Physician Training Stress and Accelerated Cellular Aging(biologicalpsychiatryjournal.com)
biologicalpsychiatryjournal.com
Physician Training Stress and Accelerated Cellular Aging
https://www.biologicalpsychiatryjournal.com/article/S0006-3223(19)31329-0/fulltext
56 comments
As a former surgical resident, can reluctantly confirm. I've had many conversations half-asleep where I've afterwards been slightly uncertain of whether I just had a conversation with someone or was dreaming.
That said though, those situations generally concern relatively safe decisions, like minor pain killer dosage adjustments. If what the nurse calls about is sufficiently serious, adrenaline kicks in - and that thing can get you going really fast.
Actually, I wouldn't be surprised if some of the most expensive (in telomeric sense) part of residency is exactly that; the situations of mobilization from near-zombie sleep state to hypervigilance within seconds.
Naturally residency can and should be organized better than it is, but there are reasons why things are fundamentally organized the way they are as well. From a resident's perspective, on-call time primarily buys you time for elective surgeries - where the real learning happens.
That said though, those situations generally concern relatively safe decisions, like minor pain killer dosage adjustments. If what the nurse calls about is sufficiently serious, adrenaline kicks in - and that thing can get you going really fast.
Actually, I wouldn't be surprised if some of the most expensive (in telomeric sense) part of residency is exactly that; the situations of mobilization from near-zombie sleep state to hypervigilance within seconds.
Naturally residency can and should be organized better than it is, but there are reasons why things are fundamentally organized the way they are as well. From a resident's perspective, on-call time primarily buys you time for elective surgeries - where the real learning happens.
What are some good reasons that things are organized this way?
I’ve heard that long shifts help with continuity as fewer doctors need to pass information about the same patient thus reducing communications overhead a bit. Anything else?
If only that, it seems the drawbacks in terms of risks to care quality as well as to the resident’s learning & long-term health may be greater than the benefits.
I’ve heard that long shifts help with continuity as fewer doctors need to pass information about the same patient thus reducing communications overhead a bit. Anything else?
If only that, it seems the drawbacks in terms of risks to care quality as well as to the resident’s learning & long-term health may be greater than the benefits.
I think 'needlesurgeon's answer otherplace in this thread answers this well. Especially in adressing the point that it is in a way essentially a numbers game; It takes a certain patient population size to provide sufficient volume and diversity of cases per year to educate a certain number of surgeons over a certain span of years. You could make on-call easier by thinning this out over more surgeons-in-training, but then it would take almost twice as long for them to get the same experience. The problem with this is that the duration of a normal career isn't really that long compared to the time it takes to master a surgical field. If you work really hard and have great progression, you may be able to be top notch in your field for maybe 5 years before your skills start to decline.
Also, those surgeons who are on top of their fields are incredibly important for the field as a whole, as it is they who inform all other surgeons through a kind of cascade of consultations.
The thing with continuity is right. Hand-overs always means some degree of information loss, especially for non-verbal information. One of the most imporant clues indicating need for surgery can be the character of stomach pains upon manual examination for example. If the same surgeon does the examination with some hours intervals, he or she may be able to detect subtle signs of deterioration which a new surgeon would not.
> resident’s [...] long-term health
Oh. Well. Haha. When an anesthesiologist colleague of mine commited suicide at one point the only thing we were told at the morning briefing was that the planned surgeries of the day would regrettably not be initiated exactly on time.
The thing with continuity is right. Hand-overs always means some degree of information loss, especially for non-verbal information. One of the most imporant clues indicating need for surgery can be the character of stomach pains upon manual examination for example. If the same surgeon does the examination with some hours intervals, he or she may be able to detect subtle signs of deterioration which a new surgeon would not.
> resident’s [...] long-term health
Oh. Well. Haha. When an anesthesiologist colleague of mine commited suicide at one point the only thing we were told at the morning briefing was that the planned surgeries of the day would regrettably not be initiated exactly on time.
The learning curve argument boils down to "yes actually long term sleep deprived surgeons learn faster then rested ones unlike the rest of population".
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Patient deaths rise during residency programs, meaning that we’re not only burning out the residents but we’re also killing random civilians for the sake of the residency program.
It's well known that mortality rates spike when new residents enter hospitals:
https://www.nber.org/digest/sep05/w11182.html
> They'll page them to consult on something, usually waking them up.
IME they're usually not asleep.
IME they're usually not asleep.
The pioneers of the modern residency system were fueled by copious amounts of cocaine & other stimulants. Perhaps we need to reevaluate the requirements & expectations we place on medical residents today. It's essentially a form of professional hazing, and I personally know many surgical residents that are literally operating on people today while absurdly sleep deprived (by no fault of their own, just the insane hours of their program).
That said, if whoever's operating on me is running on 3 hours of sleep I'd rather they be hopped up on stimulants than not...
https://en.wikipedia.org/wiki/William_Stewart_Halsted
That said, if whoever's operating on me is running on 3 hours of sleep I'd rather they be hopped up on stimulants than not...
https://en.wikipedia.org/wiki/William_Stewart_Halsted
One time I met with the head of an union and he told me many tough jobs (mining mainly) were perfomed while on drugs, which aren't available anymore causing all kinds of issues for the workers. I wonder if there was truth in that statement and maybe some formal research on this.
As I recall, the CIA did do a fair amount of this research on this, up to and including implanted cortical stimulators, which created some serious backlash.
Getting prescribed "on/off" switches in pill form is a well-known thing in the military. You just can't do combat air patrol over remote areas of Asia without some uppers. This quickly went from the pilots (mid-grade officers) and other fight crew, to being adopted by folks who have to go halfway around the world routinely (flag officers).
It's an active topic of conversation, some do, some don't. As a military physician who was a line officer and has been through 5 years of graduate medical education (internship + residency), and now occasionally has to do those round-the-world trips, it's not clear to me that there's an obvious right answer in policy or per-person. We (leaders and followers alike) expect leaders to function at the outer limits of human capacity, and have for a long time. I can tell you this: it doesn't get easier with age: a fairly common definition of success as a leader is proving your ability to take on more responsibility, so the more you do, the harder it gets. So avoid starting early.
