4 ms·

This comes up every once in a while when discussing the crazy 24+ hour shifts that doctors in residency are often assigned. One argument in favor of keeping the

by gundmc 4y ago

This comes up every once in a while when discussing the crazy 24+ hour shifts that doctors in residency are often assigned. One argument in favor of keeping the hours is that continuity of care is by far the factor most strongly correlated with good patient outcomes. So the argument goes that a change in caregiver is more detrimental to the patient than continued care from one doctor even if that doctor is sleep deprived. I am not knowledgeable or qualified enough to weigh in on this, but it's something I've heard cited by multiple friends in the field.

haldujai 4y ago
As a physician, shift length is honestly a red herring. As much as I hated doing 24-28 hour shifts on inpatient services, continuity of care does matter and errors do occur in handover. You have to keep in mind that medicine between 12am and 6am is what we call “keep people alive.” 6am to 12pm after an overnight is for handover. You’re not trying to diagnose a new illness overnight or make changes in management, your job is to deal with acute overnight concerns only. Furthermore, you’re supported by services such as RACE (an in hospital emergency response team) so you’re not dealing with critically ill patients alone. If you’re on a surgical service and need to go to the OR, staff/fellow + senior residents come in to help. Acute care services where you’re seeing new/undifferentiated patients and need to be on your game, such as ER and radiology, tend to limit shifts to 8-12 hours.
- gus_massa 4y ago
  > As a physician, shift length is honestly a red herring. This is how the Stockholm syndrome feels. I manage a few T.A. in the university, and they barely can think after a 6 hours of teaching (two consecutive classrooms, with like half an hour of rest in each one for the students, and perhaps another informal half an hour in the middle). Sometimes they have to speak in the blackboard, sometime grade informal take home exercises, sometimes reply questions on the spot, and they get very tired. So we have a strict 6 hours per day rule. And if they make a mistake, nobody dies!
  - haldujai 4y ago
    It’s essentially unheard of to have someone die because a resident made a mistake on call. On-call medicine is so rote as to not require much, if any, thinking. Ward medicine is far less intellectually challenging than teaching. Patients who are active/critical are not managed by a single tired resident overnight.
    - gus_massa 4y ago
      We had a case a few years ago in Argentina, when a child got an overdose of Potassium Chloride. The nurse was new in the hospital and in the previous hospital they had a different concentration, so she prepared a wrong dilution. [1]. Anyway, it's a problem that is common enough that the English NHS added it to a list of recommendations [page 8] https://www.england.nhs.uk/wp-content/uploads/2020/11/2018-Never-Events-List-updated-February-2021.pdf https://www.england.nhs.uk/wp-content/uploads/2020/11/2018-N... It looks like a random accident, but it's one of the silly mistakes that are more common when someone has worked 12 or 24 hours straight and has no checklists. [1] I tried looking for the case, because the details matter, but most of the recent news are about a case where it apparently was intentional https://www-telam-com-ar.translate.goog/notas/202208/602435-dos-bebes-nacidos-en-hospital-neonatal-de-cordoba-murieron-por-exceso-de-potasio.html?_x_tr_sl=es&_x_tr_tl=en&_x_tr_hl=es-419&_x_tr_pto=wapp https://www-telam-com-ar.translate.goog/notas/202208/602435-...
      - haldujai 4y ago
        Not sure what this has to do with resident/physician work hours. Nursing errors (i.e. administering the wrong dose) can certainly kill people. They also don’t / shouldn’t work 24 hours shifts (infrequently a nurse might work a double due to emergent staffing requirements, this is a systems issue though and not by design). There are both technological (EMR and ordering systems) and human safeguards (nurses and pharmacy) protecting against “silly mistakes” by physicians. Once again, resident physicians’ roles overnights are no where near as mission critical as a nurse. You also identified a key point in why 24 hour resident call shifts are safe - we have checklists. If I order the wrong med on the wrong patient on an overnight call shift this will be flagged by the nurse who’s checklist includes verifying order accuracy. This is especially true of medications that can have life threatening complications (e.g. insulin, potassium, hypertonic saline). Please also note I’m only talking about places I’ve trained (US and Canada) where all of these systems exist. I cannot comment on other countries where the infrastructure is different, perhaps this is more of an issue in Argentina than it is here.

