7 ms·

Rookie Doctors Will Soon Be Allowed to Work Up to 28 Hours Straight

39 points by happy-go-lucky 10y ago

cauterized 10y ago
Who thought this was a good idea, and why? Aren't our medical professionals the people we least want to be dangerously fatigued? Hasn't anyone read the literature on how sleep deprivation interferes with learning? Or how being up for 24 hours straight is equivalent to a blood alcohol level that would disqualify a person from driving? And we want people in this state while they're responsible for the health of people sick enough to be hospitalized? What the actual fuck?
- princeb 10y ago
  i mean, reading the article would give you several reasons why they didn't think avoiding fatigue was a good tradeoff.
  - cauterized 10y ago
    I see one in the article, which is wanting a single doctor to consistently be available through a course of treatment. But I don't see how 24 hours guarantees that any more than 16. I for one would rather my doctor worked 8 hours, went to bed for 8, and returned for the third (or 4th) 8 hours than that they be on their feet trying to keep their eyes open for 24 hours straight and remember everything that I and 20 other patients have said to them or undergone in the last 24 hours. Would you rather have your surgeon hand the scalpel off to another doctor, or have them proceed while so fatigued as to be drunk? And in case you didn't notice, the article also points out the dangers of fatigue, just with the journalistic integrity that suppresses the expression of the outrage that those of us who aren't journalists should all be responding with.
    - chimeracoder 10y ago
      > I for one would rather my doctor worked 8 hours, went to bed for 8, and returned for the third (or 4th) 8 hours than that they be on their feet trying to keep their eyes open for 24 hours straight and remember everything that I and 20 other patients have said to them or undergone in the last 24 hours. According to empirical research, that is actually more dangerous for you, because the handoff points are most likely to introduce errors. It's counterintuitive, but that's something that both providers and peer-reviewed medical journals agree on.
  - wwweston 10y ago
    I only see one -- a personal continuity of care argument ("Patients want to know 'you are the doctor taking care of them,' Kothari says."). If that's true, I think it's kind of fascinating. I'd certainly like to know that there is someone who is taking enough interest in me as a patient that they consider themselves ultimately accountable for providing or coordinating a professional standard of care. But I don't need that person to be the personal face of that care all the time, and frankly, it's ridiculous to assert the system behaves that way now. And I definitely want to know that person is operating without cognitive impairments, and definitely don't think "continuity" means "one person." I'm sure there's realities of actually doing the work that I don't understand, and I also know that handing off information and coordinating people is far from trivial (I know that we're really not all that good at it in software, a profession where for anything to work at all you have to pass around carefully encoded instructions). I just don't understand the given argument. Also, I see at least one professional counterargument in the article.
    - AnkhMorporkian 10y ago
      As someone who got out of the hospital recently after a couple weeks in, I see the continuity of care argument. I had a lot of doctors in my time there, and the left hand really didn't know what the right hand was doing. I spent an extra 4 days in because one of my doctors thought the other doctor was going to write the discharge order, and vice versa.
- surgeryres 10y ago
  I am a surgery resident. This "rule" only applied to first year residents, and was started in 2011. There in fact is a study being conducted where one arm of first year residents follows the 16 hour max and another follows the 28 hour max. It seems the results from this trial suggest the 16 hour max is detrimental to learning, hand-off logistics and scheduling. Regardless, after your first year, no matter what program or specialty, 28 hour calls become the norm. As a second year surgery resident for example, you can plan on taking a 28 hour call two or three times a week. This is just how it is. For two main reasons: 1) There are not enough of us for everyone to get 8 hours of sleep a night. People can debate why or ways we should fix this, whether it's widening scope of practice for nurse practitioners or decreasing our pay so there is more of us, but logistically there are not enough residents to keep everyone well rested. 2) There is physiological relevance to a 24 hour cycle in many diseases. For example, if a patient comes in with a bowel obstruction, the process of observation, lab evaluation, imaging, +\- surgery takes sometimes 24 hours. 12 is sometimes not enough to appreciate the full evolution of acute disease. Big topic here. My experience is anecdotal and limited. Why they did a big study to see what was best. Still, it only applies to first years.
  - Retric 10y ago
    1) Is a problem with efficiency not people. If you design things for people to be horribly incompetent due to sleep deprivation, then going through the same process while awake probably produces similar results. However, a shorter work day would mean you could use different processes.
  - rohansingh 10y ago
    These 28-hour shifts are unique to healthcare in the United States.
  - verroq 10y ago
    Solution: allow more people to become doctors.
    - surgeryres 10y ago
      Ok, but what exactly do you propose? funding to support residents comes from the federal government, and this funding is already strained. Should we lower standards? Lower quality of care? If the answer was easy we would have already implemented something.