Getting prescribed "on/off" switches in pill form is a well-known thing in the military. You just can't do combat air patrol over remote areas of Asia without some uppers. This quickly went from the pilots (mid-grade officers) and other fight crew, to being adopted by folks who have to go halfway around the world routinely (flag officers).
It's an active topic of conversation, some do, some don't. As a military physician who was a line officer and has been through 5 years of graduate medical education (internship + residency), and now occasionally has to do those round-the-world trips, it's not clear to me that there's an obvious right answer in policy or per-person. We (leaders and followers alike) expect leaders to function at the outer limits of human capacity, and have for a long time. I can tell you this: it doesn't get easier with age: a fairly common definition of success as a leader is proving your ability to take on more responsibility, so the more you do, the harder it gets. So avoid starting early.
I’ve worked on a human performance assessment program for nearly 10 years.
We induce stressors cross the spectrum to better inoculate volunteer candidates from stress and enhance their resiliency.
They are often suffering from sleep deprivation/deficit.
We have very robust safety procedures in place.
After observing hundreds of volunteer candidates in depth over nearly a decade, I would say that sleep deprivation/deficit is an exceptionally and deceptively dangerous problem.
Akin to carbon monoxide poisoning in a way.
Members of the military and first responders may need to operate for extended periods with little to no sleep/rest. And that includes physicians in training for things like mass casualty scenarios.
So it IS worthwhile to possess “reference points” of personal adversity to manage decision making while stressed.
But to LIVE a sleep deprived life of a physician resident is nothing short of madness and a recipe for failure.
I’ve been under Assessment. And it certainly feels like it ages you prematurely. And anecdotally, it appears to do so to many of our candidates. Temporarily.
I’ve had my telomeres measured a few times.
Fortunately, active effort to target 7+ hours of daily consistent sleep, fitness, nutrition, and other choices seem to play a factor in outlier telomere length.
Or I’m just lucky.
Just because we have always done it this way with residents, doesn’t mean we should.
We induce stressors cross the spectrum to better inoculate volunteer candidates from stress and enhance their resiliency.
They are often suffering from sleep deprivation/deficit.
We have very robust safety procedures in place.
After observing hundreds of volunteer candidates in depth over nearly a decade, I would say that sleep deprivation/deficit is an exceptionally and deceptively dangerous problem.
Akin to carbon monoxide poisoning in a way.
Members of the military and first responders may need to operate for extended periods with little to no sleep/rest. And that includes physicians in training for things like mass casualty scenarios.
So it IS worthwhile to possess “reference points” of personal adversity to manage decision making while stressed.
But to LIVE a sleep deprived life of a physician resident is nothing short of madness and a recipe for failure.
I’ve been under Assessment. And it certainly feels like it ages you prematurely. And anecdotally, it appears to do so to many of our candidates. Temporarily.
I’ve had my telomeres measured a few times.
Fortunately, active effort to target 7+ hours of daily consistent sleep, fitness, nutrition, and other choices seem to play a factor in outlier telomere length.
Or I’m just lucky.
Just because we have always done it this way with residents, doesn’t mean we should.
>We induce stressors cross the spectrum to better inoculate volunteer candidates from stress and enhance their resiliency.
Oh god. That gives me flashbacks to university. They gave us this super messed up exam schedule - writing majority of waking hours & not knowing what class/course/topic you're walking into. Asked the profs WTF is up with the cruel exam plan and that was that exact answer: The professional exam (country's CPA equivalent) is structured like this so yeah we structured your exams to intentionally & artificially create stress. Dry run for that level of unreasonable pressure. Never occurred to me that my uni profs might be out to intentionally stress me before that comment.
Speaking of residents - that's a key thing that gets me through all that stuff. Reminding myself that I'm not a surgeon...nobody dies if I screw up. I can do crazy stress, long hours, little sleep like a boss but 99% sure I could not emotionally do that if my steady hand determines whether someone lives. The people that can - happy concede that they are a better man than I am.
Oh god. That gives me flashbacks to university. They gave us this super messed up exam schedule - writing majority of waking hours & not knowing what class/course/topic you're walking into. Asked the profs WTF is up with the cruel exam plan and that was that exact answer: The professional exam (country's CPA equivalent) is structured like this so yeah we structured your exams to intentionally & artificially create stress. Dry run for that level of unreasonable pressure. Never occurred to me that my uni profs might be out to intentionally stress me before that comment.
Speaking of residents - that's a key thing that gets me through all that stuff. Reminding myself that I'm not a surgeon...nobody dies if I screw up. I can do crazy stress, long hours, little sleep like a boss but 99% sure I could not emotionally do that if my steady hand determines whether someone lives. The people that can - happy concede that they are a better man than I am.
> The professional exam (country's CPA equivalent) is structured like this so yeah we structured your exams to intentionally & artificially create stress.
Even on second and third thought this seems insane. I can understand doing it on something that turns out to be relatively inconsequential as a learning experience, but doing it for people's PEs and final exams? That sounds like a great way to overwhelm every possible feature related to engineering quality in favor of "how well do they survive an unrealistically horrible stress-test". Because, like you said, nobody dies if you screw up. Being able to handle acute stress is not that useful for a civil engineer or similar. Teaching people to handle chronic stress? Maybe, but the research I see says that there is no way to deal with chronic stress and even attempting it damages you, potentially permanently. Acute stress, nope.
Even on second and third thought this seems insane. I can understand doing it on something that turns out to be relatively inconsequential as a learning experience, but doing it for people's PEs and final exams? That sounds like a great way to overwhelm every possible feature related to engineering quality in favor of "how well do they survive an unrealistically horrible stress-test". Because, like you said, nobody dies if you screw up. Being able to handle acute stress is not that useful for a civil engineer or similar. Teaching people to handle chronic stress? Maybe, but the research I see says that there is no way to deal with chronic stress and even attempting it damages you, potentially permanently. Acute stress, nope.
