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Having been through residency myself, I'm actually in favor of this change back to 24 hrs. As background, when I was an intern, the "16 hr rule" was not in plac

Having been through residency myself, I'm actually in favor of this change back to 24 hrs. As background, when I was an intern, the "16 hr rule" was not in place, but I did have to manage interns as a senior resident with the rule in place. Four points that I'd make on this subject. The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts. In fact, in many cases the doc would have more of a chance to get a nap in on the 24 hr shift than the 16 hr. Basically, I'm suggesting (with zero evidence except my own experience), that I'm not sure there's a significant difference between 16 and 24 hr shifts' effects on a doc's ability to function well--both can be fine under the right circumstances and both can be equally terrible. Also related to this is the fact that nurses, doctors, respiratory therapists work as a team in hospitals ... most critical decisions are checked on a number of levels. Secondly, do not underestimate the danger of hand-offs. This is the main reason that I'm in favor of this change. Any time there is major information exchange in a hospital environment, there is increased room for error due to misunderstandings, forgotten information, etc. There have been many efforts to standardize information exchanges and they have become better in many circumstances. But I'll tell you that, in my experience, more hand-offs increased the risk of errors in patients and if I were in the hospital on a medical floor, I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift. The third point is about how healthcare functions in the country, specifically around large hospitals. Residents and fellows get their training in these places, but hospitals also rely on these trainees to staff their enormous floors. If we were to change the shifts, let's say to a maximum of 12 hrs each, we would likely need significantly more residents in the system overall. Not only does that volume need to come from increased sizes in medical school classes, but the hospital systems would need to be paying the salaries of these trainees. Hospitals with trainees receive some amount of this salary money from the federal government, and some comes directly from the hospital bottom line. Either way, the total cost burden to the system increases, meaning that we will all be paying more in an already overpriced system. The fourth point is that these work hours rules truly impact the training of residents. There are surgeons graduating after 5 years of ENT training who have not had enough experience to become attendings at the places where they are interviewing. I have spoken with a number of senior attendings about this issue and they all say that they are more and more concerned about whether the trainees coming through these programs are getting enough training. So the option to deal with that would probably be to add on another year of training to fields where competency is not being reached, again increasing the cost to the system and to the overall financial picture of the trainees (many are barely making the equivalent of minimum wage during training and need to start paying on a quarter million USD worth of debt). Basically, I'm not disputing your concerns, just pointing out that our system will likely cost much more if we move the other direction with hrs rules. I also would not jump to the conclusion that 24hrs is truly worse than 16hrs for patient outcomes. Both are terrible, and maybe not significantly different.

unprepare 10y ago
Could the reason handoffs are so bad be because the person doing the handoff has been working for 16-24 hours straight? I mean in IT i see first hand the notes left by people on pager duty in the middle of the night, and they differ significantly from the same peoples notes after a restful night of sleep. Has there been any controlling in these studies i see mentioned through this entire thread for sleep deprivation present in people performing the handoffs? If they arent controlling for the amount of rest the people in the handoffs have had in the last 24 hours, im not sure i am willing to put much weight in these studies. >I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift. But if you came into the ER at 3am and the doctor you get has been working 23 hours, youre still going to need ot be handed off, and now youve received sleep deprivated care in the interim while waiting for a fresh doctor. Sure, for the guy who arrived just as a fresh doctor arrived, it might be beneficial to have them there for 24 hours, but how many new patients are they seeing in hours 12-24?
LazaroPearson 10y ago
> Having been through residency myself Throwaway because it was so disheartening to read this perspective. > The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts. This is very location, hospital, and speciality specific. Most surgical residents would say the opposite. > Secondly, do not underestimate the danger of hand-offs Hey, why don't we work on better handoffs. Other fields (even with-in medicine) seem to manage. Maybe we should mine the airlines industry again for good ideas. The dichotomy of 16 vs 24 hours to me is a false choice. > There are surgeons graduating after 5 years of ENT training... who have not had enough experience to become attendings at the places where they are interviewing. For what it's worth, surgical sub-specialists like ENTs will do at least 2-3 times as many hours in training as a family medicine doc or pediatrician. Make the training an extra year and pay a better god damn salary if they really aren't trained well enough. Right now the system is designed around cramming as much pain and suffering as a human can withstand in their training to get the most value for the hospital. There's a reason why some ~25+% of general surgery residents leave the field completely. > The third point is about how healthcare functions in the country, specifically around large hospitals I mean, I call bullshit and I see this logic all the time from fellow physicians who try to make the cost argument from the floor. We pay NPs and PAs to work exactly these shifts, and hours. Why not residents? > conclusion that 24hrs is truly worse than 16hrs for patient outcomes I completely disagree that the late night hours have done anything towards making me a better doctor. And I'm truly sorry if I came off as feisty but the whole discussion is so frustrating to me because I think it misses the big picture. This change by ACGME signals the wrong direction we need to be going in how we treat young doctors. At some point, the aggregate weight of non-cancellable student loans (~240k on average now?), anti-competitive labor market (that went to the supreme court), inhuman hours (that would be illegal for a pilot or truck driver to do), relatively shitty pay (my SO is in tech and earns 2x what most primary care physicians do in 1/2 the hours) will be too much. They'll quit, and find other ways to "make a difference." I can't put a pillow in a pillow case after 24 hours. Do you really want me stitching up your mom?

