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The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they

The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon. My SO is in med school right now and they just changed the regs from 16 hour shifts back to 24 hour shifts.

crimsonalucard 9y ago
But there would still be a loss of information after 24 hours. Improving quality means upping the shift to 96 hours. We should encourage doctors to not sleep as sleeping means loss of information. This totally makes sense.
- yequalsx 9y ago
  So it's not reasonable for a person to work 96 hours. But apparently it is reasonable for 24 hours. The goal is to minimize information loss while maximizing performance. There's a tradeoff. Apparently 24 hours is a local max in this tradeoff.
- paviva 9y ago
  Absolutely does. And that's precisely the reason why inpatients are treated by the same doctor for as long periods as is humanely possible, i.e. usually one-week stretches on call.
carbocation 9y ago
It's pretty widely discussed but I don't think it's as well studied as it should be. The shift from 24 to ~16 was made without much evidence, and analyses subsequently didn't support the change. An awareness that we need to study these decisions before making them has finally taken hold. To that end, trials are now ongoing that have randomized residency programs to the (shorter+more handoffs) vs (longer) shifts. Patient outcomes are obviously the most important, but measures of physician wellness would be a valuable secondary outcome.
oliwarner 9y ago
And other countries got rid of long shifts for exactly the same headline reason. Standard of care suffers if your doctor has been running hot for 24 hours and does something stupid. I think it's possible that both things are true. The problem comes when traditionalism is in charge (as it usually is, being senior). "I had to work 48h shifts and I never killed anyone who didn't have it coming, why shouldn't they?!" It also ignores —in the way only a doctor can— that being away from your family has both a cost on them and you. This isn't something you can just throw money at. You need numbers. But yes, good handover procedure is essential to. However long the shift.
BeetleB 9y ago
So I take it there is data that the reduction from 24 hours to 16 hours that occurred a while ago resulted in a lower standard of care? Can you show it to me? As an engineer, I used to think I didn't have what it takes to work long hours. After about 5-6pm, I'd start making mistakes, and my productivity would be roughly halved. I'd occasionally come in the next day and realize I had screwed up and would spend the morning redoing the work I did after 5pm the previous day. Then I once stayed at work late not for my project, but to help other coworkers who I thought "had what it takes". It was insightful to see they made the same number of errors that I did, and had I not been there, they would have had to redo the work the following morning as well. This is especially true for simple, tedious work, which a lot of medicine is about (at least at the nursing level). Things like administering medications. I'd like to know what magic they use when training doctors in their residency to avoid such errors that other industries have not been able to master. Yes, handoffs are risky for patients. As is being tired.
tneely 9y ago
What can be done to mitigate the risk of handoffs? This seems like something we can use technology to solve.
solatic 9y ago
> The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. This isn't an argument that longer shifts result in better outcomes, this is an argument that the hospital's current handoff processes are insufficient, and that better handoff process would improve outcomes.
- kirse 9y ago
  the hospital's current handoff processes are insufficient Humans have 24h circadian rhythms that likely affect patient care due to timing of cortisol release and other cyclical bodily events... It makes sense for an attending nurse/physician to be present for that full 24h cycle to gain a holistic understanding of patient recovery during various phases of the day. If you're handing off a patient every 12 hrs, you're going to have fewer experiential data-points to judge if their condition is improving or worsening, no matter how detailed a hand-off can be. It'd be even worse with 8h shifts. Further, if a Dr has a patient come in with a unique condition, they're not going to leave just because their 12-hr timer dings.
  - solatic 9y ago
    > to gain a holistic understanding of patient recovery during various phases of the day. Define "holistic understanding." Is the doctor actually sitting bedside with the patient for the entire shift? Of course not. More realistically, the doctor is coming in, making some observations, and then moves on to the next patient. So here's an idea - couldn't you shoot video of the observation, and shoot a time-lapse video of the otherwise-lacking-direct-observation periods, and show those to the physician in the next shift? All that the attending physician has to do is vocalize his observations (of course a camera by itself can't sufficiently observe), and the hand-off physician can watch the clips just like he could read the chart. Such clips may also be accompanied by speech-to-text to produce quick summaries. There's simply no doctor in the world who isn't privately treating a single patient who can compete with the number of experiential data-points which a computer can provide.
mcguire 9y ago
"If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon." Do you have a citation for that?