>this seems insane
A little bit. Big part of the issue was that the professional exam results were published by originating university.
So there was this really perverse incentive for universities to send only the most battle hardened candidates into the process to kept the very public stats on the uni's performance on these independent professional exams high.
And if you think that's wild - it gets better. This being HN: Some enterprising genius looked at this entire process and decided he's going to set up a recruitment company that does nothing other than exporting survivors of above process. Literally park them anywhere globally - nothing really matters & nobody cares where cause clearly these guys can cope and collecting a juicy placement fee is easy money. One of the best/safest business models I've ever seen - leverages a beautifully subtle anomaly in the global labour market that isn't immediately obvious to outsiders.
>Being able to handle acute stress is not that useful for a civil engineer or similar.
Alas in my particular world (Accounting/auditing) it is. 3 months of soul crushing stress and rest of year is more relaxed. Rinse & repeat.
>Teaching people to handle chronic stress?
That's one saving grace I guess. I find that 3 months of intense stress is bearable. Or rather it's about the limit of my endurance.
Certainly not healthy - talking about this purely practically.
A little bit. Big part of the issue was that the professional exam results were published by originating university.
So there was this really perverse incentive for universities to send only the most battle hardened candidates into the process to kept the very public stats on the uni's performance on these independent professional exams high.
And if you think that's wild - it gets better. This being HN: Some enterprising genius looked at this entire process and decided he's going to set up a recruitment company that does nothing other than exporting survivors of above process. Literally park them anywhere globally - nothing really matters & nobody cares where cause clearly these guys can cope and collecting a juicy placement fee is easy money. One of the best/safest business models I've ever seen - leverages a beautifully subtle anomaly in the global labour market that isn't immediately obvious to outsiders.
>Being able to handle acute stress is not that useful for a civil engineer or similar.
Alas in my particular world (Accounting/auditing) it is. 3 months of soul crushing stress and rest of year is more relaxed. Rinse & repeat.
>Teaching people to handle chronic stress?
That's one saving grace I guess. I find that 3 months of intense stress is bearable. Or rather it's about the limit of my endurance.
Certainly not healthy - talking about this purely practically.
> Alas in my particular world (Accounting/auditing) it is. 3 months of soul crushing stress and rest of year is more relaxed. Rinse & repeat.
Cripes.
And I bet that the soul-crushing stress even after you've gotten the license is probably because you don't have enough people licensed to do the work, which in turn is because the universities try to keep their stats high which artificially restricts the supply. And there's probably a feedback loop going on where the industry considers the stress "normal" and adds it to the PE because "that's how the industry is and you need to be able to handle it", normalizing the deviance and inducing evaporative cooling [1].
No offense, and thank you for being able to handle your job because auditing is one of those things that's certainly necessary for the smooth functioning of civilization and it really sounds to me like the supply of that capability is dangerously restricted, but... yet again I am thankful that my interests guided me to a career in software engineering.
1. https://www.lesswrong.com/posts/ZQG9cwKbct2LtmL3p/evaporativ...
Cripes.
And I bet that the soul-crushing stress even after you've gotten the license is probably because you don't have enough people licensed to do the work, which in turn is because the universities try to keep their stats high which artificially restricts the supply. And there's probably a feedback loop going on where the industry considers the stress "normal" and adds it to the PE because "that's how the industry is and you need to be able to handle it", normalizing the deviance and inducing evaporative cooling [1].
No offense, and thank you for being able to handle your job because auditing is one of those things that's certainly necessary for the smooth functioning of civilization and it really sounds to me like the supply of that capability is dangerously restricted, but... yet again I am thankful that my interests guided me to a career in software engineering.
1. https://www.lesswrong.com/posts/ZQG9cwKbct2LtmL3p/evaporativ...
Yeah sometimes I wonder about that career choice of mine. Software or actual engineering would have been cool.
>it really sounds to me like the supply of that capability is dangerously restricted
In some countries yes quite restricted, don't think dangerously so. Way more scared of them rubberstamping poor candidates. Plus auditing isn't particularly difficult to be honest.
>one of those things that's certainly necessary for the smooth functioning of civilization
Maybe. I'm not 100% convinced. I'll definitely take the job security though.
>it really sounds to me like the supply of that capability is dangerously restricted
In some countries yes quite restricted, don't think dangerously so. Way more scared of them rubberstamping poor candidates. Plus auditing isn't particularly difficult to be honest.
>one of those things that's certainly necessary for the smooth functioning of civilization
Maybe. I'm not 100% convinced. I'll definitely take the job security though.
I definitely agree with teaching all folks to both mitigate for physical/mental/emotional/social stressors as well as for making effective decisions while experiencing stress.
Chronic stress is an interesting choice of words.
I believe far more people than we realise experience chronic stress, some of which can be mitigated effectively, and some not.
I don’t think it’s worth training people to mitigate for extreme stress unless their profession compels/requires it.
Risk of permanent damage is real.
Chronic stress is an interesting choice of words.
I believe far more people than we realise experience chronic stress, some of which can be mitigated effectively, and some not.
I don’t think it’s worth training people to mitigate for extreme stress unless their profession compels/requires it.
Risk of permanent damage is real.
Wow!
That sounds fascinating.
I’ve never heard of such an example of specifically induced stress in academia.
The concept sounds intriguing, but I wonder if the inducement of stress in a testing environment as an add-on/addendum after would be of value. Effectively two tests, one with and one without induced stress. Experimental/control groups.
That sounds fascinating.
I’ve never heard of such an example of specifically induced stress in academia.
The concept sounds intriguing, but I wonder if the inducement of stress in a testing environment as an add-on/addendum after would be of value. Effectively two tests, one with and one without induced stress. Experimental/control groups.
