First-year doctors will be allowed to work 24-hour shifts starting in July(washingtonpost.com)
washingtonpost.com
First-year doctors will be allowed to work 24-hour shifts starting in July
https://www.washingtonpost.com/news/to-your-health/wp/2017/03/10/first-year-doctors-will-be-allowed-to-work-24-hour-shifts-starting-in-july/
76 comments
Having been through residency myself, I'm actually in favor of this change back to 24 hrs. As background, when I was an intern, the "16 hr rule" was not in place, but I did have to manage interns as a senior resident with the rule in place.
Four points that I'd make on this subject. The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts. In fact, in many cases the doc would have more of a chance to get a nap in on the 24 hr shift than the 16 hr. Basically, I'm suggesting (with zero evidence except my own experience), that I'm not sure there's a significant difference between 16 and 24 hr shifts' effects on a doc's ability to function well--both can be fine under the right circumstances and both can be equally terrible. Also related to this is the fact that nurses, doctors, respiratory therapists work as a team in hospitals ... most critical decisions are checked on a number of levels.
Secondly, do not underestimate the danger of hand-offs. This is the main reason that I'm in favor of this change. Any time there is major information exchange in a hospital environment, there is increased room for error due to misunderstandings, forgotten information, etc. There have been many efforts to standardize information exchanges and they have become better in many circumstances. But I'll tell you that, in my experience, more hand-offs increased the risk of errors in patients and if I were in the hospital on a medical floor, I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift.
The third point is about how healthcare functions in the country, specifically around large hospitals. Residents and fellows get their training in these places, but hospitals also rely on these trainees to staff their enormous floors. If we were to change the shifts, let's say to a maximum of 12 hrs each, we would likely need significantly more residents in the system overall. Not only does that volume need to come from increased sizes in medical school classes, but the hospital systems would need to be paying the salaries of these trainees. Hospitals with trainees receive some amount of this salary money from the federal government, and some comes directly from the hospital bottom line. Either way, the total cost burden to the system increases, meaning that we will all be paying more in an already overpriced system.
The fourth point is that these work hours rules truly impact the training of residents. There are surgeons graduating after 5 years of ENT training who have not had enough experience to become attendings at the places where they are interviewing. I have spoken with a number of senior attendings about this issue and they all say that they are more and more concerned about whether the trainees coming through these programs are getting enough training. So the option to deal with that would probably be to add on another year of training to fields where competency is not being reached, again increasing the cost to the system and to the overall financial picture of the trainees (many are barely making the equivalent of minimum wage during training and need to start paying on a quarter million USD worth of debt).
Basically, I'm not disputing your concerns, just pointing out that our system will likely cost much more if we move the other direction with hrs rules. I also would not jump to the conclusion that 24hrs is truly worse than 16hrs for patient outcomes. Both are terrible, and maybe not significantly different.
Four points that I'd make on this subject. The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts. In fact, in many cases the doc would have more of a chance to get a nap in on the 24 hr shift than the 16 hr. Basically, I'm suggesting (with zero evidence except my own experience), that I'm not sure there's a significant difference between 16 and 24 hr shifts' effects on a doc's ability to function well--both can be fine under the right circumstances and both can be equally terrible. Also related to this is the fact that nurses, doctors, respiratory therapists work as a team in hospitals ... most critical decisions are checked on a number of levels.
Secondly, do not underestimate the danger of hand-offs. This is the main reason that I'm in favor of this change. Any time there is major information exchange in a hospital environment, there is increased room for error due to misunderstandings, forgotten information, etc. There have been many efforts to standardize information exchanges and they have become better in many circumstances. But I'll tell you that, in my experience, more hand-offs increased the risk of errors in patients and if I were in the hospital on a medical floor, I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift.
The third point is about how healthcare functions in the country, specifically around large hospitals. Residents and fellows get their training in these places, but hospitals also rely on these trainees to staff their enormous floors. If we were to change the shifts, let's say to a maximum of 12 hrs each, we would likely need significantly more residents in the system overall. Not only does that volume need to come from increased sizes in medical school classes, but the hospital systems would need to be paying the salaries of these trainees. Hospitals with trainees receive some amount of this salary money from the federal government, and some comes directly from the hospital bottom line. Either way, the total cost burden to the system increases, meaning that we will all be paying more in an already overpriced system.
The fourth point is that these work hours rules truly impact the training of residents. There are surgeons graduating after 5 years of ENT training who have not had enough experience to become attendings at the places where they are interviewing. I have spoken with a number of senior attendings about this issue and they all say that they are more and more concerned about whether the trainees coming through these programs are getting enough training. So the option to deal with that would probably be to add on another year of training to fields where competency is not being reached, again increasing the cost to the system and to the overall financial picture of the trainees (many are barely making the equivalent of minimum wage during training and need to start paying on a quarter million USD worth of debt).
