drinking water out of the bathroom sink because she was so thirsty, and was there for a possible cardiac problem so electrolyte depletion certainly can't help.) American ERs seem to be very scary, incompetently-run places.
  - JshWright 10y ago
    As a paramedic, I understand your frustration with answering the same questions repeatedly. There is absolutely information being recorded and tracked, and it's very likely the provider walking into the room has already read the notes written by those who were there earlier. However, much like debugging a technical problem, a systemic approach is necessary for patient assessment. Everyone has their process which they have developed over the years... The pattern and flow to their questions, the order in which they assess various body systems, etc. Jumping around in that process to cover the handful of questions they couldn't find the answers to in earlier reports is a recipe for skipping something. I'm not saying there isn't room for improvement here. My wife recently spent two months in the hospital, and there were several times where we had to 'educate' a provider about what the plan was (i.e. we would discuss something with the attending, but they didn't chart it well, so the senior resident wasn't up to speed on the changes, etc...)., however, when it comes to those assessment questions being asked repeatedly, there is a method to that particular madness.
  - pmarreck 10y ago
    > is that the American medical establishment, including these doctors, seem to be defending this practice. Yeah, and hazing is a pattern passed down from generation to generation, like childhood beatings /onlypartialsarcasm
mabbo 10y ago
Someone ought to do a study on what the effects truly are. Take a group of hospitals, randomly assign them to "continue insane hours for residents", "40-hour work-weeks and no more than 12-hour shifts" and maybe a third group somewhere in between. Run it for two years, and see what the effect on patients and doctors actually is. Then will come the hard questions: if we see that these insane hours are literally killing patients, surely then it will make sense to end this madness?
- bryanlarsen 10y ago
  Those studies have been done and the results were counter-intuitive. Yes, long shifts kill patients. But the other thing that kills patients are handovers -- one doctor forgetting to note or tell another doctor a crucial detail at shift change. Longer shifts mean fewer shift changes.
  - robrenaud 10y ago
    Presumably the magnitude of both effects could be measured against each other?
  - abakker 10y ago
    Couldn't we just have longer shift-change overlaps? I.e. double staff for 3 hours during handoff and have multiple overlapping 12 hour shifts / day?
    - lettergram 10y ago
      That would cost 25% more to the hospital, no way.
      - pfranz 10y ago
        In other jobs you get paid double-time after 12 hours. If the cost structures were right it would still be cheaper.
    - phil21 10y ago
SideburnsOfDoom 10y ago
The phrase "allowed to" would imply that this is optional, that it is something that they want. Is that really so?
- flat6turbo 10y ago
  sure, just like first year lawyers are "allowed to" work 16 hours a day doing paperwork for the partner that hired them.
- carbocation 10y ago
  The first thing we care about is the patients. Most studies that have looked at longer hours vs more handoffs have shown equipoise in terms of death and serious adverse events. So, in that setting, most of us feel comfortable to think about what we want for ourselves as trainees and educators. From the perspective of a trainee, on the rotations where duty hours even become a question, I was working 60-80 hour weeks. You can achieve that in a number of ways. One way is to work 5-6 days per week of 12-14 hour shifts. This sounds reasonable until you realize, a few months in, that you are at work from 7a-7-9p (assuming you're working daytime shifts) 6 days a week. It's monotonous and exhausting. You can achieve the same by mixing some 24h days into the mix. During my training, this could only happen starting in our second year and beyond. Suddenly, I had several days with ample free time to buy groceries, do laundry, think about the world around me. Medical training is extremely long and time intensive. Partitioning time into 24 hour chunks can surprisingly be preferable when 80 hour weeks are the rule (when safe for patients).
  - droopyEyelids 10y ago