A decade or two back, the US Navy used the recruiting slogan "Accelerate Your Life."
On submarines, it wasn't uncommon to see men who looked unusually old: full head of grey hair before age 40, perhaps.
I have never been a medical resident, but submarine service can be pretty damn stressful; we jokingly called the service "the life accelerator" because of how fast people seemed to age.
I always chalked it up to natural deviation, but maybe it'll turn out to be a genuine effect of sustained stress.
On submarines, it wasn't uncommon to see men who looked unusually old: full head of grey hair before age 40, perhaps.
I have never been a medical resident, but submarine service can be pretty damn stressful; we jokingly called the service "the life accelerator" because of how fast people seemed to age.
I always chalked it up to natural deviation, but maybe it'll turn out to be a genuine effect of sustained stress.
Are submarines more stressful than surface ships? I was never in the Navy but I've heard surface warfare officers complain that they were constantly sleep deprived. Between standing watches, training, maintenance, and managing subordinates they barely got a few hours of poor quality sleep per day.
I was never permanent crew on a surface ship, but that story certainly sounds familiar. For added fun, though, submarine crews are divorced from circadian rhythms: a submarine "day" is 18 hours long rather than 24.
Subs keep their air at significantly lower oxygen concentrations for fire safety reasons which may contribute to the stress. I had a teacher tell stories about sailors putting bags over whatever emitted the oxygen and then breathing it directly.
The average PPO₂ on submarines appears to be no lower than the air in Aspen CO. People living in Aspen don't age faster than normal. Since higher oxygen levels cause oxidative stress in the body it's even possible that lower oxygen might protect against some aging symptoms.
Isn't the new meta that aging isn't due to oxidization but to an impairment to the body's anti-oxidization mechanism due to under-oxidization? Because, if that's the case, more oxygen would slow your aging by putting your anti-oxidization system to work.
None of this is oversimplified and stupid.
None of this is oversimplified and stupid.
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This is not strictly true. Shipyard maintenance periods are one of the most stressful times, and the boat is openly ventilated.
What's important for fire safety is not letting oxygen get above normal atmospheric concentrations.
What's important for fire safety is not letting oxygen get above normal atmospheric concentrations.
Ahh my fault. I'll have to let my high school chemistry teacher know to stop using that story lol.
Not surprised at all. I have friends still in med school. Apparently there’s an exam called the Step 1 where you can only take it once, and if you pass but don’t do well enough then you get shipped to somewhere not great to do your residency. I thought the hardest part was the MCAT but I was totally wrong :(
Step 1 can be retaken, along with all the other exams of the USMLE.
You’re right; you can retake the Step 1 up to six times. However, you can retake it if you fail, you can’t retake if you pass. AFAIR that’s what my friends were worried about; you can retake if you fail but if you were planning on failing why retake it. It’s the pass with a low score that sends you to a bad place.
Correct.
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Just graduated from medical school. Started out with 0 gray hairs. Now I have salt and pepper hair on the sides. Not worth it.
North American Neurosurgeon here. My opinions are based on my personal experience and my understanding of the literature. I am not an expert in residency well-being or work-hour restrictions.
First: the literature is unequivocal about the effects of chronic sleep deprivation. This cellular aging article fits within what is known already. Sleep deprived humans are dumber, more stressed, and now age faster that non-sleep deprived humans.
The tacit assumption for work-hour restrictions is that sleep deprived physicians result in inferior medical care for patients. It turns out that the literature does not support the tacit assumption. When researchers looked at complications/mortality pre- and post- work-hour restriction, there was no difference. This result is somewhat counter-intuitive, and has been reproduced in various contexts. The one mortality benefit that has been for physicians themselves: less physicians get into car accidents after their call shifts. It's worth noting that there is literature to suggest that less ICU errors are made by sleepy residents, however, this also didn't translate into mortality differences.
So what's happening? There are a few interpretations of these results. The first is that resident physicians really aren't important for patient care, and that the majority of care provided comes from attending physicians. For anyone who has been admitted to an academic institution, this interpretation is silly and is unsatisfying.
The second is that there are sufficient checks and balances. When a sleepy physician makes a silly mistake, nurses can catch errors "this patient has an infection; are you sure you don't want to start antibiotics?" and pharmacists can catch errors "You ordered a hundred times the lethal dose. I'll correct that for you." When the day-team comes by and hears about the patient, they can quickly fix the errors made. Having made some silly errors myself, this certainly plays at least part of what happens.
The third is that most of medicine is rote. Frankly, after a few years of doing the same thing over and over again, you don't really need that much brain power to do a lot of medicine. I have admitted hundreds of people with brain tumors over the years, and the immediate workup and management for the majority for patients is identical. I can do this in a sleep-deprived state. I am not saying that some cases are more complicated than others. As a HN analogy: consider how much sleep you need to print "Hello World!" in your favorite language.
The fourth is that the ability to capture complications / mortality is increasing at the same rate as residency work hour restrictions are resulting in better patient care. In other words, we're searching and finding problems we wouldn't have caught otherwise. It's hard to counter this argument, but I don't know of any data for or against this position.
There are certainly more reasons, but I think the point is made. It's not obvious, it's multifactorial, but it's definitely robust.
OK, so the obvious question is this: Why do resident physicians need to work so hard?
First, let's look at the statistics. Suppose you're providing neurosurgical care for a catchment area of a million people. Brain tumors, as a category, affect 1:10,000 people. This means you'll be admitting 100 new brain tumors a year. However, not all brain tumors are the same (in fact, depending on how you want to slice the pie and what you consider a tumor, there are on the order of 200 different tumor diagnoses). Some tumors are common (e.g. metastatic lung tumors) and some are literally a one in a million diagnosis. In order to see the gamut of tumors in your training, you simply need the time in hospital. In my estimation, brain tumor surgery has a mean of 3.5 hours, with 95% of the cases being between 90 minutes and 24 hours. This means that the average academic center is doing at most two tumors per day. The argument here is that you need the hours to see the cases. There's no doubt that sleepier doctors learn worse than non-sleepy doctors. But I can tell you that I have participated in very rare operations in sleep deprived states, and I remember the approaches much better than common operations I've seen in non-sleep deprived states.