Basically, I'm not disputing your concerns, just pointing out that our system will likely cost much more if we move the other direction with hrs rules. I also would not jump to the conclusion that 24hrs is truly worse than 16hrs for patient outcomes. Both are terrible, and maybe not significantly different.
Could the reason handoffs are so bad be because the person doing the handoff has been working for 16-24 hours straight?
I mean in IT i see first hand the notes left by people on pager duty in the middle of the night, and they differ significantly from the same peoples notes after a restful night of sleep.
Has there been any controlling in these studies i see mentioned through this entire thread for sleep deprivation present in people performing the handoffs? If they arent controlling for the amount of rest the people in the handoffs have had in the last 24 hours, im not sure i am willing to put much weight in these studies.
>I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift.
But if you came into the ER at 3am and the doctor you get has been working 23 hours, youre still going to need ot be handed off, and now youve received sleep deprivated care in the interim while waiting for a fresh doctor. Sure, for the guy who arrived just as a fresh doctor arrived, it might be beneficial to have them there for 24 hours, but how many new patients are they seeing in hours 12-24?
I mean in IT i see first hand the notes left by people on pager duty in the middle of the night, and they differ significantly from the same peoples notes after a restful night of sleep.
Has there been any controlling in these studies i see mentioned through this entire thread for sleep deprivation present in people performing the handoffs? If they arent controlling for the amount of rest the people in the handoffs have had in the last 24 hours, im not sure i am willing to put much weight in these studies.
>I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift.
But if you came into the ER at 3am and the doctor you get has been working 23 hours, youre still going to need ot be handed off, and now youve received sleep deprivated care in the interim while waiting for a fresh doctor. Sure, for the guy who arrived just as a fresh doctor arrived, it might be beneficial to have them there for 24 hours, but how many new patients are they seeing in hours 12-24?
> Having been through residency myself
Throwaway because it was so disheartening to read this perspective.
> The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts.
This is very location, hospital, and speciality specific. Most surgical residents would say the opposite.
> Secondly, do not underestimate the danger of hand-offs
Hey, why don't we work on better handoffs. Other fields (even with-in medicine) seem to manage. Maybe we should mine the airlines industry again for good ideas. The dichotomy of 16 vs 24 hours to me is a false choice.
> There are surgeons graduating after 5 years of ENT training... who have not had enough experience to become attendings at the places where they are interviewing.
For what it's worth, surgical sub-specialists like ENTs will do at least 2-3 times as many hours in training as a family medicine doc or pediatrician. Make the training an extra year and pay a better god damn salary if they really aren't trained well enough. Right now the system is designed around cramming as much pain and suffering as a human can withstand in their training to get the most value for the hospital. There's a reason why some ~25+% of general surgery residents leave the field completely.
> The third point is about how healthcare functions in the country, specifically around large hospitals
I mean, I call bullshit and I see this logic all the time from fellow physicians who try to make the cost argument from the floor. We pay NPs and PAs to work exactly these shifts, and hours. Why not residents?
> conclusion that 24hrs is truly worse than 16hrs for patient outcomes
I completely disagree that the late night hours have done anything towards making me a better doctor. And I'm truly sorry if I came off as feisty but the whole discussion is so frustrating to me because I think it misses the big picture. This change by ACGME signals the wrong direction we need to be going in how we treat young doctors.
At some point, the aggregate weight of non-cancellable student loans (~240k on average now?), anti-competitive labor market (that went to the supreme court), inhuman hours (that would be illegal for a pilot or truck driver to do), relatively shitty pay (my SO is in tech and earns 2x what most primary care physicians do in 1/2 the hours) will be too much. They'll quit, and find other ways to "make a difference."
I can't put a pillow in a pillow case after 24 hours. Do you really want me stitching up your mom?
Throwaway because it was so disheartening to read this perspective.
> The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts.
This is very location, hospital, and speciality specific. Most surgical residents would say the opposite.
> Secondly, do not underestimate the danger of hand-offs
Hey, why don't we work on better handoffs. Other fields (even with-in medicine) seem to manage. Maybe we should mine the airlines industry again for good ideas. The dichotomy of 16 vs 24 hours to me is a false choice.
> There are surgeons graduating after 5 years of ENT training... who have not had enough experience to become attendings at the places where they are interviewing.
For what it's worth, surgical sub-specialists like ENTs will do at least 2-3 times as many hours in training as a family medicine doc or pediatrician. Make the training an extra year and pay a better god damn salary if they really aren't trained well enough. Right now the system is designed around cramming as much pain and suffering as a human can withstand in their training to get the most value for the hospital. There's a reason why some ~25+% of general surgery residents leave the field completely.
> The third point is about how healthcare functions in the country, specifically around large hospitals
I mean, I call bullshit and I see this logic all the time from fellow physicians who try to make the cost argument from the floor. We pay NPs and PAs to work exactly these shifts, and hours. Why not residents?