    Did they study the effect of sleep deprivation on the quality of handoffs?
    - JshWright 10y ago
      The FIRST study found that increased scheduling flexibility (including allowing longer shifts) was not worse than forcing shorter shifts (in terms of patient outcomes). http://www.nejm.org/doi/full/10.1056/NEJMoa1515724 http://www.nejm.org/doi/full/10.1056/NEJMoa1515724
sarreph 10y ago
I do not personally understand how healthcare — the fundamental preservation of human life — allows for this kind of risk exposure. Many programmers in the tech community know that half of the listed time (12 hours) of solid work is enough to start to slow your decision-making and reasoning ability. When peoples LIVES are in the hands of junior doctors who are essentially drunk off'f sleep deprivation[0], how can we trust the system to to its job? Why are the incentives continuing to be placed in the wrong areas? When will we remedy this properly? [0] - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1739867/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1739867/
- ianai 10y ago
  As a human, the concept of anyone working 20-24 hours straight...really, anything over 10 hours straight, infuriates me. I'd rather solve problems associated with shift change over than force someone to work like that. Further, life is short. Forcing someone to be so confined for such a period of time is...wrong.
  - ge96 10y ago
    Hopefully automation can help free up time for doctors.
    - pfranz 10y ago
      How would automation help? Is it not a supply/demand issue already (an increase in doctors alleviate things)? Was it worse before we had electronic records and fancy medical equipment? Maybe it's because of cost (and automation will drive that down)? We're willing to pay fewer doctors at the expense overworking and low supply? If so, I don't see that fixing anything. It would keep status quo, but drive down doctor's salaries or the demand of doctors.
      - ge96 10y ago
        I mean how else does automation help in life. I'd think we're far from an AI making the tough life or death decisions but if their potential work load of 24 hours could be decreased with automated systems performing specific tasks. What exactly is automated? I don't know maybe the pre-checks/questionnaires screening patients. I realize a doctor is not the same as a burger flipper/dishwasher so their tasks would be harder to automate. Fancy medical equipment haha. Throw that x-ray imaging away let me just touch your bones and see if it's broken or not. A tumor did you say? We'll I don't see it. It was just a thought of my part I'm not a doctor, or a 'leading analyst's just the usual forum BS on my part.
carbocation 10y ago
This doesn't return things to the pre-duty-hours era. However, it does roll back specific limits that were created for first year residents (interns). When eventually studied, the interpretation that most of us had was that there is not a significant difference in patient care with these shorter hours. This is due to, we think, the tradeoff between a tired doctor who knows your current condition well, and better rested doctors who are handing off responsibility more often.
jgamman 10y ago
love the orwellian way this is spun as to how it is letting doctors do another 4 hours on top of the current pathetic 20. no @%^@%#$ way i'd let myself be diagnosed by someone 23 hours into their shift, let alone do a procedure requiring basic hand eye co-ordination.
- maxerickson 10y ago
  So if you are bleeding profusely you are going to ask? And then refuse stitches if there is no other doctor available?
- JshWright 10y ago
  How many times would you want to be passed off from one "primary" provider to another over the course of 24 hours? Those handoffs are where things falls through the cracks... Allowing doctors to work fewer, longer shifts is correlated with increased happiness for the docs (they end up with actual days off), and no increased risk for patients. http://www.absurgery.org/default.jsp?news_trial0216 http://www.absurgery.org/default.jsp?news_trial0216
jimlawruk 10y ago
Hopefully future AI can help alleviate the healthcare shortages we seem to be facing.
- dominotw 10y ago
  or we can just import foreign doctors like NHS does.
- lettergram 10y ago
  Or they can increase the number of people going through medical schools. The AAMC understands the law(s) of supply and demand and doesn't want too many new medical doctors, then they would get paid less. For reference, the number of students graduating from medical school is dropping: https://www.aamc.org/download/321526/data/factstableb1-2.pdf https://www.aamc.org/download/321526/data/factstableb1-2.pdf