Suppose we are interested in maximizing physician well-being, regardless of the literature supporting patient outcomes. The simple solution is to simply restrict work hours. So, who runs the hospitals? One approach is to hire more residents. Well, residents eventually need jobs. Suffice it to say, swamping the medical profession with more doctors who have less training is not an intuitively satisfying solution to the problem. Moreover, more doctors means more handovers. Increasing handovers has been shown to result in order more unnecessary tests for patients, and to result in inferior patient care.
Restricting work hours means that surgeons may have to train longer. Well, at minimum in the US, becoming a neurosurgeon is 4 + 4 + 7 years of post-secondary education (undergraduate, medical school, residency -- residency used to be 6 years). Many residents choose to become subspecialists, adding another year or two (or possibly 3 or 4). Further work hour restrictions could turn the 15-year training process into a 16 or 17 year process. Fair enough, this could solve the problem. But really? From a purely economic perspective, this is silly. Think of the opportunity cost of educating yourself for 20 years (i.e. 20 years of debt) to work for 25 more before being asked to retire.
Suffice it to say, it's a tough problem. In recognition of this last point, many specialties are moving towards competency based training. That is, graduating surgeons when they meet a competency rather than having spent sufficient time in hospital. This is a no brainer in other fields (e.g. flying planes, building bridges). While this is in fact reflecting the times (greater emphasis on patient safety than in the past), there's no doubt in my mind that this is being implemented because those in power feel that they are graduating surgeons less competent than the generation before them.
This last point, is in my opinion, the important question to ask. If anyone knows of any literature about this last point, I'd be grateful.
First: the literature is unequivocal about the effects of chronic sleep deprivation. This cellular aging article fits within what is known already. Sleep deprived humans are dumber, more stressed, and now age faster that non-sleep deprived humans.
The tacit assumption for work-hour restrictions is that sleep deprived physicians result in inferior medical care for patients. It turns out that the literature does not support the tacit assumption. When researchers looked at complications/mortality pre- and post- work-hour restriction, there was no difference. This result is somewhat counter-intuitive, and has been reproduced in various contexts. The one mortality benefit that has been for physicians themselves: less physicians get into car accidents after their call shifts. It's worth noting that there is literature to suggest that less ICU errors are made by sleepy residents, however, this also didn't translate into mortality differences.
So what's happening? There are a few interpretations of these results. The first is that resident physicians really aren't important for patient care, and that the majority of care provided comes from attending physicians. For anyone who has been admitted to an academic institution, this interpretation is silly and is unsatisfying.
The second is that there are sufficient checks and balances. When a sleepy physician makes a silly mistake, nurses can catch errors "this patient has an infection; are you sure you don't want to start antibiotics?" and pharmacists can catch errors "You ordered a hundred times the lethal dose. I'll correct that for you." When the day-team comes by and hears about the patient, they can quickly fix the errors made. Having made some silly errors myself, this certainly plays at least part of what happens.
The third is that most of medicine is rote. Frankly, after a few years of doing the same thing over and over again, you don't really need that much brain power to do a lot of medicine. I have admitted hundreds of people with brain tumors over the years, and the immediate workup and management for the majority for patients is identical. I can do this in a sleep-deprived state. I am not saying that some cases are more complicated than others. As a HN analogy: consider how much sleep you need to print "Hello World!" in your favorite language.
The fourth is that the ability to capture complications / mortality is increasing at the same rate as residency work hour restrictions are resulting in better patient care. In other words, we're searching and finding problems we wouldn't have caught otherwise. It's hard to counter this argument, but I don't know of any data for or against this position.
There are certainly more reasons, but I think the point is made. It's not obvious, it's multifactorial, but it's definitely robust.
OK, so the obvious question is this: Why do resident physicians need to work so hard?
First, let's look at the statistics. Suppose you're providing neurosurgical care for a catchment area of a million people. Brain tumors, as a category, affect 1:10,000 people. This means you'll be admitting 100 new brain tumors a year. However, not all brain tumors are the same (in fact, depending on how you want to slice the pie and what you consider a tumor, there are on the order of 200 different tumor diagnoses). Some tumors are common (e.g. metastatic lung tumors) and some are literally a one in a million diagnosis. In order to see the gamut of tumors in your training, you simply need the time in hospital. In my estimation, brain tumor surgery has a mean of 3.5 hours, with 95% of the cases being between 90 minutes and 24 hours. This means that the average academic center is doing at most two tumors per day. The argument here is that you need the hours to see the cases. There's no doubt that sleepier doctors learn worse than non-sleepy doctors. But I can tell you that I have participated in very rare operations in sleep deprived states, and I remember the approaches much better than common operations I've seen in non-sleep deprived states.
Suppose we are interested in maximizing physician well-being, regardless of the literature supporting patient outcomes. The simple solution is to simply restrict work hours. So, who runs the hospitals? One approach is to hire more residents. Well, residents eventually need jobs. Suffice it to say, swamping the medical profession with more doctors who have less training is not an intuitively satisfying solution to the problem. Moreover, more doctors means more handovers. Increasing handovers has been shown to result in order more unnecessary tests for patients, and to result in inferior patient care.
Restricting work hours means that surgeons may have to train longer. Well, at minimum in the US, becoming a neurosurgeon is 4 + 4 + 7 years of post-secondary education (undergraduate, medical school, residency -- residency used to be 6 years). Many residents choose to become subspecialists, adding another year or two (or possibly 3 or 4). Further work hour restrictions could turn the 15-year training process into a 16 or 17 year process. Fair enough, this could solve the problem. But really? From a purely economic perspective, this is silly. Think of the opportunity cost of educating yourself for 20 years (i.e. 20 years of debt) to work for 25 more before being asked to retire.