> conclusion that 24hrs is truly worse than 16hrs for patient outcomes
I completely disagree that the late night hours have done anything towards making me a better doctor. And I'm truly sorry if I came off as feisty but the whole discussion is so frustrating to me because I think it misses the big picture. This change by ACGME signals the wrong direction we need to be going in how we treat young doctors.
At some point, the aggregate weight of non-cancellable student loans (~240k on average now?), anti-competitive labor market (that went to the supreme court), inhuman hours (that would be illegal for a pilot or truck driver to do), relatively shitty pay (my SO is in tech and earns 2x what most primary care physicians do in 1/2 the hours) will be too much. They'll quit, and find other ways to "make a difference."
I can't put a pillow in a pillow case after 24 hours. Do you really want me stitching up your mom?
You sound pretty frustrated about the whole situation, and I totally get it. I've been there and it sucks. I'd recommend getting involved with the politics of this issue so that you can help make a change. Are you involved with the ACGME? Does your residency / fellowship have a union? If not, consider making contact with the the Committee of Interns and Residents (CIR)--I met with them when I was a resident and learned a lot more about what I could do to help make things better for myself and my colleagues.
As a human, the concept of anyone working 20-24 hours straight...really, anything over 10 hours straight, infuriates me. I'd rather solve problems associated with shift change over than force someone to work like that. Further, life is short. Forcing someone to be so confined for such a period of time is...wrong.
It's not uncommon for EMS workers to work shifts > 24 hours. That includes companies where you aren't at a specific station, but the crew is "posted" with their vehicle somewhere in the service area (gas station parking lot, etc...).
They're still limited in the number of hours they work per week. It's not like they're working 24/7.
Unfortunately, those limitations aren't strictly enforced (the hospitals seem to care more about their bottom line than about their cheap labor's well-being -- so I don't see this changing soon).
In addition to that, this stuff accumulates over time, especially in a super-high-stress environment that frequently requires life-or-death decisions. Really think about the limitations described in that article -- interns must have one day off every seven, and cannot work 24h more than one night in three. So they work 16 hour shifts for seven straight days -- which means they have to get to and from work, shower, sleep, and eat some meals during that time -- and that's assuming that handoffs are always performed perfectly on time (they're not, the hospital is hectic), and that you can always leave exactly after 16 hours (you often physically can't, given the nature of the work).
And then you get a single day off. Which you use almost entirely for sleep, because not only do you barely have enough time to get a full night's sleep every worknight under "ideal" conditions, but you also have a hard time falling asleep because you're so hyped up/stressed from everything that's happened during the day.
And then, somewhere in that mix, you have to work for 24h. That might be ok if you had some chance to recharge your batteries during the past few months/year, but you're so overworked and over-stressed that even your two two-week vacations aren't enough to erase the bags under your eyes.
So, in short: this decision is really, really irresponsible. It caters to super-alpha types (which are indeed often attracted to medicine, and especially to surgery) who are willing to sacrifice everything in order to accomplish their lofty career goals as quickly as possible, and to hospitals who want more, cheaper, labor. Having been afforded the opportunity to talk with residents at a couple of the best-regarded hospitals in the country (my girlfriend is going through this "experience" at the moment), and seeing first-hand how this affects them, I'm pretty confident in saying that the handoff problem, while real, is not going to get better by making interns stay for four extra hours after their already inhumane 24h shift.
In addition to that, this stuff accumulates over time, especially in a super-high-stress environment that frequently requires life-or-death decisions. Really think about the limitations described in that article -- interns must have one day off every seven, and cannot work 24h more than one night in three. So they work 16 hour shifts for seven straight days -- which means they have to get to and from work, shower, sleep, and eat some meals during that time -- and that's assuming that handoffs are always performed perfectly on time (they're not, the hospital is hectic), and that you can always leave exactly after 16 hours (you often physically can't, given the nature of the work).
And then you get a single day off. Which you use almost entirely for sleep, because not only do you barely have enough time to get a full night's sleep every worknight under "ideal" conditions, but you also have a hard time falling asleep because you're so hyped up/stressed from everything that's happened during the day.
And then, somewhere in that mix, you have to work for 24h. That might be ok if you had some chance to recharge your batteries during the past few months/year, but you're so overworked and over-stressed that even your two two-week vacations aren't enough to erase the bags under your eyes.
So, in short: this decision is really, really irresponsible. It caters to super-alpha types (which are indeed often attracted to medicine, and especially to surgery) who are willing to sacrifice everything in order to accomplish their lofty career goals as quickly as possible, and to hospitals who want more, cheaper, labor. Having been afforded the opportunity to talk with residents at a couple of the best-regarded hospitals in the country (my girlfriend is going through this "experience" at the moment), and seeing first-hand how this affects them, I'm pretty confident in saying that the handoff problem, while real, is not going to get better by making interns stay for four extra hours after their already inhumane 24h shift.
