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> 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 e

> 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?
  - falcolas 10y ago
    From other comments here, it sounds like there really hasn't been a lot of experimentation or innovation in the "sign-off" process. It seems like things like body cameras and audio recordings could help with the transfer of knowledge between two people about a specific patient. So could telepresence, IMO, if the off shift doctors weren't trying to recover for their next marathon. > a solution that they know works For what definition of works? My (thankfully few) trips to the hospital have not exactly inspired a lot of confidence in the hospital system. Duplicated questions, minimized interaction with an actual doctor, being kept in the dark about what's going on, waiting for hours between human interactions, empty IV bags which hang for hours... This is questionable definition of "works".
karzeem 10y ago
I'd say that's a good argument for fixing whatever the flaws are in the handoff process that make it even worse than 28-hour shifts.
- chimeracoder 10y ago
  > I'd say that's a good argument for fixing whatever the flaws are in the handoff process that make it even worse than 28-hour shifts. That's a good idea. Do you know what those flaws are, and how to fix them? I'm not being sarcastic - there's a whole lot of money that's been poured into this over the last few decades, and it's not easy. While we wait for someone to figure out the answer, in the meantime, it's reasonable for providers to go back to the policy that empirically produced lower rates of medical errors, which we know because that's what was standard practice up until a few years ago, and it already is standard practice for all other residents.
  - phil21 10y ago
    I agree with this assessment having only briefly paid attention to this topic while a friend was going through residency. This is not something that is being ignored - I would say the exact opposite is true, it was probably one of the most discussed topics of residents at the time. But I also think the answer is pretty obvious, if not practical. You need to basically double the number of doctors, and stagger shifts so they have half-shift overlaps and scheduled 8hr (max) shifts to begin with. Then doctors can stay longer through the next shift if needed (and this would be common) to complete the handoffs properly as well as get through critical periods of patient care. I think that would be far safer than the current model - but also would effectively double your salary costs which is of course a non-starter.
    - chimeracoder 10y ago
      > But I also think the answer is pretty obvious, if not practical. You need to basically double the number of doctors, As mentioned in the article, one of the problems they found with the shorter shifts is that it was less effective for teaching, meaning that they would need longer training periods overall to achieve the same results with shorter shifts. So that would mean increasing the costs of residency, which is already an unprofitable program to begin with. So, doubling the number of doctors without compromising on training would mean increasing the per-resident costs significantly and then doubling them. That's... a hard approach to execute. Also, that's assuming that having twice the number of doctors caring for each patient per unit time does not introduce any other problems, which is an assumption I'd question.
Havoc 10y ago
>the handoff points can themselves be more problematic than the effects of working for 28 hours. Handoffs are dangerous so longer shifts make sense...but 28 hrs is way too long. People are pretty much walking zombies at that point.
LazaroPearson 10y ago
>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. Do you really want me operating on your Mom after 28 hours? I wouldn't. I can't tell you the amount of times a fellow resident has got in a car crash, or made a mistake related to patient care because of lack of sleep. Also, let me clear up the "periods of downtime" part for you. For the last 6 call nights, I got a grand total of two hours sleep. Honestly, I created a throwaway specifically to reply to many of (what are in my opinion) very misguided opinions on how these types of hours effect quality of care.
- chimeracoder 10y ago
  > Do you really want me operating on your Mom after 28 hours? I wouldn't. No, but I don't want 3 different doctors treating her with that time period either[0] - at least, not with the findings of the peer-reviewed research demonstrating that this leads to higher rates of serious medical errors. > I can't tell you the amount of times a fellow resident has got in a car crash, or made a mistake related to patient care because of lack of sleep. Nor could I tell you the number of times critical information has gotten dropped at a handoff boundary, impacting the care of the patient. Nobody's saying that sleep deprivation doesn't impact medical care. What the peer-reviewed research is saying is that sleep deprivation is less dangerous than frequent handoffs. [0] which is what 12-hours shifts (as you proposed) could entail.