crimsonalucard 9y ago

But there would still be a loss of information after 24 hours. Improving quality means upping the shift to 96 hours. We should encourage doctors to not sleep as sleeping means loss of information. This totally makes sense.

yequalsx 9y ago
So it's not reasonable for a person to work 96 hours. But apparently it is reasonable for 24 hours. The goal is to minimize information loss while maximizing performance. There's a tradeoff. Apparently 24 hours is a local max in this tradeoff.
paviva 9y ago
Absolutely does. And that's precisely the reason why inpatients are treated by the same doctor for as long periods as is humanely possible, i.e. usually one-week stretches on call.

carbocation 9y ago

It's pretty widely discussed but I don't think it's as well studied as it should be. The shift from 24 to ~16 was made without much evidence, and analyses subsequently didn't support the change. An awareness that we need to study these decisions before making them has finally taken hold. To that end, trials are now ongoing that have randomized residency programs to the (shorter+more handoffs) vs (longer) shifts. Patient outcomes are obviously the most important, but measures of physician wellness would be a valuable secondary outcome.

oliwarner 9y ago

And other countries got rid of long shifts for exactly the same headline reason. Standard of care suffers if your doctor has been running hot for 24 hours and does something stupid. I think it's possible that both things are true. The problem comes when traditionalism is in charge (as it usually is, being senior). "I had to work 48h shifts and I never killed anyone who didn't have it coming, why shouldn't they?!" It also ignores —in the way only a doctor can— that being away from your family has both a cost on them and you. This isn't something you can just throw money at. You need numbers. But yes, good handover procedure is essential to. However long the shift.

BeetleB 9y ago

So I take it there is data that the reduction from 24 hours to 16 hours that occurred a while ago resulted in a lower standard of care? Can you show it to me? As an engineer, I used to think I didn't have what it takes to work long hours. After about 5-6pm, I'd start making mistakes, and my productivity would be roughly halved. I'd occasionally come in the next day and realize I had screwed up and would spend the morning redoing the work I did after 5pm the previous day. Then I once stayed at work late not for my project, but to help other coworkers who I thought "had what it takes". It was insightful to see they made the same number of errors that I did, and had I not been there, they would have had to redo the work the following morning as well. This is especially true for simple, tedious work, which a lot of medicine is about (at least at the nursing level). Things like administering medications. I'd like to know what magic they use when training doctors in their residency to avoid such errors that other industries have not been able to master. Yes, handoffs are risky for patients. As is being tired.

tneely 9y ago

What can be done to mitigate the risk of handoffs? This seems like something we can use technology to solve.

solatic 9y ago

> The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. This isn't an argument that longer shifts result in better outcomes, this is an argument that the hospital's current handoff processes are insufficient, and that better handoff process would improve outcomes.

kirse 9y ago
the hospital's current handoff processes are insufficient Humans have 24h circadian rhythms that likely affect patient care due to timing of cortisol release and other cyclical bodily events... It makes sense for an attending nurse/physician to be present for that full 24h cycle to gain a holistic understanding of patient recovery during various phases of the day. If you're handing off a patient every 12 hrs, you're going to have fewer experiential data-points to judge if their condition is improving or worsening, no matter how detailed a hand-off can be. It'd be even worse with 8h shifts. Further, if a Dr has a patient come in with a unique condition, they're not going to leave just because their 12-hr timer dings.
- solatic 9y ago
  > to gain a holistic understanding of patient recovery during various phases of the day. Define "holistic understanding." Is the doctor actually sitting bedside with the patient for the entire shift? Of course not. More realistically, the doctor is coming in, making some observations, and then moves on to the next patient. So here's an idea - couldn't you shoot video of the observation, and shoot a time-lapse video of the otherwise-lacking-direct-observation periods, and show those to the physician in the next shift? All that the attending physician has to do is vocalize his observations (of course a camera by itself can't sufficiently observe), and the hand-off physician can watch the clips just like he could read the chart. Such clips may also be accompanied by speech-to-text to produce quick summaries. There's simply no doctor in the world who isn't privately treating a single patient who can compete with the number of experiential data-points which a computer can provide.

mcguire 9y ago

"If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon." Do you have a citation for that?