thatoneguy 10y ago
How is this not a form of hazing? "I did it so the young people have to do it, too."
docthrowaway 10y ago
So now they will be "allowed" to work the hours that they already do. I have multiple resident physician friends and family members who routinely work 24+ hour shifts once a week, on top of 14-16 hour shifts daily yet if their time sheet says more than 80 hours/week, they are instructed to correct it.
jason_slack 10y ago
Wow, 24 hours is insane. I work 10 hour, overnight, shifts at an elderly care facility and sometimes I have to pull a double or 1.5 shift due to call-ins. I'm exhausted and I can barely drive home. My work doesn't compare to that of an M.D.
hhw 10y ago
My father is a urologist trained at McGill in its heyday back in the 60's, and they often worked much longer shifts than 24 hours. It was part of the training to be working while sleep deprived. In real life, a doctor often has to take calls in the middle of the night, and it was important for the medical school to either train students to be able to work under such conditions or be failed out if they couldn't hack it. Mind you, they also had other traditions like working with cadavers with their bare hands only, out of respect for the people who had donated their own bodies. Back then, it was expected that 2/3rds of students would end up failing out. Not just from long shifts, but the program was designed to be that challenging so as to weed out many people, to ensure that only the best would succeed. Nowadays, medical schools perceive the dollars spent training a medical student as too great of an investment, and want all their students graduate so failures are uncommon. Now once accepted, a student has pretty much made it even though the acceptance criteria is quite distanced from how they actually perform as a medical doctor. This potentially results in less qualified individuals becoming licensed.
- tanderson92 10y ago
  But this article is about residency programs, not medical schools. That is, tho/e stuck with the new hours have already made it through medical school. Did you read the featured article?
droopyEyelids 10y ago
> said the change will enhance patient safety because there will be fewer handoffs from doctor to doctor. It also said the longer shifts will improve the new doctors’ training by allowing them to follow their patients for more extended periods, especially in the critical hours after admission. We really need the name of the human being who said that. That quote needs to be attributed to an individual who has to take some sort of responsibility for it.
pasbesoin 10y ago
Who is this serving? Because it certainly isn't serving patient health. So, in that case, stop calling it "health care".
gdulli 10y ago
And the only way that can go wrong is immediately.
unabridged 10y ago
Instead of 1 doctor working 75 hrs, how about 5 doctors working 15 hrs? And don't tell me there aren't enough candidates, the average acceptance rate for med schools is about 7%. Also its possible that there are people that would make great doctors but aren't in the top 10% of memorizing biology.
- JshWright 10y ago
  Longer shifts reduce the numbers of times a patient is passed from one provider to another. Reducing those "handoffs" is good for the patient (that tends to be where things fall through the cracks).
  - unabridged 10y ago
    It doesn't have to be 15 hrs, it can be 30 hrs. You can have systems like all patients covered by 3 doctors and only 1 of 3 handoff at a time.
squidbot 10y ago
Does anyone know if doctors on shifts like this are given ample breaks to peruse polyphasic sleep? A 24-28 hour shift with 3-5 hours of polyphasic sleep doesn't seem quite as bad as just staying awake for 24 hours+
caoimhin 10y ago
If I go into hospital I hope I'm not being treated by the doctor on hour 22 of their shift. The problem with handovers is bogus - doctors can't work for weeks at a time so there have to be handovers. Figure that out.
mnm1 10y ago
These residents can't even safely drive home after a 24-hour shift, but they're perfectly fine to practice medicine on others. The "studies" say that, so it must be true, right?
kapauldo 10y ago
The AMA is a cartel that has artificially constrained the supply of doctors to keep incomes high. It is the most successful union in history.