And they're probably, still, making worse decisions after 10 hours than before 10 hours on the shift.
Hopefully automation can help free up time for doctors.
How would automation help? Is it not a supply/demand issue already (an increase in doctors alleviate things)? Was it worse before we had electronic records and fancy medical equipment?
Maybe it's because of cost (and automation will drive that down)? We're willing to pay fewer doctors at the expense overworking and low supply? If so, I don't see that fixing anything. It would keep status quo, but drive down doctor's salaries or the demand of doctors.
Maybe it's because of cost (and automation will drive that down)? We're willing to pay fewer doctors at the expense overworking and low supply? If so, I don't see that fixing anything. It would keep status quo, but drive down doctor's salaries or the demand of doctors.
I mean how else does automation help in life. I'd think we're far from an AI making the tough life or death decisions but if their potential work load of 24 hours could be decreased with automated systems performing specific tasks. What exactly is automated? I don't know maybe the pre-checks/questionnaires screening patients.
I realize a doctor is not the same as a burger flipper/dishwasher so their tasks would be harder to automate.
Fancy medical equipment haha. Throw that x-ray imaging away let me just touch your bones and see if it's broken or not.
A tumor did you say? We'll I don't see it.
It was just a thought of my part I'm not a doctor, or a 'leading analyst's just the usual forum BS on my part.
I realize a doctor is not the same as a burger flipper/dishwasher so their tasks would be harder to automate.
Fancy medical equipment haha. Throw that x-ray imaging away let me just touch your bones and see if it's broken or not.
A tumor did you say? We'll I don't see it.
It was just a thought of my part I'm not a doctor, or a 'leading analyst's just the usual forum BS on my part.
As has been mentioned throughout this thread, in the studies so far conducted (e.g. FIRST), longer shifts are non-inferior for patient safety compared to shorter shifts with more handoffs. There is no such thing as a free lunch, nor is something that is facially obvious safe to treat as true in medicine unless you test it. The changes that were made due to assumptions (not measurements) about safety were found not to be supported when the evidence became available.
Is there any good research into improving the handoff process?
It seems it would be beneficial regardless of how well rested the doctors were.
It seems it would be beneficial regardless of how well rested the doctors were.
Active area of research. Take a look at IPASS.
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But at some point sleep deprivation must cause issues.
12 hour days I could buy, not 24
12 hour days I could buy, not 24
The argument I've heard is also in the article, "the change will enhance patient safety because there will be fewer handoffs from doctor to doctor." I've been told studies have shown this--of course there's a limit. I thought that limit was 16 hours (the previous max listed in the article). I'm sure handoff procedures also affect this. When our first son was born the nurses would come in and verbally handoff in front of my wife so she could clarify and confirm things (unless something critical was happening). You could see the nurses scribbled notes before handoff and they were diligent in recording things in their computer system.
On the business side, are doctor's paid hourly? I imagine having fewer doctors paid overtime would be cheaper overall. At least in other professions after 12 hours they get paid double-time.
On the business side, are doctor's paid hourly? I imagine having fewer doctors paid overtime would be cheaper overall. At least in other professions after 12 hours they get paid double-time.
Lots of doctors who are attendings get paid for what they bill. But this change is for doctors who are 1st year residents/ interns. They haven't graduated to being an attending yet. Residents do not have a medical license yet and must operate under the supervision of an attending. In theory, they are getting paid a salary to learn / sharpen their skills in their chosen specialty (ie family medicine, internal medicine, etc.). But in reality, they are more like low wage labor as 1 attending can supervise many residents.
Yeah, this is a stupid excuse. If handoffs are a problem don't make doctors work more, figure out a better handoff system.
The handoff stuff is at least fixable in principle, whereas sleep deprivation is...not (at least not sustainably).
We don't especially know what purpose sleep serves. It's possible someone will figure it out and how to work around the need for it.
> Many programmers in the tech community know that half of the listed time (12 hours) of solid work is enough to start to slow your decision-making and reasoning ability.
I don't think it's fair to compare doctors who have a rigorous medical school and academic path to 'programmers' which includes a wide group of people some of which haven't even graduated college. This is simply a different group of people at the core. And even within that group there are those (in medicine) that choose what appears to be an easier path (let's say psych or family medicine) vs. surgery which might involve standing in an operating theater for 9 to 12 hours and having to be attentive. Along the same lines it is a bit different to make the grade to fly a small single engine airplane (get training) and be able to fly and land fighter jets on an aircraft carrier.
Not taking away from your point of slowing decision making and reasoning but quite honestly not everyone is built from the same bolt of cloth and is impacted the same.
One small example. My wife would take call overnight, get woken up regularly, and easily get back to bed and be fresh the next day at the hospital. If I get woken up (and I am not a programmer) I can't fall back to sleep and would be a wreck the next day. People are different and in some cases the career path and training separates the type of people that end up being in the profession.
