7 ms·

Even more disconcerting is the sleeping culture/routine throughout medical residency and fellowship; arguably, the most important stages of medical education, w

by mjfern 16y ago

Even more disconcerting is the sleeping culture/routine throughout medical residency and fellowship; arguably, the most important stages of medical education, where doctors in training learn the hands-on skills to practice medicine. Despite the importance of learning during this stage, individuals are routinely sleep-deprived: "20% of all residents reported sleeping an average of 5 hours or less per night, with 66% averaging 6 hours or less per night. Residents averaging 5 or fewer hours of sleep per night were more likely to report serious accidents or injuries, conflict with other professional staff, use of alcohol, use of medications to stay awake, noticeable weight change, working in an "impaired condition," and having made significant medical errors." - http://www.ncbi.nlm.nih.gov/pubmed/15124713 http://www.ncbi.nlm.nih.gov/pubmed/15124713 A Wikipedia article focused on medical resident work hours: http://en.wikipedia.org/wiki/Medical_resident_work_hours http://en.wikipedia.org/wiki/Medical_resident_work_hours

kylek 16y ago
One thing that I wanted to try (but never had the schedule to support) is polyphasic sleep (http://en.wikipedia.org/wiki/Polyphasic_sleep http://en.wikipedia.org/wiki/Polyphasic_sleep). The idea that sleeping 15 minutes every 4 hours (on a very strict schedule) to keep your mind close to a waking-REM-type sleep. Granted, every few weeks you would have to crash HARD (20+ hour rest).
- Jcasc 16y ago
  I also considered experimenting with this in college. I never ended up doing it, though.
  - ramchip 16y ago
    I'm... not sure what the point of such a comment can be. It's interesting in unintended ways.
- rick888 16y ago
  The problem with this is that everyone is on the regular sleep 8 hours per-night schedule and you wouldn't be able to do this if you were working a regular job.
- scott_s 16y ago
  This has come up on HN many, many times: http://news.ycombinator.com/item?id=1464142 http://news.ycombinator.com/item?id=1464142 http://news.ycombinator.com/item?id=652650 http://news.ycombinator.com/item?id=652650
- MicahSeff 16y ago
  Seeing as I have an inability to get more than five or six hours of uninterrupted sleep a night, polyphasic sleep has always appealed to me. My life is a constant struggle against sleep deprivation and running a startup for the past year hasn't helped matters one bit. Still, it's rather hard to see a way for a sleep schedule like this to be viable for most people unless it becomes the dominant way that people find their rest (which is hardly likely).
- mattm 16y ago
  From what I've read about polyphasic sleep, it doesn't seem to be best for humans. A lot of people have difficulty with it. I've come to the conclusion that people are biphasic. I think people perform their best with a long night's sleep and then a short nap around 2pm. I've noticed this works for me. YMMV.
pyre 16y ago
To some extent the sleep deprivation is a weeding process/learning experience in and of itself. Being able to perform under stress/lack of sleep is a good quality in a doctor.
- philwelch 16y ago
  How many doctors are actually weeded out after they get to their residency, though? First year of med school, absolutely. Residency is a bit late.
  - RK 16y ago
    By the time you hit residency, you are so far into debt that not having a job that pays $100k+ (eventually) is suicidal. That being said, some people do drop out. I know one person who dropped out, but was at married to another resident, so has a safety net. Another resident dropped out due to a medical condition that prevented him from standing for hours a day and landed a job at McKinsey. Another friend dropped out and became a receptionist! Eventually she went into a residency for a lower stress specialty (surgery -> psychiatry).
- esoteriq 16y ago
  Does it have to be? There are only 133 Medical Schools in the U.S. and there is a marked shortage of doctors in some areas, most notably general family doctors. The only area that learning how to deal with sleep deprivation would be a benefit is surgery and critical care areas (ICUs). But then again, if you could schedule things better and get more doctors in, maybe these doctors don't have to learn how to function on 5 hours of sleep. I think you're right to the extent that the current medical service system requires doctors to learn to sleep less and less while functioning on an acceptable level (note that I didn't say satisfactory or even exceptional). But I think that's begging the question. Shouldn't we be able to change the current system and allow doctors to focus on building skills/knowledge, not the ability to function without sleep. tl;dr: sleep deprivation is not a necessary part of being a doctor if we change the system, so saying that doctors must learn how to deal with sleep deprivation is a circular argument.
silverlake 16y ago
I've asked many doctors about this. They insist that they are not effected by sleep deprivation. They claim it is safer to have the same doctor for 24-48 hours rather than hand off a patient to a new, fresh doctor.
- hartror 16y ago
  I've had a few doctors in my family say the same thing.
- phil 16y ago
  I've heard this argument from medical residents, too. They say it's important for training to see full 24-hour cycles in a patient's care, and that shorter shifts would make that impossible.
- Poiesis 16y ago
  I don't doubt that the handoff is a risky part of the process. But that doesn't mean that we can't do a better job at figuring out how to make the handoff process better.