39 points by finid 10y ago

pmarreck 10y ago

Cruel and unusual punishment? Sleep deprivation has some pretty serious negative side effects

walshemj 10y ago
And will lead to mistakes with fatal consequences
- deleted 10y ago
  [deleted]
- pmarreck 10y ago
  "First, do no harm... but fuck your sleep, that can't possibly harm you or anyone you work on, duh"
Arizhel 10y ago
What's really bad is that the American medical establishment, including these doctors, seem to be defending this practice. It'd be really interesting to see a good study comparing the rate of medical errors and resultant patient deaths/injuries in hospitals in the US and in other industrialized nations, and to also compare the hours worked between them. Another thing that came up in the article is the problem of hand-over between doctors and medical teams, and that having ridiculously-long hours seems to be a patch to avoid all the problems that come from that. That sounds like an organizational and procedural problem: doctors and nurses aren't properly writing things down, or if they are, they're not writing them in a legible way. I had a recent experience where I had to accompany a friend on an ER trip. Different doctors and nurses kept asking her, over and over throughout the lengthy visit, what she was there for, and to describe the symptoms. It was eerie; there seemed to be absolutely no information recording and usage by these people, it was like everything was all-new every time some new person came on the scene. It was also really strange how they kept telling her totally different and contradictory things: one nurse says she's not allowed to have any food or water (despite being parched), another nurse says this is wrong, etc. (She ended up drinking water out of the bathroom sink because she was so thirsty, and was there for a possible cardiac problem so electrolyte depletion certainly can't help.) American ERs seem to be very scary, incompetently-run places.
- JshWright 10y ago
  As a paramedic, I understand your frustration with answering the same questions repeatedly. There is absolutely information being recorded and tracked, and it's very likely the provider walking into the room has already read the notes written by those who were there earlier. However, much like debugging a technical problem, a systemic approach is necessary for patient assessment. Everyone has their process which they have developed over the years... The pattern and flow to their questions, the order in which they assess various body systems, etc. Jumping around in that process to cover the handful of questions they couldn't find the answers to in earlier reports is a recipe for skipping something. I'm not saying there isn't room for improvement here. My wife recently spent two months in the hospital, and there were several times where we had to 'educate' a provider about what the plan was (i.e. we would discuss something with the attending, but they didn't chart it well, so the senior resident wasn't up to speed on the changes, etc...)., however, when it comes to those assessment questions being asked repeatedly, there is a method to that particular madness.
- pmarreck 10y ago
  > is that the American medical establishment, including these doctors, seem to be defending this practice. Yeah, and hazing is a pattern passed down from generation to generation, like childhood beatings /onlypartialsarcasm

mabbo 10y ago

Someone ought to do a study on what the effects truly are. Take a group of hospitals, randomly assign them to "continue insane hours for residents", "40-hour work-weeks and no more than 12-hour shifts" and maybe a third group somewhere in between. Run it for two years, and see what the effect on patients and doctors actually is. Then will come the hard questions: if we see that these insane hours are literally killing patients, surely then it will make sense to end this madness?

bryanlarsen 10y ago
Those studies have been done and the results were counter-intuitive. Yes, long shifts kill patients. But the other thing that kills patients are handovers -- one doctor forgetting to note or tell another doctor a crucial detail at shift change. Longer shifts mean fewer shift changes.
- robrenaud 10y ago
  Presumably the magnitude of both effects could be measured against each other?
- abakker 10y ago
  Couldn't we just have longer shift-change overlaps? I.e. double staff for 3 hours during handoff and have multiple overlapping 12 hour shifts / day?
  - lettergram 10y ago
    That would cost 25% more to the hospital, no way.
    - pfranz 10y ago
      In other jobs you get paid double-time after 12 hours. If the cost structures were right it would still be cheaper.
  - phil21 10y ago

SideburnsOfDoom 10y ago

The phrase "allowed to" would imply that this is optional, that it is something that they want. Is that really so?