- marze 10y ago
  Any time you see a policy in the medical world (or elsewhere) that appears completely irrational and nuts, ask yourself one question: Does this policy increase medical industry revenue? With the exception of instant death to the patient, medical errors always increase revenue.
aabajian 10y ago
Oh great, I come to HN for tech news and see this. As a graduating medical student doing a surgical prelim, I'm certainly not looking forward to 28 hour work days. I think what many don't realize is that day-to-day medicine is super low-tech. The ACGME is still acting off a model where sign-outs are face-to-face following a checklist (see: https://www.ncbi.nlm.nih.gov/books/NBK43722/ https://www.ncbi.nlm.nih.gov/books/NBK43722/). This is the best we've come up with, and it frankly takes a lot of time. It's no wonder 16 hours didn't cut it. What we need is a better way to do sign-outs so that residents can know what's going on even during their days off. The very wording "sign-out" is rather a misnomer. Just because you're leaving the hospital for two days doesn't mean you forget about your patients. What we need is something like a Twitter feed so you can get updates on your patients when you're not in the hospital. Then you wouldn't have to have a full-blown sign-out when you return.
- brianwawok 10y ago
  Do you really want to work a long day and then be barraged by questions and data on your offtime? Seems like sign out us a reasonable way to prevent burnout.
  - thesmallestcat 10y ago
    > work a long day and then be barraged by questions and data on your offtime Sounds a lot like "dev-ops."
  - pharrington 10y ago
    He's proposing an alternative to the current reality where medical residents literally do not have offtime. The burnout is happening right now, because the current "solution" to tracking patients' updates is to store all of that information in human beings.
- aswanson 10y ago
  That Twitter feed sounds like a start up opportunity. Would it be easy to maneuver around hippa?
FLUX-YOU 10y ago
>the cap would occasionally prevent doctors from seeing a treatment or surgery through from beginning to end I would be pretty annoyed at that, but I also probably wouldn't report it just to see it through. Seems weird they'd suddenly get honest about it.
maxerickson 10y ago
Dupe of https://news.ycombinator.com/item?id=13840429 https://news.ycombinator.com/item?id=13840429
dbg31415 10y ago
"Allowed" is a nice way to put it.
sebringj 10y ago
Medical errors are the 3rd leading cause of death. Didn't that wake them up to make it less error prone, not more?
- chimeracoder 10y ago
  > Medical errors are the 3rd leading cause of death. Didn't that wake them up to make it less error prone, not more? It did. And they did the research, and they found that frequent handoffs introduce more errors than longer shifts do. So, they're taking action to address that.
  - sebringj 10y ago
    That would make sense I guess but in a "lesser evil" type way.
PeterisP 10y ago
If a truck driver is working 28 hours straight, we consider their decision making capability so impaired that they endanger others and we take away their licence if they dare to do 28 hours without rest. Doctors apparently don't make mistakes that can hurt people.
- chimeracoder 10y ago
  > Doctors apparently don't make mistakes that can hurt people. They can, but it turns out that the handoff points can themselves be more problematic than the effects of working for 28 hours. They did lots of published research which showed that, which is why this policy change is even happening. Also, a 28 hour shift doesn't mean that the doctor is working (or even awake) the entire time - they're on-shift, but there are periods of downtime. It's not necessarily 28 hours of constant activity.
  - falcolas 10y ago
    Improving the handoff seems like a much more tractable problem than eliminating mistakes caused by fatigue.
    - chimeracoder 10y ago
      > Improving the handoff seems like a much more tractable problem You'd think, but it's a lot harder than it looks, and I'm speaking from experience. In the meantime, they're going back to a solution that they know works, because in this case it's literally what they used to do before and what they already do for all other residents, and it has a lower failure rate. All they're doing here is reverting a failed experiment in response to the measurable, documented problems it introduced.
      - hashkb 10y ago
        But it goes against my uneducated intuitive beliefs! What are they thinking?
      - 10y ago
deleted 10y ago
[deleted]
chris_7 10y ago
This should just be generally illegal from a labor law perspective, not even something specific to doctors.
- kwhitefoot 10y ago
  You'll have to join the EU to get that, look up the European Working Time Directive.
  - chris_7 10y ago
    It could be implemented at the state level here (Republicans would never allow a pro-labor law like that to be passed federally). If New York, California, or Massachusetts passed a law like this, it could be a competitive advantage in attracting top talent in fields that treat their laborers terribly (like medicine, apparently).
deleted 10y ago
[deleted]
kwhitefoot 10y ago
Strange how some countries expect doctors to work ridiculous hours and justify it on the grounds that not doing it would increase the risk of medical errors and yet other countries seem to manage without excessive hours, see this study about Norwegian doctor's working hours http://bmjopen.bmj.com/content/4/10/e005704 http://bmjopen.bmj.com/content/4/10/e005704. I come from the UK but live in Norway and am impressed by the health system here.

