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>One group runs a gauntlet of fire by sleep deprivation during pre-med training: with on-call work hours up to 120 hours a week. I would argue this is the sour

>One group runs a gauntlet of fire by sleep deprivation during pre-med training: with on-call work hours up to 120 hours a week. I would argue this is the source of injury and death to the patients that needs to be addressed rather than powered through in some sort of macho hazing ritual. Anecdotally a very tired doctor is allegedly how my wife lost her mother.

mfe5003 8y ago
I've always assumed that the failure rate for handing off care to another person and the rate because of long hours must go in favor of long hours. I don't have anything to back this up except the MCAT being designed to check how you perform when tired. Now with electronic records I've been wondering if long hours are still be necessary, assuming I'm right about the failure rates. I'm sorry about your mother in law regardless.
- mattkrause 8y ago
  This is the claim, but if you look at the experiments supporting it, they’re all bonkers. For example, care is no worse from doctors on 28 hr shifts vs 24. I would argue that both of these are so far from a well-rested baseline that they’re meaningless. We know from lab experiments that performance craters way, way before that, which is why pilots, truck drivers, cops, and every other profession work shorter shifts.
  - jchanimal 8y ago
    All this talk is insane. I have like maybe 4 top-performing hours on my best days. The idea of working more than 8 in a life safety critical situation boggles the mind.
- verelo 8y ago
  Super intersting to see people discussing this! As someone that holds a pilots license and talks with a lot of commercial pilots about their jobs, sleep is often a hot topic of discussion. It would be illegal, not just irresponsible, for a pilot to try pull off a 120 hour work week. Why do we treat doctors differently? Their macho behaviour in my opinion is unacceptable, and likely reduces positive patient outcomes, yet it goes on?
  - GavinMcG 8y ago
    Medicine has different concerns than piloting, though. Pilots don't have to ensure continuity of care for their passengers, and can accomplish their work in reasonable chunks. Doubling the number of patient handoffs, on the other hand, significantly increases the risk of one of the more common sources of error.
    - km3k 8y ago
      But could the increase in errors from increased hand-offs be smaller than the increase in errors from sleep-deprived doctors, nurses and patients combined with the increase in disease spread and disease progression from the effect of sleep deprivation on the immune systems of doctors, nurses and patients? Additionally, could there be benefits from getting more eyes on a patient's condition?
    - foobarchu 8y ago
      I've always wondered if the problem might be in the handoff procedures. Those studies about mortality in the event of a handoff always make it sound like obviously handoffs are an inherently dangerous thing, but perhaps the modern way of doing them is just poorly implemented? It feels extremely unlikely to me that absurdly long hours are the only solution.
      - verelo 8y ago
        I think this is a rational question to ask! Often people will jump to conclusions "handoffs cause errors", and while errors are a symptom of handoffs executed poorly, it seems uncommon for people to often ask for improvements to these processes.
      - snowwrestler 8y ago
        There's just no way efficient way to capture, log, and communicate every single little detail a doctor observes while diagnosing and setting treatment for a patient. First impressions are often wrong, and little details can become significant later. Early treatment might be designed not only to address symptoms but to exclude other diagnoses. In a plane in level controlled flight, there is very little to hand off between two type-rated pilots. Both folks understand the machine, and the machine is working the way it is supposed to. Humans work the same way! Parents "hand off" their healthy kids to schools or babysitters or relatives every day. But imagine a plane that is in the process of crashing; it's in a dive, controls are not responding as expected, one of the engines keeps turning off. A pilot is fighting to regain control... how comfy are you with THAT pilot handing off the aircraft to another pilot in the middle of that situation? It's a little silly as an analogy, since plane crashes tend to be resolved pretty quickly one or the other. But conceptually, just imagine a plane that is in the process of maybe crashing for 12 hours. There's a good argument for a pilot to just see that through instead of "clocking out" at 8 hours.
Nasrudith 8y ago