flat6turbo 10y ago
sure, just like first year lawyers are "allowed to" work 16 hours a day doing paperwork for the partner that hired them.
carbocation 10y ago
The first thing we care about is the patients. Most studies that have looked at longer hours vs more handoffs have shown equipoise in terms of death and serious adverse events. So, in that setting, most of us feel comfortable to think about what we want for ourselves as trainees and educators. From the perspective of a trainee, on the rotations where duty hours even become a question, I was working 60-80 hour weeks. You can achieve that in a number of ways. One way is to work 5-6 days per week of 12-14 hour shifts. This sounds reasonable until you realize, a few months in, that you are at work from 7a-7-9p (assuming you're working daytime shifts) 6 days a week. It's monotonous and exhausting. You can achieve the same by mixing some 24h days into the mix. During my training, this could only happen starting in our second year and beyond. Suddenly, I had several days with ample free time to buy groceries, do laundry, think about the world around me. Medical training is extremely long and time intensive. Partitioning time into 24 hour chunks can surprisingly be preferable when 80 hour weeks are the rule (when safe for patients).
- droopyEyelids 10y ago
  Did they study the effect of sleep deprivation on the quality of handoffs?
  - JshWright 10y ago
    The FIRST study found that increased scheduling flexibility (including allowing longer shifts) was not worse than forcing shorter shifts (in terms of patient outcomes). http://www.nejm.org/doi/full/10.1056/NEJMoa1515724 http://www.nejm.org/doi/full/10.1056/NEJMoa1515724

sarreph 10y ago

I do not personally understand how healthcare — the fundamental preservation of human life — allows for this kind of risk exposure. Many programmers in the tech community know that half of the listed time (12 hours) of solid work is enough to start to slow your decision-making and reasoning ability. When peoples LIVES are in the hands of junior doctors who are essentially drunk off'f sleep deprivation[0], how can we trust the system to to its job? Why are the incentives continuing to be placed in the wrong areas? When will we remedy this properly? [0] - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1739867/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1739867/

ianai 10y ago
As a human, the concept of anyone working 20-24 hours straight...really, anything over 10 hours straight, infuriates me. I'd rather solve problems associated with shift change over than force someone to work like that. Further, life is short. Forcing someone to be so confined for such a period of time is...wrong.
- ge96 10y ago
  Hopefully automation can help free up time for doctors.
  - pfranz 10y ago
    How would automation help? Is it not a supply/demand issue already (an increase in doctors alleviate things)? Was it worse before we had electronic records and fancy medical equipment? Maybe it's because of cost (and automation will drive that down)? We're willing to pay fewer doctors at the expense overworking and low supply? If so, I don't see that fixing anything. It would keep status quo, but drive down doctor's salaries or the demand of doctors.
    - ge96 10y ago
      I mean how else does automation help in life. I'd think we're far from an AI making the tough life or death decisions but if their potential work load of 24 hours could be decreased with automated systems performing specific tasks. What exactly is automated? I don't know maybe the pre-checks/questionnaires screening patients. I realize a doctor is not the same as a burger flipper/dishwasher so their tasks would be harder to automate. Fancy medical equipment haha. Throw that x-ray imaging away let me just touch your bones and see if it's broken or not. A tumor did you say? We'll I don't see it. It was just a thought of my part I'm not a doctor, or a 'leading analyst's just the usual forum BS on my part.

carbocation 10y ago

This doesn't return things to the pre-duty-hours era. However, it does roll back specific limits that were created for first year residents (interns). When eventually studied, the interpretation that most of us had was that there is not a significant difference in patient care with these shorter hours. This is due to, we think, the tradeoff between a tired doctor who knows your current condition well, and better rested doctors who are handing off responsibility more often.

jgamman 10y ago

love the orwellian way this is spun as to how it is letting doctors do another 4 hours on top of the current pathetic 20. no @%^@%#$ way i'd let myself be diagnosed by someone 23 hours into their shift, let alone do a procedure requiring basic hand eye co-ordination.

maxerickson 10y ago
So if you are bleeding profusely you are going to ask? And then refuse stitches if there is no other doctor available?
JshWright 10y ago
How many times would you want to be passed off from one "primary" provider to another over the course of 24 hours? Those handoffs are where things falls through the cracks... Allowing doctors to work fewer, longer shifts is correlated with increased happiness for the docs (they end up with actual days off), and no increased risk for patients. http://www.absurgery.org/default.jsp?news_trial0216 http://www.absurgery.org/default.jsp?news_trial0216

jimlawruk 10y ago

Hopefully future AI can help alleviate the healthcare shortages we seem to be facing.