Who thought this was a good idea, and why? Aren't our medical professionals the people we least want to be dangerously fatigued? Hasn't anyone read the literature on how sleep deprivation interferes with learning? Or how being up for 24 hours straight is equivalent to a blood alcohol level that would disqualify a person from driving? And we want people in this state while they're responsible for the health of people sick enough to be hospitalized? What the actual fuck?

princeb 10y ago
i mean, reading the article would give you several reasons why they didn't think avoiding fatigue was a good tradeoff.
- cauterized 10y ago
  I see one in the article, which is wanting a single doctor to consistently be available through a course of treatment. But I don't see how 24 hours guarantees that any more than 16. I for one would rather my doctor worked 8 hours, went to bed for 8, and returned for the third (or 4th) 8 hours than that they be on their feet trying to keep their eyes open for 24 hours straight and remember everything that I and 20 other patients have said to them or undergone in the last 24 hours. Would you rather have your surgeon hand the scalpel off to another doctor, or have them proceed while so fatigued as to be drunk? And in case you didn't notice, the article also points out the dangers of fatigue, just with the journalistic integrity that suppresses the expression of the outrage that those of us who aren't journalists should all be responding with.
  - chimeracoder 10y ago
    > I for one would rather my doctor worked 8 hours, went to bed for 8, and returned for the third (or 4th) 8 hours than that they be on their feet trying to keep their eyes open for 24 hours straight and remember everything that I and 20 other patients have said to them or undergone in the last 24 hours. According to empirical research, that is actually more dangerous for you, because the handoff points are most likely to introduce errors. It's counterintuitive, but that's something that both providers and peer-reviewed medical journals agree on.
- wwweston 10y ago
  I only see one -- a personal continuity of care argument ("Patients want to know 'you are the doctor taking care of them,' Kothari says."). If that's true, I think it's kind of fascinating. I'd certainly like to know that there is someone who is taking enough interest in me as a patient that they consider themselves ultimately accountable for providing or coordinating a professional standard of care. But I don't need that person to be the personal face of that care all the time, and frankly, it's ridiculous to assert the system behaves that way now. And I definitely want to know that person is operating without cognitive impairments, and definitely don't think "continuity" means "one person." I'm sure there's realities of actually doing the work that I don't understand, and I also know that handing off information and coordinating people is far from trivial (I know that we're really not all that good at it in software, a profession where for anything to work at all you have to pass around carefully encoded instructions). I just don't understand the given argument. Also, I see at least one professional counterargument in the article.
  - AnkhMorporkian 10y ago
    As someone who got out of the hospital recently after a couple weeks in, I see the continuity of care argument. I had a lot of doctors in my time there, and the left hand really didn't know what the right hand was doing. I spent an extra 4 days in because one of my doctors thought the other doctor was going to write the discharge order, and vice versa.
surgeryres 10y ago
I am a surgery resident. This "rule" only applied to first year residents, and was started in 2011. There in fact is a study being conducted where one arm of first year residents follows the 16 hour max and another follows the 28 hour max. It seems the results from this trial suggest the 16 hour max is detrimental to learning, hand-off logistics and scheduling. Regardless, after your first year, no matter what program or specialty, 28 hour calls become the norm. As a second year surgery resident for example, you can plan on taking a 28 hour call two or three times a week. This is just how it is. For two main reasons: 1) There are not enough of us for everyone to get 8 hours of sleep a night. People can debate why or ways we should fix this, whether it's widening scope of practice for nurse practitioners or decreasing our pay so there is more of us, but logistically there are not enough residents to keep everyone well rested. 2) There is physiological relevance to a 24 hour cycle in many diseases. For example, if a patient comes in with a bowel obstruction, the process of observation, lab evaluation, imaging, +\- surgery takes sometimes 24 hours. 12 is sometimes not enough to appreciate the full evolution of acute disease. Big topic here. My experience is anecdotal and limited. Why they did a big study to see what was best. Still, it only applies to first years.
- Retric 10y ago
  1) Is a problem with efficiency not people. If you design things for people to be horribly incompetent due to sleep deprivation, then going through the same process while awake probably produces similar results. However, a shorter work day would mean you could use different processes.
- rohansingh 10y ago
  These 28-hour shifts are unique to healthcare in the United States.
- verroq 10y ago
  Solution: allow more people to become doctors.
  - surgeryres 10y ago
    Ok, but what exactly do you propose? funding to support residents comes from the federal government, and this funding is already strained. Should we lower standards? Lower quality of care? If the answer was easy we would have already implemented something.
marze 10y ago
Any time you see a policy in the medical world (or elsewhere) that appears completely irrational and nuts, ask yourself one question: Does this policy increase medical industry revenue? With the exception of instant death to the patient, medical errors always increase revenue.