Suffice it to say, it's a tough problem. In recognition of this last point, many specialties are moving towards competency based training. That is, graduating surgeons when they meet a competency rather than having spent sufficient time in hospital. This is a no brainer in other fields (e.g. flying planes, building bridges). While this is in fact reflecting the times (greater emphasis on patient safety than in the past), there's no doubt in my mind that this is being implemented because those in power feel that they are graduating surgeons less competent than the generation before them.
This last point, is in my opinion, the important question to ask. If anyone knows of any literature about this last point, I'd be grateful.
I wonder how changing technology might change system design tradeoffs and opportunities?
Better VR/AR, and event capture with lots of cameras, will blur the current gulf between "I saw it done" and "I saw a recording".
Medical simulation is improving and increasing. And some changes in medicine make it easier to simulate (arthroscopic, robotic). Changing optimal training mix.
Simulation big picture and long term... how will pilot training change, when even basic flight sim games are fully immersive environments with hands-on haptic controls? So how might medical training change, if a kid's "Operation" game includes AI patient interviews, playmate and automated-character resource management, and perhaps off-the-shelf haptics comparable to current med school sims?
Improving general education. This is more a social/political/systems change, but tech may help catalyze it. Let's see... a first-tier genetics course instructor says what they most wish their incoming students had learned, but haven't, from earlier undergraduate and pre-college bio courses, was simply a firm grasp of central dogma. Something that with good tooling, can be made accessible in early primary school. And I've talked with first-tier med students, who had no idea how big cells are, beyond "really really small". How might medical training change, if the education of its incoming students was failing less badly?
Apropos competency-based training, I years ago saw a proposal, I presume unimplemented, for a large-scale reentrant medical-training curriculum for India. Without having to start from scratch, an EMT could become a nurse, a nurse could train as a GP MD, an optometrist could level up to a non-surgical ophthalmologist, and so on. If our ability to do assessment improves, both simulation and non, then at least where there is a medical training shortage, perhaps there might be alternatives to quality control of training and practice being founded on institutional training-process controls.
Better VR/AR, and event capture with lots of cameras, will blur the current gulf between "I saw it done" and "I saw a recording".
Medical simulation is improving and increasing. And some changes in medicine make it easier to simulate (arthroscopic, robotic). Changing optimal training mix.
Simulation big picture and long term... how will pilot training change, when even basic flight sim games are fully immersive environments with hands-on haptic controls? So how might medical training change, if a kid's "Operation" game includes AI patient interviews, playmate and automated-character resource management, and perhaps off-the-shelf haptics comparable to current med school sims?
Improving general education. This is more a social/political/systems change, but tech may help catalyze it. Let's see... a first-tier genetics course instructor says what they most wish their incoming students had learned, but haven't, from earlier undergraduate and pre-college bio courses, was simply a firm grasp of central dogma. Something that with good tooling, can be made accessible in early primary school. And I've talked with first-tier med students, who had no idea how big cells are, beyond "really really small". How might medical training change, if the education of its incoming students was failing less badly?
Apropos competency-based training, I years ago saw a proposal, I presume unimplemented, for a large-scale reentrant medical-training curriculum for India. Without having to start from scratch, an EMT could become a nurse, a nurse could train as a GP MD, an optometrist could level up to a non-surgical ophthalmologist, and so on. If our ability to do assessment improves, both simulation and non, then at least where there is a medical training shortage, perhaps there might be alternatives to quality control of training and practice being founded on institutional training-process controls.
Simulators are effective only as their verisimilitude. Certain neurosurgical procedures are well-reproduced using simulators (most notably the insertion of external ventricular drains[0] for hydrocephalus). Surgical simulation have also shown to be be effective in systems where the principle goal is to get the trainee used to getting visual and limited tactile feedback in specific settings, such as laparoscopic procedures. One thing that has been extensively explored is providing trainees biofeedback about their roughness of manipulating tissues. This in itself is useful; but, to use a musical metaphor, it's more like practicing scales than practicing a performance.
It turns out that recreating tissue in a VR environment that looks and feels like real tissue is a really hard problem. This is a growing industry, and I have no doubt that developers / biophysicists / clinicians will continue to produce more and more realistic systems. Frankly, we're just not there yet. Right now, there is no substitute for the real thing.
Put another way: imagine using a flight simulator where one couldn't reproduce the physics of a real plane. This would be somewhat useful, but have limited transference to actually flying a real plane.
[0] https://www.ncbi.nlm.nih.gov/pubmed/26115472
It turns out that recreating tissue in a VR environment that looks and feels like real tissue is a really hard problem. This is a growing industry, and I have no doubt that developers / biophysicists / clinicians will continue to produce more and more realistic systems. Frankly, we're just not there yet. Right now, there is no substitute for the real thing.
Put another way: imagine using a flight simulator where one couldn't reproduce the physics of a real plane. This would be somewhat useful, but have limited transference to actually flying a real plane.
[0] https://www.ncbi.nlm.nih.gov/pubmed/26115472
It sounds like the strategy is put in a lot of hours doing routine cases (where little learning happens) in order to experience the rare cases. This seems inefficient? Couldn't residents be called in to look at the rare cases?
I guess they would need to be close by when it happens, but that doesn't seem to justify sleep deprivation?
Or maybe there are other ways to increase the odds of seeing a rare case?
I guess they would need to be close by when it happens, but that doesn't seem to justify sleep deprivation?
Or maybe there are other ways to increase the odds of seeing a rare case?
This is the difference between coding the solution to a tough technical problem yourself versus watching someone else code it.
There can only be so many assistants.
There can only be so many assistants.
I'm told by my anesthesia friends that it take about 6 weeks to train someone to be technically proficient at putting someone to sleep and waking them back up again.
The five years of training are needed to understand why you're doing it, and to see enough disasters to know how to get yourself out of the disaster situations.
While I don't fly planes, I would imagine flying a plane would be similar.