Medicine is a conservative field - unfortunately that also includes ignoring anything harmful to their cult aspects even if it is trivially obvious like "wash your hands" after doing a damn autopsy before delivering a baby. Or yes infants can feel pain - not using anesthesia because the control isn't fine enough to not have a better chance of killing them is a grim but justifiable thing initially but inexcusable once it becomes possible to do so safely. And the sleep deprivation and hazing "I did it so everbody else must too!" is definitely a cultic thing. I use cult very deliberately to point at the reasoning being entirely irrational and social as opposed to underlying value. And also because actual cults use slerp deprivation.
IB885588 8y ago
Peter Attia (MD) had a podcast episode where he talked about being a resident and how it almost killed him (asleep while driving) and was bad for patient. Also explained that the guy who created the residency program was a cocaine addict who rarely slept, and since then all doctors have to try to follow his crazy schedule for no good reason..
- ineedasername 8y ago
  Yeah. I mean, I get that hospitals are 24-hour operations that need doctors & nurses available at all times. So some people are going to get the crap end of that stick and have to do night shifts. But is it really necessary for them to work 80+ hours while they're at it? It seems like there's enough people trying to be doctors that you could cut that down to a healthier 40 hours+ 15 hours on call if it's really necessary to. Heck, even 50 hours.
  - pc86 8y ago
    You would likely have to extend residency based on everything that you need to learn for a given specialty. Med school graduates have an average of over $180k in student loan debt - from med school alone - and resident salaries in the 2-4 year programs are mid five figures. Given the choice, I'm not sure someone whose 4-year earning potential is capped at $60k with $200k in student loans would want to extend that to 5/6/7 years.
    - antidesitter 8y ago
      I believe the GP is talking about increasing the number of doctors, not their years in residency.
      - pc86 8y ago
        You learn how to do your entire specialty during residency. If you cut the number of hours, you have the same amount to learn in less time.
da_chicken 8y ago
I used to work in hospital IT at a level 1 trauma center from 2004-2006. While I was there, an article was released which studied the relationship between time on shift and errors made by staff. As I recall (and it has been 10 years) the findings were: * Through roughly 9 hours, the error rate was about the same. Say, x% * In the 10th hour, the error rate increased. Say x + y%. * In hours 11 and 12, the amount the error rate increase doubled the 10th hour's increase. So x + 2y%. * In hours 13 and 14, the amount the error rate increase quadrupled the 10th hour's increase. So x + 4y%. * In every subsequent hour studied, the error rate increase doubled again. x + 8y% in hour 15, x + 16y% in hour 16. I want to say the study went to 18 hours, but I don't recall if it was 16 or 18 at this point. The paper made the recommendation that shift lengths should be limited to 10 hours maximum. Every health care professional I spoke to about the article (resident doctors and nurses, maybe 10 overall, mostly in the ER) said the same three things: 1. They had personally witnessed someone make an error they could attribute to tiredness. 2. They themselves had never made a mistake due to tiredness. 3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.
- technofiend 8y ago
  2. They themselves had never made a mistake due to tiredness. 3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem. I think those two items and the tribal knowledge that handoffs are more dangerous to the patient helps the overwork model persist. Sounds like it's past time the medical industry prove that handoffs are more dangerous to patient outcomes. Doctors are trained to be problem owners and problem solvers, but that doesn't make them good team players. And lowering handoffs also limits oversight and prevents second guessing which is great if you're convinced you're always right, but clearly doctors are not always right and patients often pay the price.
brahmwg 8y ago
There's been some study(s) which suggest that medical error is the 3rd leading cause of death. This may have been debunked so if wrong please correct me. https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html https://www.cnbc.com/2018/02/22/medical-errors-third-leading...
SkyPuncher 8y ago
Many sane minds would argue that, but the ACGME is actively arguing otherwise. They are actively building rules that allow residents to work longer shifts (up to 28 hours straight) while claiming these rules improve patient safety. Patient hand-offs between shifts tends to introduce errors. Instead of finding ways to improve hand-offs, the ACGME is simply trying to have fewer of them. These are supposed to be some of the "top minds" in medicine and that's the best they can come up with.
- technofiend 8y ago
  That's no really addressing the problem, it's just doubling down on the mistaken notion that the treating physician is the best one to tend to the patient under any circumstance. Doctors need to learn to be team players.