aabajian 10y ago

Oh great, I come to HN for tech news and see this. As a graduating medical student doing a surgical prelim, I'm certainly not looking forward to 28 hour work days. I think what many don't realize is that day-to-day medicine is super low-tech. The ACGME is still acting off a model where sign-outs are face-to-face following a checklist (see: https://www.ncbi.nlm.nih.gov/books/NBK43722/ https://www.ncbi.nlm.nih.gov/books/NBK43722/). This is the best we've come up with, and it frankly takes a lot of time. It's no wonder 16 hours didn't cut it. What we need is a better way to do sign-outs so that residents can know what's going on even during their days off. The very wording "sign-out" is rather a misnomer. Just because you're leaving the hospital for two days doesn't mean you forget about your patients. What we need is something like a Twitter feed so you can get updates on your patients when you're not in the hospital. Then you wouldn't have to have a full-blown sign-out when you return.

brianwawok 10y ago
Do you really want to work a long day and then be barraged by questions and data on your offtime? Seems like sign out us a reasonable way to prevent burnout.
- thesmallestcat 10y ago
  > work a long day and then be barraged by questions and data on your offtime Sounds a lot like "dev-ops."
- pharrington 10y ago
  He's proposing an alternative to the current reality where medical residents literally do not have offtime. The burnout is happening right now, because the current "solution" to tracking patients' updates is to store all of that information in human beings.
aswanson 10y ago
That Twitter feed sounds like a start up opportunity. Would it be easy to maneuver around hippa?

FLUX-YOU 10y ago

>the cap would occasionally prevent doctors from seeing a treatment or surgery through from beginning to end I would be pretty annoyed at that, but I also probably wouldn't report it just to see it through. Seems weird they'd suddenly get honest about it.

maxerickson 10y ago

Dupe of https://news.ycombinator.com/item?id=13840429 https://news.ycombinator.com/item?id=13840429

dbg31415 10y ago

"Allowed" is a nice way to put it.

sebringj 10y ago

Medical errors are the 3rd leading cause of death. Didn't that wake them up to make it less error prone, not more?

chimeracoder 10y ago
> Medical errors are the 3rd leading cause of death. Didn't that wake them up to make it less error prone, not more? It did. And they did the research, and they found that frequent handoffs introduce more errors than longer shifts do. So, they're taking action to address that.
- sebringj 10y ago
  That would make sense I guess but in a "lesser evil" type way.

PeterisP 10y ago

If a truck driver is working 28 hours straight, we consider their decision making capability so impaired that they endanger others and we take away their licence if they dare to do 28 hours without rest. Doctors apparently don't make mistakes that can hurt people.

chimeracoder 10y ago
> Doctors apparently don't make mistakes that can hurt people. They can, but it turns out that the handoff points can themselves be more problematic than the effects of working for 28 hours. They did lots of published research which showed that, which is why this policy change is even happening. Also, a 28 hour shift doesn't mean that the doctor is working (or even awake) the entire time - they're on-shift, but there are periods of downtime. It's not necessarily 28 hours of constant activity.
- falcolas 10y ago
  Improving the handoff seems like a much more tractable problem than eliminating mistakes caused by fatigue.
  - chimeracoder 10y ago
    > Improving the handoff seems like a much more tractable problem You'd think, but it's a lot harder than it looks, and I'm speaking from experience. In the meantime, they're going back to a solution that they know works, because in this case it's literally what they used to do before and what they already do for all other residents, and it has a lower failure rate. All they're doing here is reverting a failed experiment in response to the measurable, documented problems it introduced.
    - hashkb 10y ago
      But it goes against my uneducated intuitive beliefs! What are they thinking?
    - 10y ago

deleted 10y ago

[deleted]

chris_7 10y ago

This should just be generally illegal from a labor law perspective, not even something specific to doctors.

kwhitefoot 10y ago
You'll have to join the EU to get that, look up the European Working Time Directive.
- chris_7 10y ago
  It could be implemented at the state level here (Republicans would never allow a pro-labor law like that to be passed federally). If New York, California, or Massachusetts passed a law like this, it could be a competitive advantage in attracting top talent in fields that treat their laborers terribly (like medicine, apparently).

deleted 10y ago

[deleted]

kwhitefoot 10y ago

Strange how some countries expect doctors to work ridiculous hours and justify it on the grounds that not doing it would increase the risk of medical errors and yet other countries seem to manage without excessive hours, see this study about Norwegian doctor's working hours http://bmjopen.bmj.com/content/4/10/e005704 http://bmjopen.bmj.com/content/4/10/e005704. I come from the UK but live in Norway and am impressed by the health system here.