I also drive a car. While I was technically proficient while I got my license, it took years to get to the point of predicting the behavior of other drivers on the road, and to not panic when unexpected events happened (hydroplaning, odd pedestrian behavior, etc.).
The five years of training are needed to understand why you're doing it, and to see enough disasters to know how to get yourself out of the disaster situations.
While I don't fly planes, I would imagine flying a plane would be similar.
I also drive a car. While I was technically proficient while I got my license, it took years to get to the point of predicting the behavior of other drivers on the road, and to not panic when unexpected events happened (hydroplaning, odd pedestrian behavior, etc.).
It's a similar telescoping training problem in Radiology. We can train someone to have basic proficiency in interpreting a specific imaging examination in a relatively short period of time, but building the knowledge base, following up ambiguous diagnoses with pathology correlation, and seeing sufficient volume requires 5 years after internship. This doesn't even include all the knowledge we have to know for image acquisition, artifacts, and protocol design/QA. After all, you don't see what you don't know.
Yes you can look at case books and question banks and sample teaching cases, but until you are dictating the case primarily and have to decide whether to call a diagnosis which will have profound downstream treatment implications, it's a very different experience. While most specialists are comfortable with their area of imaging, I'm talking Radiologists remote reading cases for a rural location, where their report will determine if the patient is transferred and to where, with significant costs to the system and the patient if they are wrong.
I'm not sure how to "fix" it other than adopt a variant of the "commonwealth" competency-based system in Australia, where residencies have "usual" terms but if someone is competent and willing to sit the board certification exam early, they can try.
Yes you can look at case books and question banks and sample teaching cases, but until you are dictating the case primarily and have to decide whether to call a diagnosis which will have profound downstream treatment implications, it's a very different experience. While most specialists are comfortable with their area of imaging, I'm talking Radiologists remote reading cases for a rural location, where their report will determine if the patient is transferred and to where, with significant costs to the system and the patient if they are wrong.
I'm not sure how to "fix" it other than adopt a variant of the "commonwealth" competency-based system in Australia, where residencies have "usual" terms but if someone is competent and willing to sit the board certification exam early, they can try.
First of all thanks for this comment. That's a lot of interesting input.
To be honest I don't really see any reason to treat doctors differently than other professionals. There are plenty of difficult jobs that people's lives depend upon but I've yet to see a career path forcing trainees or juniors to go through such hard conditions for several years for pennies.
> Further work hour restrictions could turn the 15-year training process into a 16 or 17 year process. Fair enough, this could solve the problem. But really? From a purely economic perspective, this is silly.
From a purely economic perspective everyone works too little for too much. Why don't we start to treat residents like human beings, cut the long hours and pay them decently. Where do we find the money? Maybe in regular doctors' sacks - the difference in pay before and after residency is crazy. In 2017 residents went on a country-wide strike over working conditions in my country (https://www.bbc.com/news/world-europe-41777785) and it's said they'll go on another one this year.
As a side note I think a lot of issues in health service is a lack of proper management. Every time I'm in a hospital I can't help to notice hiring someone like an office manager, who's only job is to smooth communication between workers and patients and workers themselves would be huge.
To be honest I don't really see any reason to treat doctors differently than other professionals. There are plenty of difficult jobs that people's lives depend upon but I've yet to see a career path forcing trainees or juniors to go through such hard conditions for several years for pennies.
> Further work hour restrictions could turn the 15-year training process into a 16 or 17 year process. Fair enough, this could solve the problem. But really? From a purely economic perspective, this is silly.
From a purely economic perspective everyone works too little for too much. Why don't we start to treat residents like human beings, cut the long hours and pay them decently. Where do we find the money? Maybe in regular doctors' sacks - the difference in pay before and after residency is crazy. In 2017 residents went on a country-wide strike over working conditions in my country (https://www.bbc.com/news/world-europe-41777785) and it's said they'll go on another one this year.
As a side note I think a lot of issues in health service is a lack of proper management. Every time I'm in a hospital I can't help to notice hiring someone like an office manager, who's only job is to smooth communication between workers and patients and workers themselves would be huge.
The salaries of resident physicians are often available online. Here are some example salaries:
https://medschool.ucsd.edu/som/medicine/education/residency/...
https://med.nyu.edu/medicine/education/residency-compensatio...
http://www.myparo.ca/starting-residency/#salary-and-benefits
While these salaries may be dramatically different than what the doctors make when they finish residency, you'll see they're decent.
That being said: as a first year resident I once did the math and found that based on the number of hours I was working per month, I was making less than minimum wage.
Could we pay residents better? Absolutely. But, my suspicion is that people would still want to be doctors even if you paid residents half of what they currently made. I don't think medical school admissions would sky-rocket if you paid residents twice as much as they were making right now.
https://medschool.ucsd.edu/som/medicine/education/residency/...
https://med.nyu.edu/medicine/education/residency-compensatio...
http://www.myparo.ca/starting-residency/#salary-and-benefits
While these salaries may be dramatically different than what the doctors make when they finish residency, you'll see they're decent.
That being said: as a first year resident I once did the math and found that based on the number of hours I was working per month, I was making less than minimum wage.
Could we pay residents better? Absolutely. But, my suspicion is that people would still want to be doctors even if you paid residents half of what they currently made. I don't think medical school admissions would sky-rocket if you paid residents twice as much as they were making right now.
Do you think hyper-specializing might be a solution? Right now I see many physicians end up only working within a narrow sub field of the field they trained in. For example, a neurologist goes through 4 years of general neurology training and then ends up only working in an epilepsy clinic and after a few years probably forgot how to manage myasthenia gravis. Or a neurosurgeon that ends up only doing spine cases. Wouldn't it be better if we just had shorter but more specialized residencies? If people are going to end up forgetting half their training anyway...