dominotw 10y ago
or we can just import foreign doctors like NHS does.
lettergram 10y ago
Or they can increase the number of people going through medical schools. The AAMC understands the law(s) of supply and demand and doesn't want too many new medical doctors, then they would get paid less. For reference, the number of students graduating from medical school is dropping: https://www.aamc.org/download/321526/data/factstableb1-2.pdf https://www.aamc.org/download/321526/data/factstableb1-2.pdf

thatoneguy 10y ago

How is this not a form of hazing? "I did it so the young people have to do it, too."

docthrowaway 10y ago

So now they will be "allowed" to work the hours that they already do. I have multiple resident physician friends and family members who routinely work 24+ hour shifts once a week, on top of 14-16 hour shifts daily yet if their time sheet says more than 80 hours/week, they are instructed to correct it.

jason_slack 10y ago

Wow, 24 hours is insane. I work 10 hour, overnight, shifts at an elderly care facility and sometimes I have to pull a double or 1.5 shift due to call-ins. I'm exhausted and I can barely drive home. My work doesn't compare to that of an M.D.

hhw 10y ago

My father is a urologist trained at McGill in its heyday back in the 60's, and they often worked much longer shifts than 24 hours. It was part of the training to be working while sleep deprived. In real life, a doctor often has to take calls in the middle of the night, and it was important for the medical school to either train students to be able to work under such conditions or be failed out if they couldn't hack it. Mind you, they also had other traditions like working with cadavers with their bare hands only, out of respect for the people who had donated their own bodies. Back then, it was expected that 2/3rds of students would end up failing out. Not just from long shifts, but the program was designed to be that challenging so as to weed out many people, to ensure that only the best would succeed. Nowadays, medical schools perceive the dollars spent training a medical student as too great of an investment, and want all their students graduate so failures are uncommon. Now once accepted, a student has pretty much made it even though the acceptance criteria is quite distanced from how they actually perform as a medical doctor. This potentially results in less qualified individuals becoming licensed.

tanderson92 10y ago
But this article is about residency programs, not medical schools. That is, tho/e stuck with the new hours have already made it through medical school. Did you read the featured article?

droopyEyelids 10y ago

> said the change will enhance patient safety because there will be fewer handoffs from doctor to doctor. It also said the longer shifts will improve the new doctors’ training by allowing them to follow their patients for more extended periods, especially in the critical hours after admission. We really need the name of the human being who said that. That quote needs to be attributed to an individual who has to take some sort of responsibility for it.

pasbesoin 10y ago

Who is this serving? Because it certainly isn't serving patient health. So, in that case, stop calling it "health care".

gdulli 10y ago

And the only way that can go wrong is immediately.

unabridged 10y ago

Instead of 1 doctor working 75 hrs, how about 5 doctors working 15 hrs? And don't tell me there aren't enough candidates, the average acceptance rate for med schools is about 7%. Also its possible that there are people that would make great doctors but aren't in the top 10% of memorizing biology.

JshWright 10y ago
Longer shifts reduce the numbers of times a patient is passed from one provider to another. Reducing those "handoffs" is good for the patient (that tends to be where things fall through the cracks).
- unabridged 10y ago
  It doesn't have to be 15 hrs, it can be 30 hrs. You can have systems like all patients covered by 3 doctors and only 1 of 3 handoff at a time.

squidbot 10y ago

Does anyone know if doctors on shifts like this are given ample breaks to peruse polyphasic sleep? A 24-28 hour shift with 3-5 hours of polyphasic sleep doesn't seem quite as bad as just staying awake for 24 hours+

caoimhin 10y ago

If I go into hospital I hope I'm not being treated by the doctor on hour 22 of their shift. The problem with handovers is bogus - doctors can't work for weeks at a time so there have to be handovers. Figure that out.

mnm1 10y ago

These residents can't even safely drive home after a 24-hour shift, but they're perfectly fine to practice medicine on others. The "studies" say that, so it must be true, right?

kapauldo 10y ago

The AMA is a cartel that has artificially constrained the supply of doctors to keep incomes high. It is the most successful union in history.