I don't think it's fair to compare doctors who have a rigorous medical school and academic path to 'programmers' which includes a wide group of people some of which haven't even graduated college. This is simply a different group of people at the core. And even within that group there are those (in medicine) that choose what appears to be an easier path (let's say psych or family medicine) vs. surgery which might involve standing in an operating theater for 9 to 12 hours and having to be attentive. Along the same lines it is a bit different to make the grade to fly a small single engine airplane (get training) and be able to fly and land fighter jets on an aircraft carrier.
Not taking away from your point of slowing decision making and reasoning but quite honestly not everyone is built from the same bolt of cloth and is impacted the same.
One small example. My wife would take call overnight, get woken up regularly, and easily get back to bed and be fresh the next day at the hospital. If I get woken up (and I am not a programmer) I can't fall back to sleep and would be a wreck the next day. People are different and in some cases the career path and training separates the type of people that end up being in the profession.
I think you overestimate the abilities and knowledge of doctors and nurses. Healing is an art not a science, and it will likely always be so. Bodies are not necessarily understandable, especially as the person can tell you lies, is forgetful, or does not speak your language or understand your version of English words, and you have to do this in sometimes small time windows. The idea of a 'good' doctor is not attainable for most patients, it is a 'good enough' doctor that we are aiming for. So, stress testing docs in the field is looked highly upon by many of the elder docs, they then know that they can depend upon that doc when called for. I know that is not something that a patient necessarily wants to have happen to them, but that is the truth. We live in a world of limited time, money, information, planning, etc, more so in a hospital than anywhere else. Life is risky and will always be so.
Cruel and unusual punishment?
Sleep deprivation has some pretty serious negative side effects
Sleep deprivation has some pretty serious negative side effects
What's really bad is that the American medical establishment, including these doctors, seem to be defending this practice.
It'd be really interesting to see a good study comparing the rate of medical errors and resultant patient deaths/injuries in hospitals in the US and in other industrialized nations, and to also compare the hours worked between them.
Another thing that came up in the article is the problem of hand-over between doctors and medical teams, and that having ridiculously-long hours seems to be a patch to avoid all the problems that come from that. That sounds like an organizational and procedural problem: doctors and nurses aren't properly writing things down, or if they are, they're not writing them in a legible way.
I had a recent experience where I had to accompany a friend on an ER trip. Different doctors and nurses kept asking her, over and over throughout the lengthy visit, what she was there for, and to describe the symptoms. It was eerie; there seemed to be absolutely no information recording and usage by these people, it was like everything was all-new every time some new person came on the scene. It was also really strange how they kept telling her totally different and contradictory things: one nurse says she's not allowed to have any food or water (despite being parched), another nurse says this is wrong, etc. (She ended up drinking water out of the bathroom sink because she was so thirsty, and was there for a possible cardiac problem so electrolyte depletion certainly can't help.)
American ERs seem to be very scary, incompetently-run places.
It'd be really interesting to see a good study comparing the rate of medical errors and resultant patient deaths/injuries in hospitals in the US and in other industrialized nations, and to also compare the hours worked between them.
Another thing that came up in the article is the problem of hand-over between doctors and medical teams, and that having ridiculously-long hours seems to be a patch to avoid all the problems that come from that. That sounds like an organizational and procedural problem: doctors and nurses aren't properly writing things down, or if they are, they're not writing them in a legible way.
I had a recent experience where I had to accompany a friend on an ER trip. Different doctors and nurses kept asking her, over and over throughout the lengthy visit, what she was there for, and to describe the symptoms. It was eerie; there seemed to be absolutely no information recording and usage by these people, it was like everything was all-new every time some new person came on the scene. It was also really strange how they kept telling her totally different and contradictory things: one nurse says she's not allowed to have any food or water (despite being parched), another nurse says this is wrong, etc. (She ended up drinking water out of the bathroom sink because she was so thirsty, and was there for a possible cardiac problem so electrolyte depletion certainly can't help.)
American ERs seem to be very scary, incompetently-run places.
As a paramedic, I understand your frustration with answering the same questions repeatedly. There is absolutely information being recorded and tracked, and it's very likely the provider walking into the room has already read the notes written by those who were there earlier.
However, much like debugging a technical problem, a systemic approach is necessary for patient assessment. Everyone has their process which they have developed over the years... The pattern and flow to their questions, the order in which they assess various body systems, etc. Jumping around in that process to cover the handful of questions they couldn't find the answers to in earlier reports is a recipe for skipping something.
I'm not saying there isn't room for improvement here. My wife recently spent two months in the hospital, and there were several times where we had to 'educate' a provider about what the plan was (i.e. we would discuss something with the attending, but they didn't chart it well, so the senior resident wasn't up to speed on the changes, etc...)., however, when it comes to those assessment questions being asked repeatedly, there is a method to that particular madness.