unprepare 10y ago

Could the reason handoffs are so bad be because the person doing the handoff has been working for 16-24 hours straight? I mean in IT i see first hand the notes left by people on pager duty in the middle of the night, and they differ significantly from the same peoples notes after a restful night of sleep. Has there been any controlling in these studies i see mentioned through this entire thread for sleep deprivation present in people performing the handoffs? If they arent controlling for the amount of rest the people in the handoffs have had in the last 24 hours, im not sure i am willing to put much weight in these studies. >I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift. But if you came into the ER at 3am and the doctor you get has been working 23 hours, youre still going to need ot be handed off, and now youve received sleep deprivated care in the interim while waiting for a fresh doctor. Sure, for the guy who arrived just as a fresh doctor arrived, it might be beneficial to have them there for 24 hours, but how many new patients are they seeing in hours 12-24?

LazaroPearson 10y ago

> Having been through residency myself Throwaway because it was so disheartening to read this perspective. > The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts. This is very location, hospital, and speciality specific. Most surgical residents would say the opposite. > Secondly, do not underestimate the danger of hand-offs Hey, why don't we work on better handoffs. Other fields (even with-in medicine) seem to manage. Maybe we should mine the airlines industry again for good ideas. The dichotomy of 16 vs 24 hours to me is a false choice. > There are surgeons graduating after 5 years of ENT training... who have not had enough experience to become attendings at the places where they are interviewing. For what it's worth, surgical sub-specialists like ENTs will do at least 2-3 times as many hours in training as a family medicine doc or pediatrician. Make the training an extra year and pay a better god damn salary if they really aren't trained well enough. Right now the system is designed around cramming as much pain and suffering as a human can withstand in their training to get the most value for the hospital. There's a reason why some ~25+% of general surgery residents leave the field completely. > The third point is about how healthcare functions in the country, specifically around large hospitals I mean, I call bullshit and I see this logic all the time from fellow physicians who try to make the cost argument from the floor. We pay NPs and PAs to work exactly these shifts, and hours. Why not residents? > conclusion that 24hrs is truly worse than 16hrs for patient outcomes I completely disagree that the late night hours have done anything towards making me a better doctor. And I'm truly sorry if I came off as feisty but the whole discussion is so frustrating to me because I think it misses the big picture. This change by ACGME signals the wrong direction we need to be going in how we treat young doctors. At some point, the aggregate weight of non-cancellable student loans (~240k on average now?), anti-competitive labor market (that went to the supreme court), inhuman hours (that would be illegal for a pilot or truck driver to do), relatively shitty pay (my SO is in tech and earns 2x what most primary care physicians do in 1/2 the hours) will be too much. They'll quit, and find other ways to "make a difference." I can't put a pillow in a pillow case after 24 hours. Do you really want me stitching up your mom?