by gundmc 4y ago

haldujai 4y ago

As a physician, shift length is honestly a red herring. As much as I hated doing 24-28 hour shifts on inpatient services, continuity of care does matter and errors do occur in handover. You have to keep in mind that medicine between 12am and 6am is what we call “keep people alive.” 6am to 12pm after an overnight is for handover. You’re not trying to diagnose a new illness overnight or make changes in management, your job is to deal with acute overnight concerns only. Furthermore, you’re supported by services such as RACE (an in hospital emergency response team) so you’re not dealing with critically ill patients alone. If you’re on a surgical service and need to go to the OR, staff/fellow + senior residents come in to help. Acute care services where you’re seeing new/undifferentiated patients and need to be on your game, such as ER and radiology, tend to limit shifts to 8-12 hours.

gus_massa 4y ago
> As a physician, shift length is honestly a red herring. This is how the Stockholm syndrome feels. I manage a few T.A. in the university, and they barely can think after a 6 hours of teaching (two consecutive classrooms, with like half an hour of rest in each one for the students, and perhaps another informal half an hour in the middle). Sometimes they have to speak in the blackboard, sometime grade informal take home exercises, sometimes reply questions on the spot, and they get very tired. So we have a strict 6 hours per day rule. And if they make a mistake, nobody dies!
- haldujai 4y ago
  It’s essentially unheard of to have someone die because a resident made a mistake on call. On-call medicine is so rote as to not require much, if any, thinking. Ward medicine is far less intellectually challenging than teaching. Patients who are active/critical are not managed by a single tired resident overnight.
  - gus_massa 4y ago
    We had a case a few years ago in Argentina, when a child got an overdose of Potassium Chloride. The nurse was new in the hospital and in the previous hospital they had a different concentration, so she prepared a wrong dilution. [1]. Anyway, it's a problem that is common enough that the English NHS added it to a list of recommendations [page 8] https://www.england.nhs.uk/wp-content/uploads/2020/11/2018-Never-Events-List-updated-February-2021.pdf https://www.england.nhs.uk/wp-content/uploads/2020/11/2018-N... It looks like a random accident, but it's one of the silly mistakes that are more common when someone has worked 12 or 24 hours straight and has no checklists. [1] I tried looking for the case, because the details matter, but most of the recent news are about a case where it apparently was intentional https://www-telam-com-ar.translate.goog/notas/202208/602435-dos-bebes-nacidos-en-hospital-neonatal-de-cordoba-murieron-por-exceso-de-potasio.html?_x_tr_sl=es&_x_tr_tl=en&_x_tr_hl=es-419&_x_tr_pto=wapp https://www-telam-com-ar.translate.goog/notas/202208/602435-...
    - haldujai 4y ago
      Not sure what this has to do with resident/physician work hours. Nursing errors (i.e. administering the wrong dose) can certainly kill people. They also don’t / shouldn’t work 24 hours shifts (infrequently a nurse might work a double due to emergent staffing requirements, this is a systems issue though and not by design). There are both technological (EMR and ordering systems) and human safeguards (nurses and pharmacy) protecting against “silly mistakes” by physicians. Once again, resident physicians’ roles overnights are no where near as mission critical as a nurse. You also identified a key point in why 24 hour resident call shifts are safe - we have checklists. If I order the wrong med on the wrong patient on an overnight call shift this will be flagged by the nurse who’s checklist includes verifying order accuracy. This is especially true of medications that can have life threatening complications (e.g. insulin, potassium, hypertonic saline). Please also note I’m only talking about places I’ve trained (US and Canada) where all of these systems exist. I cannot comment on other countries where the infrastructure is different, perhaps this is more of an issue in Argentina than it is here.