mfe5003 8y ago

I've always assumed that the failure rate for handing off care to another person and the rate because of long hours must go in favor of long hours. I don't have anything to back this up except the MCAT being designed to check how you perform when tired. Now with electronic records I've been wondering if long hours are still be necessary, assuming I'm right about the failure rates. I'm sorry about your mother in law regardless.

mattkrause 8y ago
This is the claim, but if you look at the experiments supporting it, they’re all bonkers. For example, care is no worse from doctors on 28 hr shifts vs 24. I would argue that both of these are so far from a well-rested baseline that they’re meaningless. We know from lab experiments that performance craters way, way before that, which is why pilots, truck drivers, cops, and every other profession work shorter shifts.
- jchanimal 8y ago
  All this talk is insane. I have like maybe 4 top-performing hours on my best days. The idea of working more than 8 in a life safety critical situation boggles the mind.
verelo 8y ago
Super intersting to see people discussing this! As someone that holds a pilots license and talks with a lot of commercial pilots about their jobs, sleep is often a hot topic of discussion. It would be illegal, not just irresponsible, for a pilot to try pull off a 120 hour work week. Why do we treat doctors differently? Their macho behaviour in my opinion is unacceptable, and likely reduces positive patient outcomes, yet it goes on?
- GavinMcG 8y ago
  Medicine has different concerns than piloting, though. Pilots don't have to ensure continuity of care for their passengers, and can accomplish their work in reasonable chunks. Doubling the number of patient handoffs, on the other hand, significantly increases the risk of one of the more common sources of error.
  - km3k 8y ago
    But could the increase in errors from increased hand-offs be smaller than the increase in errors from sleep-deprived doctors, nurses and patients combined with the increase in disease spread and disease progression from the effect of sleep deprivation on the immune systems of doctors, nurses and patients? Additionally, could there be benefits from getting more eyes on a patient's condition?
  - foobarchu 8y ago
    I've always wondered if the problem might be in the handoff procedures. Those studies about mortality in the event of a handoff always make it sound like obviously handoffs are an inherently dangerous thing, but perhaps the modern way of doing them is just poorly implemented? It feels extremely unlikely to me that absurdly long hours are the only solution.
    - verelo 8y ago
      I think this is a rational question to ask! Often people will jump to conclusions "handoffs cause errors", and while errors are a symptom of handoffs executed poorly, it seems uncommon for people to often ask for improvements to these processes.
    - snowwrestler 8y ago
      There's just no way efficient way to capture, log, and communicate every single little detail a doctor observes while diagnosing and setting treatment for a patient. First impressions are often wrong, and little details can become significant later. Early treatment might be designed not only to address symptoms but to exclude other diagnoses. In a plane in level controlled flight, there is very little to hand off between two type-rated pilots. Both folks understand the machine, and the machine is working the way it is supposed to. Humans work the same way! Parents "hand off" their healthy kids to schools or babysitters or relatives every day. But imagine a plane that is in the process of crashing; it's in a dive, controls are not responding as expected, one of the engines keeps turning off. A pilot is fighting to regain control... how comfy are you with THAT pilot handing off the aircraft to another pilot in the middle of that situation? It's a little silly as an analogy, since plane crashes tend to be resolved pretty quickly one or the other. But conceptually, just imagine a plane that is in the process of maybe crashing for 12 hours. There's a good argument for a pilot to just see that through instead of "clocking out" at 8 hours.

Nasrudith 8y ago

Medicine is a conservative field - unfortunately that also includes ignoring anything harmful to their cult aspects even if it is trivially obvious like "wash your hands" after doing a damn autopsy before delivering a baby. Or yes infants can feel pain - not using anesthesia because the control isn't fine enough to not have a better chance of killing them is a grim but justifiable thing initially but inexcusable once it becomes possible to do so safely. And the sleep deprivation and hazing "I did it so everbody else must too!" is definitely a cultic thing. I use cult very deliberately to point at the reasoning being entirely irrational and social as opposed to underlying value. And also because actual cults use slerp deprivation.