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?
- falcolas 10y ago
  From other comments here, it sounds like there really hasn't been a lot of experimentation or innovation in the "sign-off" process. It seems like things like body cameras and audio recordings could help with the transfer of knowledge between two people about a specific patient. So could telepresence, IMO, if the off shift doctors weren't trying to recover for their next marathon. > a solution that they know works For what definition of works? My (thankfully few) trips to the hospital have not exactly inspired a lot of confidence in the hospital system. Duplicated questions, minimized interaction with an actual doctor, being kept in the dark about what's going on, waiting for hours between human interactions, empty IV bags which hang for hours... This is questionable definition of "works".

karzeem 10y ago

I'd say that's a good argument for fixing whatever the flaws are in the handoff process that make it even worse than 28-hour shifts.

chimeracoder 10y ago
> I'd say that's a good argument for fixing whatever the flaws are in the handoff process that make it even worse than 28-hour shifts. That's a good idea. Do you know what those flaws are, and how to fix them? I'm not being sarcastic - there's a whole lot of money that's been poured into this over the last few decades, and it's not easy. While we wait for someone to figure out the answer, in the meantime, it's reasonable for providers to go back to the policy that empirically produced lower rates of medical errors, which we know because that's what was standard practice up until a few years ago, and it already is standard practice for all other residents.
- phil21 10y ago
  I agree with this assessment having only briefly paid attention to this topic while a friend was going through residency. This is not something that is being ignored - I would say the exact opposite is true, it was probably one of the most discussed topics of residents at the time. But I also think the answer is pretty obvious, if not practical. You need to basically double the number of doctors, and stagger shifts so they have half-shift overlaps and scheduled 8hr (max) shifts to begin with. Then doctors can stay longer through the next shift if needed (and this would be common) to complete the handoffs properly as well as get through critical periods of patient care. I think that would be far safer than the current model - but also would effectively double your salary costs which is of course a non-starter.
  - chimeracoder 10y ago
    > But I also think the answer is pretty obvious, if not practical. You need to basically double the number of doctors, As mentioned in the article, one of the problems they found with the shorter shifts is that it was less effective for teaching, meaning that they would need longer training periods overall to achieve the same results with shorter shifts. So that would mean increasing the costs of residency, which is already an unprofitable program to begin with. So, doubling the number of doctors without compromising on training would mean increasing the per-resident costs significantly and then doubling them. That's... a hard approach to execute. Also, that's assuming that having twice the number of doctors caring for each patient per unit time does not introduce any other problems, which is an assumption I'd question.

Havoc 10y ago

>the handoff points can themselves be more problematic than the effects of working for 28 hours. Handoffs are dangerous so longer shifts make sense...but 28 hrs is way too long. People are pretty much walking zombies at that point.

LazaroPearson 10y ago

>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. Do you really want me operating on your Mom after 28 hours? I wouldn't. I can't tell you the amount of times a fellow resident has got in a car crash, or made a mistake related to patient care because of lack of sleep. Also, let me clear up the "periods of downtime" part for you. For the last 6 call nights, I got a grand total of two hours sleep. Honestly, I created a throwaway specifically to reply to many of (what are in my opinion) very misguided opinions on how these types of hours effect quality of care.

chimeracoder 10y ago
> Do you really want me operating on your Mom after 28 hours? I wouldn't. No, but I don't want 3 different doctors treating her with that time period either[0] - at least, not with the findings of the peer-reviewed research demonstrating that this leads to higher rates of serious medical errors. > I can't tell you the amount of times a fellow resident has got in a car crash, or made a mistake related to patient care because of lack of sleep. Nor could I tell you the number of times critical information has gotten dropped at a handoff boundary, impacting the care of the patient. Nobody's saying that sleep deprivation doesn't impact medical care. What the peer-reviewed research is saying is that sleep deprivation is less dangerous than frequent handoffs. [0] which is what 12-hours shifts (as you proposed) could entail.