Hyper-specialization has been an approach taken by the medical establishment. For instance, within the last decade, the "vascular surgery" specialty opened up as a specialty straight out of medical school. Vascular surgery procedures used to be a subset of procedures largely (but not exclusively) performed by general surgeons (neurosurgeons still routinely do carotid endarterectomy procedures, for example). There are murmurs of "Spine surgeon" becoming a separate specialty as well, which is currently performed either by neurosurgeons or orthopedic surgeons (often with dramatically different specialty-biases in their surgical technical and reasoning).
Sub-specialists are needed and are important for a variety of reasons, including realistic demands on training time. If my loved one had a single medical issue, I would certainly wanted them operated on by the person who does nothing but that operation.
Woe is the person with two complex medical issues in a hyper-specialized hospital institution. Consider the situation where someone has two medical problems in direct conflict with each other. For instance: some people can develop chronic subdural hematomas (translated: blood clots on the surface of the brain) which causes neurologic dysfunction. The general advice here is to stop any blot-clotting medication someone is on, to prevent further bleeding or expansion of the cSDH. However, what if that person has an artificial heart valve and needs to be on blood thinners to prevent strokes?
How do we proceed? Ask the neurosurgeon, and the answer is "stop." Ask the cardiologist, and the answer is "don't stop."
Sub-specialization is happening, and it's important. But it turns physicians into finer-grained hammers: so every problem they can hit becomes a nail.
In my opinion, one will always need generalists to make the tough calls and to identify which specialist is required. The only way to train generalists is to know what the outcomes are for both stopping and continuing the blot clotting medication.
Sub-specialists are needed and are important for a variety of reasons, including realistic demands on training time. If my loved one had a single medical issue, I would certainly wanted them operated on by the person who does nothing but that operation.
Woe is the person with two complex medical issues in a hyper-specialized hospital institution. Consider the situation where someone has two medical problems in direct conflict with each other. For instance: some people can develop chronic subdural hematomas (translated: blood clots on the surface of the brain) which causes neurologic dysfunction. The general advice here is to stop any blot-clotting medication someone is on, to prevent further bleeding or expansion of the cSDH. However, what if that person has an artificial heart valve and needs to be on blood thinners to prevent strokes?
How do we proceed? Ask the neurosurgeon, and the answer is "stop." Ask the cardiologist, and the answer is "don't stop."
Sub-specialization is happening, and it's important. But it turns physicians into finer-grained hammers: so every problem they can hit becomes a nail.
In my opinion, one will always need generalists to make the tough calls and to identify which specialist is required. The only way to train generalists is to know what the outcomes are for both stopping and continuing the blot clotting medication.
I'm not a professional so what I'm saying could be stupid, but I don't see why anti-coagulant medication has to act globally in the organism for something that is a localized issue. I realize the circulatory system is not segmented, however couldn't there be something to be done with the time of action of the anti-coagulant? From my vague recollection, clot formation has something to do with turbulent flow post-valve as well, so improvements might be made in this area as well... try getting a fluid dynamics expert in the team that designs the valves, and I'm not joking.
FWIW.
For the cSDH conundrum and similar tough calls, it is indeed complicated, that's why one needs to stick to guidelines or expert opinion. If there are no clear instructions, then the attending's way is the highway. Or your gut feeling. The most important thing in this case is to document your decision and notify patient and relatives.
(resident neurologist here) :)
(resident neurologist here) :)
Hyper specialized internal med sub-subspecialist here.
I unequivocally agree with GP poster about the value of generalists. The systematic devaluation of internal medicine physicians (by this I mean not ABIM subspecialty boarded) is a tragedy.
I unequivocally agree with GP poster about the value of generalists. The systematic devaluation of internal medicine physicians (by this I mean not ABIM subspecialty boarded) is a tragedy.
Do intense residencies make better doctors or is this one of those self destructive cost saving measures?
Sort of reminds me of the concussion situation in football. Some coaches, I believe especially college level, are looking at subbing in other training methods to reduce on field practice time and thus chance for injury. Maybe walking the hospital floor 12 hours a day isn’t the best training.
Sort of reminds me of the concussion situation in football. Some coaches, I believe especially college level, are looking at subbing in other training methods to reduce on field practice time and thus chance for injury. Maybe walking the hospital floor 12 hours a day isn’t the best training.
I think a lot of it is just hazing. Attendings probably feel like just because they were given a hard time during residency they need to do the same to the newcomers.
Procedural specialities will always need an extreme amount of hours spent honing their skills. Considering that your experience is the basis for a good outcome for your future patients when you are solely responsible, you know that the more you work the better off you'll be.
The procedural specialities operate on a hierarchy that emphasizes underlings doing most of the grunt work while senior residents can be all day in the operating room. There's likely a better way to do it, but this is how it has been done for decades and just won't change.
The procedural specialities operate on a hierarchy that emphasizes underlings doing most of the grunt work while senior residents can be all day in the operating room. There's likely a better way to do it, but this is how it has been done for decades and just won't change.
Perhaps working 50 hour weeks and being well rested would result in faster and more efficient learning than working 80 hours. Yes - you have to do your time, but humans don't learn well sleep deprived.
You could try and force them to work 100, or 160 hours per week and I suspect you'd rapidly find quality of work and learning nosedive.
I think it's worth considering 80 hours is already on the wrong side of that curve.
You could try and force them to work 100, or 160 hours per week and I suspect you'd rapidly find quality of work and learning nosedive.
I think it's worth considering 80 hours is already on the wrong side of that curve.
Do not make the mistake of undervaluing experience gained from an unbelievable number of hours in cognitive specialties as well.
Is the medical profession finally looking in the mirror?!?
Related, the residency process needs to be massively reformed. The flimsy justification for making people responsible for human lives work 80 hours a week is usually that the long hours help them learn faster. But that's really BS. The brain has an incredibly hard time forming new memories when sleep deprived.
I know a couple of nurses who often talk about how spaced-out residents are at night. They'll page them to consult on something, usually waking them up. The residents will usually just blearily agree with whatever the nurse was planning on doing, so they aren't getting in meaningful physician supervision.