3 ms·

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 w

by 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
    This is what we do in 24/7 network operations centers - so issues can be cleanly handed off between shifts. However I don't think the additional staffing costs will fly, you're talking a hugely substantial increase if you were to enforce this - more than 25%, since current staffing levels are so thin.
    - pfranz 10y ago
      (not sure who would fix this) but that still sounds like a problem with the cost structure. In other businesses, after 8 hours you get paid 1.5x, after 12 hours 2x. If those were the incentives here, it'd be cheaper to overlap and pay two salaries (I'm ignoring benefits here). It's a balance of what people are willing to pay, the risk we're willing to accept, how ethically we treat workers (doctors). Unfortunately, like many places in the economy, there aren't rational actors on each side to negotiate these things.
- colmvp 10y ago
  I recognize my naïveté, but surely a more humane method of dealing with this is trying to increase information exchange at handover rather than depriving humans of valuable sleep. There are studies that show partial sleep deprivation can affect cognitive performance, and specific studies that show sleep deprivation on doctors can affect their own performance.
- u801e 10y ago
  Perhaps some work should be put into the hand-off procedure. I've heard things like checklists suggested in the past. Perhaps having a checklist to go through when handing off the patient with, say, congestive heart failure to another physician. They could be developed for the most common conditions that residents and their attendings deal with.
  - carbocation 10y ago
    This is well trodden material in medicine. "IPASS" is a search term that might help if you're interested to look at what has been tried.
lliw 10y ago
Though not exactly as you described, something similar was done and published in 2016 (largely leading to this change, since there was not an increase in mortality risk) http://www.nejm.org/doi/full/10.1056/NEJMoa1515724 http://www.nejm.org/doi/full/10.1056/NEJMoa1515724 One of the main challenges of course in this area is looking at patient outcomes with an incredible amount of potentially confounding variables, since "resident work hours" is just one of the many things that influence patient outcomes at a hospital.
- ggrothendieck 10y ago
  There is also the iCompare trial which is underway and to be completed in 2019.
- mattkrause 10y ago
  The other challenge is that this study is comparing 28 hr shifts with >28 shifts. This is probably the best that can be done without totally reworking the hospital, but it's not exactly a sensible test: data from lab experiments shows performance cratering well before that.
mattkrause 10y ago
These studies have been done, but they're basically worthless: they look at relatively small modulations around an insane baseline, like switching between 24, 28, and 30 hours on. The major issue (other than $$$) is thought to be hand-offs: information gets lost when one caregiver takes over for another. For example, you might notice that Mrs. Jones looks just a little bit paler than she did earlier, and take that into account when treating her, even subconsciously. This gets lost when a new doctor takes over, and allegedly, the increase in hand-off-related issues is not outweighed by the decrease in sleep-related ones. That said, I'm also not convinced that this has been aggressively optimised, or even tested over long-enough durations that people adapt to increased hand-off frequencies.

by mabbo 10y ago

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
  This is what we do in 24/7 network operations centers - so issues can be cleanly handed off between shifts. However I don't think the additional staffing costs will fly, you're talking a hugely substantial increase if you were to enforce this - more than 25%, since current staffing levels are so thin.
  - pfranz 10y ago
    (not sure who would fix this) but that still sounds like a problem with the cost structure. In other businesses, after 8 hours you get paid 1.5x, after 12 hours 2x. If those were the incentives here, it'd be cheaper to overlap and pay two salaries (I'm ignoring benefits here). It's a balance of what people are willing to pay, the risk we're willing to accept, how ethically we treat workers (doctors). Unfortunately, like many places in the economy, there aren't rational actors on each side to negotiate these things.
colmvp 10y ago
I recognize my naïveté, but surely a more humane method of dealing with this is trying to increase information exchange at handover rather than depriving humans of valuable sleep. There are studies that show partial sleep deprivation can affect cognitive performance, and specific studies that show sleep deprivation on doctors can affect their own performance.
u801e 10y ago
Perhaps some work should be put into the hand-off procedure. I've heard things like checklists suggested in the past. Perhaps having a checklist to go through when handing off the patient with, say, congestive heart failure to another physician. They could be developed for the most common conditions that residents and their attendings deal with.
- carbocation 10y ago
  This is well trodden material in medicine. "IPASS" is a search term that might help if you're interested to look at what has been tried.

lliw 10y ago

Though not exactly as you described, something similar was done and published in 2016 (largely leading to this change, since there was not an increase in mortality risk) http://www.nejm.org/doi/full/10.1056/NEJMoa1515724 http://www.nejm.org/doi/full/10.1056/NEJMoa1515724 One of the main challenges of course in this area is looking at patient outcomes with an incredible amount of potentially confounding variables, since "resident work hours" is just one of the many things that influence patient outcomes at a hospital.

ggrothendieck 10y ago
There is also the iCompare trial which is underway and to be completed in 2019.
mattkrause 10y ago
The other challenge is that this study is comparing 28 hr shifts with >28 shifts. This is probably the best that can be done without totally reworking the hospital, but it's not exactly a sensible test: data from lab experiments shows performance cratering well before that.

mattkrause 10y ago

These studies have been done, but they're basically worthless: they look at relatively small modulations around an insane baseline, like switching between 24, 28, and 30 hours on. The major issue (other than $$$) is thought to be hand-offs: information gets lost when one caregiver takes over for another. For example, you might notice that Mrs. Jones looks just a little bit paler than she did earlier, and take that into account when treating her, even subconsciously. This gets lost when a new doctor takes over, and allegedly, the increase in hand-off-related issues is not outweighed by the decrease in sleep-related ones. That said, I'm also not convinced that this has been aggressively optimised, or even tested over long-enough durations that people adapt to increased hand-off frequencies.