- Silhouette 16y ago
  That level of delusion is actually more scary than the sleep deprivation itself. It's like a guy who's driving home after a 20 hour day that ended with a couple of drinks at the bar, calling home from the car to tell the wife that he's on his way and his driving is perfectly safe. In reality, he is so impaired by the tiredness, the alcohol, and the distraction of the call that he can no longer even understand how far off his game he must be, nor judge the horrific risk he must be taking by driving in that way.
- plastics 16y ago
  The problem with sleep deprivation is that unless you have an objective way of measuring your (mental) performance you're usually not able to realize when it declines, because your're self monitoring capabilities decline as well. A simple test, that worked very well for me, was testing my reading speed (I know it is only a weak indicator for mental acuity, but it is easy and fast to test). Under perfect conditions (well rested, optimal nutrition, completely silent room, no visual distractions, after mediation and a good cup of green tea) I am able to read about 800 WPM (which is not to bad) of the kind of text I usually need to read with good retention. For me this declines rapidly to less than 200 WPM (which is quite bad for a "knowledge worker") with sleep deprivation and/or a noisy environment, even though I believe I am doing fine. That being said, even though I would say that doctors are handicapped "mental performance" is handicapped by their working conditions, I fully agree that it is better for patient safety to not hand off a patient to a new doctor say every 8 or 12 hours due to the amount implicit knowledge that a doctor gathers during a >24h time period about his patients that can't be transferred in a handoff. Software Developers, imagine what a screw up it would be if you'd have to hand off your code every 8h to another developer, who'd have to continue right were you left... add to this not having a version control system, spotty test coverage and highly ambiguous specifications
melissamiranda 16y ago
It's peculiar that medical residents are systematically sleep deprived but commercial airline pilots cannot fly/work longer than ~8. Most of the time the plane is on auto-pilot, but there's no such thing for zombie residents doing triage at the ER.
- fadec 16y ago
  I'm an airline pilot. Actually, the maximum duty day is 16 hours. The maximum time that may be spent behind the controls is 8 hours. The minimum length overnight is also 8 hours from leaving the airport to showing up again curbside. This means that transportation, food, and hygiene reduces time in the bed to about 6.5 hours, after which it is legal to work a 16 hour day. We are expecting new duty regulations later this year in response to scientific data on fatigue and the crash of Colgan 3407. Currently the data shows that on a four-day trip we are equivalently drunk with fatigue by the afternoon of day three even with around eight hours of sleep. Most people really need about nine. Personally, I've never intentionally flown fatigued but I have been surprised by it. By the time I notice I'm fatigued the heading indicator looks like alphanumeric soup and I cannot differentiate 030 from 300 from 330 without the utmost concentration. I tell myself to "THINK, DAMN IT", but that is futile. It is something that cannot be overcome. Having this experience, there is no way I'd want medical attention from fatigued doctors. Sleep is important for any safety sensitive job. It's always better to error on the side of safety.
  - melissamiranda 16y ago
    Thanks for writing, I knew about the 8 hours in the cockpit, didn't realize there were an extra 8 outside.
stick 16y ago
Yeah, the medical training model fosters a culture of working ridiculously long hours and shunning those that don't. As a first year surgical resident it's not uncommon to work 110-hour weeks and anything less than 80 feels like a joke. And, as other posters have pointed out, this is despite legislation limiting the number of work hours. The fact of the matter is that if you were to actually work to the letter of the law you'd be sneered at, receive poor evaluations, and patients would suffer because there'd be no one around to do the work. Most programs argue that these hours are necessary to train surgeons since there's not only the usual cognitive side of medicine, but also the technical side of cutting, sewing, etc. That being said, 70% of the hours I put in at the hospital are BS "scut" work which could be automated, streamlined, or passed off to assistants. The actual challenging decision points are few and far between. Thus, even the 10,000 hour rule--which a lot of programs use to defend their dismal hours--misses the mark completely since, well, the practice isn't focused. I don't think surgeons are going to be replaced by robots in a significant way for some time, but I would like to see the hands-on part of surgery being performed by techs. A three year, well planned course would be plenty to turn you into a competent operator--as competent as many just-licensed MDs. After all, do you really need 10 years of academic training (four year undergrad, fours of medical school, two years of little operating as a junior resident) to screw bones back together? Why should we expect surgeons to be technically AND intellectually gifted?
byw 16y ago
My friend is doing his residency right now. He says they make up their sleep with "power naps" during the day. http://en.wikipedia.org/wiki/Power_nap http://en.wikipedia.org/wiki/Power_nap I don't have any personal experience with this though.