IB885588 8y ago

Peter Attia (MD) had a podcast episode where he talked about being a resident and how it almost killed him (asleep while driving) and was bad for patient. Also explained that the guy who created the residency program was a cocaine addict who rarely slept, and since then all doctors have to try to follow his crazy schedule for no good reason..

ineedasername 8y ago
Yeah. I mean, I get that hospitals are 24-hour operations that need doctors & nurses available at all times. So some people are going to get the crap end of that stick and have to do night shifts. But is it really necessary for them to work 80+ hours while they're at it? It seems like there's enough people trying to be doctors that you could cut that down to a healthier 40 hours+ 15 hours on call if it's really necessary to. Heck, even 50 hours.
- pc86 8y ago
  You would likely have to extend residency based on everything that you need to learn for a given specialty. Med school graduates have an average of over $180k in student loan debt - from med school alone - and resident salaries in the 2-4 year programs are mid five figures. Given the choice, I'm not sure someone whose 4-year earning potential is capped at $60k with $200k in student loans would want to extend that to 5/6/7 years.
  - antidesitter 8y ago
    I believe the GP is talking about increasing the number of doctors, not their years in residency.
    - pc86 8y ago
      You learn how to do your entire specialty during residency. If you cut the number of hours, you have the same amount to learn in less time.

da_chicken 8y ago

I used to work in hospital IT at a level 1 trauma center from 2004-2006. While I was there, an article was released which studied the relationship between time on shift and errors made by staff. As I recall (and it has been 10 years) the findings were: * Through roughly 9 hours, the error rate was about the same. Say, x% * In the 10th hour, the error rate increased. Say x + y%. * In hours 11 and 12, the amount the error rate increase doubled the 10th hour's increase. So x + 2y%. * In hours 13 and 14, the amount the error rate increase quadrupled the 10th hour's increase. So x + 4y%. * In every subsequent hour studied, the error rate increase doubled again. x + 8y% in hour 15, x + 16y% in hour 16. I want to say the study went to 18 hours, but I don't recall if it was 16 or 18 at this point. The paper made the recommendation that shift lengths should be limited to 10 hours maximum. Every health care professional I spoke to about the article (resident doctors and nurses, maybe 10 overall, mostly in the ER) said the same three things: 1. They had personally witnessed someone make an error they could attribute to tiredness. 2. They themselves had never made a mistake due to tiredness. 3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.

technofiend 8y ago
2. They themselves had never made a mistake due to tiredness. 3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem. I think those two items and the tribal knowledge that handoffs are more dangerous to the patient helps the overwork model persist. Sounds like it's past time the medical industry prove that handoffs are more dangerous to patient outcomes. Doctors are trained to be problem owners and problem solvers, but that doesn't make them good team players. And lowering handoffs also limits oversight and prevents second guessing which is great if you're convinced you're always right, but clearly doctors are not always right and patients often pay the price.

brahmwg 8y ago

There's been some study(s) which suggest that medical error is the 3rd leading cause of death. This may have been debunked so if wrong please correct me. https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html https://www.cnbc.com/2018/02/22/medical-errors-third-leading...

SkyPuncher 8y ago

Many sane minds would argue that, but the ACGME is actively arguing otherwise. They are actively building rules that allow residents to work longer shifts (up to 28 hours straight) while claiming these rules improve patient safety. Patient hand-offs between shifts tends to introduce errors. Instead of finding ways to improve hand-offs, the ACGME is simply trying to have fewer of them. These are supposed to be some of the "top minds" in medicine and that's the best they can come up with.

technofiend 8y ago
That's no really addressing the problem, it's just doubling down on the mistaken notion that the treating physician is the best one to tend to the patient under any circumstance. Doctors need to learn to be team players.