However, much like debugging a technical problem, a systemic approach is necessary for patient assessment. Everyone has their process which they have developed over the years... The pattern and flow to their questions, the order in which they assess various body systems, etc. Jumping around in that process to cover the handful of questions they couldn't find the answers to in earlier reports is a recipe for skipping something.
I'm not saying there isn't room for improvement here. My wife recently spent two months in the hospital, and there were several times where we had to 'educate' a provider about what the plan was (i.e. we would discuss something with the attending, but they didn't chart it well, so the senior resident wasn't up to speed on the changes, etc...)., however, when it comes to those assessment questions being asked repeatedly, there is a method to that particular madness.
> is that the American medical establishment, including these doctors, seem to be defending this practice.
Yeah, and hazing is a pattern passed down from generation to generation, like childhood beatings /onlypartialsarcasm
Yeah, and hazing is a pattern passed down from generation to generation, like childhood beatings /onlypartialsarcasm
These residents can't even safely drive home after a 24-hour shift, but they're perfectly fine to practice medicine on others. The "studies" say that, so it must be true, right?
The AMA is a cartel that has artificially constrained the supply of doctors to keep incomes high. It is the most successful union in history.
Someone ought to do a study on what the effects truly are.
Take a group of hospitals, randomly assign them to "continue insane hours for residents", "40-hour work-weeks and no more than 12-hour shifts" and maybe a third group somewhere in between. Run it for two years, and see what the effect on patients and doctors actually is.
Then will come the hard questions: if we see that these insane hours are literally killing patients, surely then it will make sense to end this madness?
Take a group of hospitals, randomly assign them to "continue insane hours for residents", "40-hour work-weeks and no more than 12-hour shifts" and maybe a third group somewhere in between. Run it for two years, and see what the effect on patients and doctors actually is.
Then will come the hard questions: if we see that these insane hours are literally killing patients, surely then it will make sense to end this madness?
Those studies have been done and the results were counter-intuitive.
Yes, long shifts kill patients. But the other thing that kills patients are handovers -- one doctor forgetting to note or tell another doctor a crucial detail at shift change. Longer shifts mean fewer shift changes.
Yes, long shifts kill patients. But the other thing that kills patients are handovers -- one doctor forgetting to note or tell another doctor a crucial detail at shift change. Longer shifts mean fewer shift changes.
I recognize my naïveté, but surely a more humane method of dealing with this is trying to increase information exchange at handover rather than depriving humans of valuable sleep.
There are studies that show partial sleep deprivation can affect cognitive performance, and specific studies that show sleep deprivation on doctors can affect their own performance.
Couldn't we just have longer shift-change overlaps? I.e. double staff for 3 hours during handoff and have multiple overlapping 12 hour shifts / day?
This is what we do in 24/7 network operations centers - so issues can be cleanly handed off between shifts.
However I don't think the additional staffing costs will fly, you're talking a hugely substantial increase if you were to enforce this - more than 25%, since current staffing levels are so thin.
However I don't think the additional staffing costs will fly, you're talking a hugely substantial increase if you were to enforce this - more than 25%, since current staffing levels are so thin.
(not sure who would fix this) but that still sounds like a problem with the cost structure. In other businesses, after 8 hours you get paid 1.5x, after 12 hours 2x. If those were the incentives here, it'd be cheaper to overlap and pay two salaries (I'm ignoring benefits here).
It's a balance of what people are willing to pay, the risk we're willing to accept, how ethically we treat workers (doctors). Unfortunately, like many places in the economy, there aren't rational actors on each side to negotiate these things.
It's a balance of what people are willing to pay, the risk we're willing to accept, how ethically we treat workers (doctors). Unfortunately, like many places in the economy, there aren't rational actors on each side to negotiate these things.
That would cost 25% more to the hospital, no way.
In other jobs you get paid double-time after 12 hours. If the cost structures were right it would still be cheaper.
Perhaps some work should be put into the hand-off procedure. I've heard things like checklists suggested in the past. Perhaps having a checklist to go through when handing off the patient with, say, congestive heart failure to another physician. They could be developed for the most common conditions that residents and their attendings deal with.
This is well trodden material in medicine. "IPASS" is a search term that might help if you're interested to look at what has been tried.
Presumably the magnitude of both effects could be measured against each other?
These studies have been done, but they're basically worthless: they look at relatively small modulations around an insane baseline, like switching between 24, 28, and 30 hours on.
The major issue (other than $$$) is thought to be hand-offs: information gets lost when one caregiver takes over for another. For example, you might notice that Mrs. Jones looks just a little bit paler than she did earlier, and take that into account when treating her, even subconsciously. This gets lost when a new doctor takes over, and allegedly, the increase in hand-off-related issues is not outweighed by the decrease in sleep-related ones. That said, I'm also not convinced that this has been aggressively optimised, or even tested over long-enough durations that people adapt to increased hand-off frequencies.