by mjfern 16y ago

kylek 16y ago

One thing that I wanted to try (but never had the schedule to support) is polyphasic sleep (http://en.wikipedia.org/wiki/Polyphasic_sleep http://en.wikipedia.org/wiki/Polyphasic_sleep). The idea that sleeping 15 minutes every 4 hours (on a very strict schedule) to keep your mind close to a waking-REM-type sleep. Granted, every few weeks you would have to crash HARD (20+ hour rest).

Jcasc 16y ago
I also considered experimenting with this in college. I never ended up doing it, though.
- ramchip 16y ago
  I'm... not sure what the point of such a comment can be. It's interesting in unintended ways.
rick888 16y ago
The problem with this is that everyone is on the regular sleep 8 hours per-night schedule and you wouldn't be able to do this if you were working a regular job.
scott_s 16y ago
This has come up on HN many, many times: http://news.ycombinator.com/item?id=1464142 http://news.ycombinator.com/item?id=1464142 http://news.ycombinator.com/item?id=652650 http://news.ycombinator.com/item?id=652650
MicahSeff 16y ago
Seeing as I have an inability to get more than five or six hours of uninterrupted sleep a night, polyphasic sleep has always appealed to me. My life is a constant struggle against sleep deprivation and running a startup for the past year hasn't helped matters one bit. Still, it's rather hard to see a way for a sleep schedule like this to be viable for most people unless it becomes the dominant way that people find their rest (which is hardly likely).
mattm 16y ago
From what I've read about polyphasic sleep, it doesn't seem to be best for humans. A lot of people have difficulty with it. I've come to the conclusion that people are biphasic. I think people perform their best with a long night's sleep and then a short nap around 2pm. I've noticed this works for me. YMMV.

pyre 16y ago

To some extent the sleep deprivation is a weeding process/learning experience in and of itself. Being able to perform under stress/lack of sleep is a good quality in a doctor.

philwelch 16y ago
How many doctors are actually weeded out after they get to their residency, though? First year of med school, absolutely. Residency is a bit late.
- RK 16y ago
  By the time you hit residency, you are so far into debt that not having a job that pays $100k+ (eventually) is suicidal. That being said, some people do drop out. I know one person who dropped out, but was at married to another resident, so has a safety net. Another resident dropped out due to a medical condition that prevented him from standing for hours a day and landed a job at McKinsey. Another friend dropped out and became a receptionist! Eventually she went into a residency for a lower stress specialty (surgery -> psychiatry).
esoteriq 16y ago
Does it have to be? There are only 133 Medical Schools in the U.S. and there is a marked shortage of doctors in some areas, most notably general family doctors. The only area that learning how to deal with sleep deprivation would be a benefit is surgery and critical care areas (ICUs). But then again, if you could schedule things better and get more doctors in, maybe these doctors don't have to learn how to function on 5 hours of sleep. I think you're right to the extent that the current medical service system requires doctors to learn to sleep less and less while functioning on an acceptable level (note that I didn't say satisfactory or even exceptional). But I think that's begging the question. Shouldn't we be able to change the current system and allow doctors to focus on building skills/knowledge, not the ability to function without sleep. tl;dr: sleep deprivation is not a necessary part of being a doctor if we change the system, so saying that doctors must learn how to deal with sleep deprivation is a circular argument.

silverlake 16y ago

I've asked many doctors about this. They insist that they are not effected by sleep deprivation. They claim it is safer to have the same doctor for 24-48 hours rather than hand off a patient to a new, fresh doctor.

hartror 16y ago
I've had a few doctors in my family say the same thing.
phil 16y ago
I've heard this argument from medical residents, too. They say it's important for training to see full 24-hour cycles in a patient's care, and that shorter shifts would make that impossible.
Poiesis 16y ago
I don't doubt that the handoff is a risky part of the process. But that doesn't mean that we can't do a better job at figuring out how to make the handoff process better.
Silhouette 16y ago
That level of delusion is actually more scary than the sleep deprivation itself. It's like a guy who's driving home after a 20 hour day that ended with a couple of drinks at the bar, calling home from the car to tell the wife that he's on his way and his driving is perfectly safe. In reality, he is so impaired by the tiredness, the alcohol, and the distraction of the call that he can no longer even understand how far off his game he must be, nor judge the horrific risk he must be taking by driving in that way.
plastics 16y ago
The problem with sleep deprivation is that unless you have an objective way of measuring your (mental) performance you're usually not able to realize when it declines, because your're self monitoring capabilities decline as well. A simple test, that worked very well for me, was testing my reading speed (I know it is only a weak indicator for mental acuity, but it is easy and fast to test). Under perfect conditions (well rested, optimal nutrition, completely silent room, no visual distractions, after mediation and a good cup of green tea) I am able to read about 800 WPM (which is not to bad) of the kind of text I usually need to read with good retention. For me this declines rapidly to less than 200 WPM (which is quite bad for a "knowledge worker") with sleep deprivation and/or a noisy environment, even though I believe I am doing fine. That being said, even though I would say that doctors are handicapped "mental performance" is handicapped by their working conditions, I fully agree that it is better for patient safety to not hand off a patient to a new doctor say every 8 or 12 hours due to the amount implicit knowledge that a doctor gathers during a >24h time period about his patients that can't be transferred in a handoff. Software Developers, imagine what a screw up it would be if you'd have to hand off your code every 8h to another developer, who'd have to continue right were you left... add to this not having a version control system, spotty test coverage and highly ambiguous specifications

melissamiranda 16y ago

It's peculiar that medical residents are systematically sleep deprived but commercial airline pilots cannot fly/work longer than ~8. Most of the time the plane is on auto-pilot, but there's no such thing for zombie residents doing triage at the ER.

fadec 16y ago
I'm an airline pilot. Actually, the maximum duty day is 16 hours. The maximum time that may be spent behind the controls is 8 hours. The minimum length overnight is also 8 hours from leaving the airport to showing up again curbside. This means that transportation, food, and hygiene reduces time in the bed to about 6.5 hours, after which it is legal to work a 16 hour day. We are expecting new duty regulations later this year in response to scientific data on fatigue and the crash of Colgan 3407. Currently the data shows that on a four-day trip we are equivalently drunk with fatigue by the afternoon of day three even with around eight hours of sleep. Most people really need about nine. Personally, I've never intentionally flown fatigued but I have been surprised by it. By the time I notice I'm fatigued the heading indicator looks like alphanumeric soup and I cannot differentiate 030 from 300 from 330 without the utmost concentration. I tell myself to "THINK, DAMN IT", but that is futile. It is something that cannot be overcome. Having this experience, there is no way I'd want medical attention from fatigued doctors. Sleep is important for any safety sensitive job. It's always better to error on the side of safety.
- melissamiranda 16y ago
  Thanks for writing, I knew about the 8 hours in the cockpit, didn't realize there were an extra 8 outside.

stick 16y ago

Yeah, the medical training model fosters a culture of working ridiculously long hours and shunning those that don't. As a first year surgical resident it's not uncommon to work 110-hour weeks and anything less than 80 feels like a joke. And, as other posters have pointed out, this is despite legislation limiting the number of work hours. The fact of the matter is that if you were to actually work to the letter of the law you'd be sneered at, receive poor evaluations, and patients would suffer because there'd be no one around to do the work. Most programs argue that these hours are necessary to train surgeons since there's not only the usual cognitive side of medicine, but also the technical side of cutting, sewing, etc. That being said, 70% of the hours I put in at the hospital are BS "scut" work which could be automated, streamlined, or passed off to assistants. The actual challenging decision points are few and far between. Thus, even the 10,000 hour rule--which a lot of programs use to defend their dismal hours--misses the mark completely since, well, the practice isn't focused. I don't think surgeons are going to be replaced by robots in a significant way for some time, but I would like to see the hands-on part of surgery being performed by techs. A three year, well planned course would be plenty to turn you into a competent operator--as competent as many just-licensed MDs. After all, do you really need 10 years of academic training (four year undergrad, fours of medical school, two years of little operating as a junior resident) to screw bones back together? Why should we expect surgeons to be technically AND intellectually gifted?

byw 16y ago

My friend is doing his residency right now. He says they make up their sleep with "power naps" during the day. http://en.wikipedia.org/wiki/Power_nap http://en.wikipedia.org/wiki/Power_nap I don't have any personal experience with this though.