The major issue (other than $$$) is thought to be hand-offs: information gets lost when one caregiver takes over for another. For example, you might notice that Mrs. Jones looks just a little bit paler than she did earlier, and take that into account when treating her, even subconsciously. This gets lost when a new doctor takes over, and allegedly, the increase in hand-off-related issues is not outweighed by the decrease in sleep-related ones. That said, I'm also not convinced that this has been aggressively optimised, or even tested over long-enough durations that people adapt to increased hand-off frequencies.
Though not exactly as you described, something similar was done and published in 2016 (largely leading to this change, since there was not an increase in mortality risk)
http://www.nejm.org/doi/full/10.1056/NEJMoa1515724
One of the main challenges of course in this area is looking at patient outcomes with an incredible amount of potentially confounding variables, since "resident work hours" is just one of the many things that influence patient outcomes at a hospital.
http://www.nejm.org/doi/full/10.1056/NEJMoa1515724
One of the main challenges of course in this area is looking at patient outcomes with an incredible amount of potentially confounding variables, since "resident work hours" is just one of the many things that influence patient outcomes at a hospital.
The other challenge is that this study is comparing 28 hr shifts with >28 shifts.
This is probably the best that can be done without totally reworking the hospital, but it's not exactly a sensible test: data from lab experiments shows performance cratering well before that.
This is probably the best that can be done without totally reworking the hospital, but it's not exactly a sensible test: data from lab experiments shows performance cratering well before that.
There is also the iCompare trial which is underway and to be completed in 2019.
The phrase "allowed to" would imply that this is optional, that it is something that they want. Is that really so?
The first thing we care about is the patients. Most studies that have looked at longer hours vs more handoffs have shown equipoise in terms of death and serious adverse events. So, in that setting, most of us feel comfortable to think about what we want for ourselves as trainees and educators.
From the perspective of a trainee, on the rotations where duty hours even become a question, I was working 60-80 hour weeks. You can achieve that in a number of ways. One way is to work 5-6 days per week of 12-14 hour shifts. This sounds reasonable until you realize, a few months in, that you are at work from 7a-7-9p (assuming you're working daytime shifts) 6 days a week. It's monotonous and exhausting.
You can achieve the same by mixing some 24h days into the mix. During my training, this could only happen starting in our second year and beyond. Suddenly, I had several days with ample free time to buy groceries, do laundry, think about the world around me.
Medical training is extremely long and time intensive. Partitioning time into 24 hour chunks can surprisingly be preferable when 80 hour weeks are the rule (when safe for patients).
From the perspective of a trainee, on the rotations where duty hours even become a question, I was working 60-80 hour weeks. You can achieve that in a number of ways. One way is to work 5-6 days per week of 12-14 hour shifts. This sounds reasonable until you realize, a few months in, that you are at work from 7a-7-9p (assuming you're working daytime shifts) 6 days a week. It's monotonous and exhausting.
You can achieve the same by mixing some 24h days into the mix. During my training, this could only happen starting in our second year and beyond. Suddenly, I had several days with ample free time to buy groceries, do laundry, think about the world around me.
Medical training is extremely long and time intensive. Partitioning time into 24 hour chunks can surprisingly be preferable when 80 hour weeks are the rule (when safe for patients).
But if you do 80 hour weeks and 24 hour shifts, then you will end up doing Monday, Wednesday, Friday and Sunday, so you have two 24 hour shifts back to back, resulting in a 48 hour shift? Is that correct? Or do you do 4 days one week and 3 days the other? Do you get to nap during your shift?
The rule is no more than 80 hours per week averaged over a 4 week period, so some weeks you pull more, others less. Not every block requires 80 hours/week. Generally though, 24h shifts are placed into your schedule ("call day"), and other days you work a usual/shorter shift.
Did they study the effect of sleep deprivation on the quality of handoffs?
The FIRST study found that increased scheduling flexibility (including allowing longer shifts) was not worse than forcing shorter shifts (in terms of patient outcomes).
http://www.nejm.org/doi/full/10.1056/NEJMoa1515724
http://www.nejm.org/doi/full/10.1056/NEJMoa1515724
This doesn't return things to the pre-duty-hours era. However, it does roll back specific limits that were created for first year residents (interns). When eventually studied, the interpretation that most of us had was that there is not a significant difference in patient care with these shorter hours. This is due to, we think, the tradeoff between a tired doctor who knows your current condition well, and better rested doctors who are handing off responsibility more often.
love the orwellian way this is spun as to how it is letting doctors do another 4 hours on top of the current pathetic 20. no @%^@%#$ way i'd let myself be diagnosed by someone 23 hours into their shift, let alone do a procedure requiring basic hand eye co-ordination.
How many times would you want to be passed off from one "primary" provider to another over the course of 24 hours? Those handoffs are where things falls through the cracks...
Allowing doctors to work fewer, longer shifts is correlated with increased happiness for the docs (they end up with actual days off), and no increased risk for patients.
http://www.absurgery.org/default.jsp?news_trial0216
Allowing doctors to work fewer, longer shifts is correlated with increased happiness for the docs (they end up with actual days off), and no increased risk for patients.
http://www.absurgery.org/default.jsp?news_trial0216
So if you are bleeding profusely you are going to ask?
And then refuse stitches if there is no other doctor available?
And then refuse stitches if there is no other doctor available?
Hopefully future AI can help alleviate the healthcare shortages we seem to be facing.
Or they can increase the number of people going through medical schools. The AAMC understands the law(s) of supply and demand and doesn't want too many new medical doctors, then they would get paid less.
For reference, the number of students graduating from medical school is dropping:
https://www.aamc.org/download/321526/data/factstableb1-2.pdf
For reference, the number of students graduating from medical school is dropping:
https://www.aamc.org/download/321526/data/factstableb1-2.pdf
or we can just import foreign doctors like NHS does.
How is this not a form of hazing?
"I did it so the young people have to do it, too."
"I did it so the young people have to do it, too."
So now they will be "allowed" to work the hours that they already do. I have multiple resident physician friends and family members who routinely work 24+ hour shifts once a week, on top of 14-16 hour shifts daily yet if their time sheet says more than 80 hours/week, they are instructed to correct it.
Wow, 24 hours is insane. I work 10 hour, overnight, shifts at an elderly care facility and sometimes I have to pull a double or 1.5 shift due to call-ins. I'm exhausted and I can barely drive home. My work doesn't compare to that of an M.D.
My father is a urologist trained at McGill in its heyday back in the 60's, and they often worked much longer shifts than 24 hours. It was part of the training to be working while sleep deprived. In real life, a doctor often has to take calls in the middle of the night, and it was important for the medical school to either train students to be able to work under such conditions or be failed out if they couldn't hack it.
Mind you, they also had other traditions like working with cadavers with their bare hands only, out of respect for the people who had donated their own bodies.
Back then, it was expected that 2/3rds of students would end up failing out. Not just from long shifts, but the program was designed to be that challenging so as to weed out many people, to ensure that only the best would succeed. Nowadays, medical schools perceive the dollars spent training a medical student as too great of an investment, and want all their students graduate so failures are uncommon. Now once accepted, a student has pretty much made it even though the acceptance criteria is quite distanced from how they actually perform as a medical doctor. This potentially results in less qualified individuals becoming licensed.
Mind you, they also had other traditions like working with cadavers with their bare hands only, out of respect for the people who had donated their own bodies.
Back then, it was expected that 2/3rds of students would end up failing out. Not just from long shifts, but the program was designed to be that challenging so as to weed out many people, to ensure that only the best would succeed. Nowadays, medical schools perceive the dollars spent training a medical student as too great of an investment, and want all their students graduate so failures are uncommon. Now once accepted, a student has pretty much made it even though the acceptance criteria is quite distanced from how they actually perform as a medical doctor. This potentially results in less qualified individuals becoming licensed.
But this article is about residency programs, not medical schools. That is, tho/e stuck with the new hours have already made it through medical school.
Did you read the featured article?
Did you read the featured article?
> said the change will enhance patient safety because there will be fewer handoffs from doctor to doctor. It also said the longer shifts will improve the new doctors’ training by allowing them to follow their patients for more extended periods, especially in the critical hours after admission.
We really need the name of the human being who said that. That quote needs to be attributed to an individual who has to take some sort of responsibility for it.
We really need the name of the human being who said that. That quote needs to be attributed to an individual who has to take some sort of responsibility for it.
Who is this serving? Because it certainly isn't serving patient health.
So, in that case, stop calling it "health care".
So, in that case, stop calling it "health care".
And the only way that can go wrong is immediately.
Instead of 1 doctor working 75 hrs, how about 5 doctors working 15 hrs? And don't tell me there aren't enough candidates, the average acceptance rate for med schools is about 7%. Also its possible that there are people that would make great doctors but aren't in the top 10% of memorizing biology.
Longer shifts reduce the numbers of times a patient is passed from one provider to another. Reducing those "handoffs" is good for the patient (that tends to be where things fall through the cracks).
It doesn't have to be 15 hrs, it can be 30 hrs. You can have systems like all patients covered by 3 doctors and only 1 of 3 handoff at a time.
Does anyone know if doctors on shifts like this are given ample breaks to peruse polyphasic sleep? A 24-28 hour shift with 3-5 hours of polyphasic sleep doesn't seem quite as bad as just staying awake for 24 hours+
Why are the incentives continuing to be placed in the wrong areas? When will we remedy this properly?
[0] - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1739867/