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Comment by jseliger | Hacker News Reader

The culture of medicine, at least at the physician level, is completely insane; it's so insane that describing its insanity is part of the reason I wrote "Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school" (https://jakeseliger.com/2012/10/20/why-you-should-become-a-n...). Residents in particular have no power, and even physicians themselves frequently feel they have no choice but to match the death-march pace set by administrators or their most deranged colleagues.

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My wife's a second-year resident and it's pretty unbelievable how hard and how much they work. She's on her 18th straight day of working long days during the week and long nights during the weekend. Legally there's an 80-hour per week cap, but no resident would ever complain. They do 24 hour shifts, but never 30 hour ones, though other programs at her hospital do.

I felt upset about her hours all through medical school only to discover residency is worse. There are no fellows in her program either so the residents handle it all. I feel I've just accepted her terrible schedule at this point. I'm most saddened that we won't be able to have children for another five years until she's completed her fellowship, especially because I'm in my mid-30s.

Writing this comment makes me realize how painful it feels at times that her medical training runs our lives.

If she is pursuing a demanding specialty, consider having your kids while she's a resident; I've known a few people that did it and while it's hard, it can be the lesser of evils. Fellowship is just as hard - maybe even harder - than residency, and when you're practicing she likely won't be eligible for maternity leave initially and can face pressure from the group to keep on working (otherwise someone else might end up having those brutal all-weekend calls back-to-back... not a good way for the new person to make themselves popular with their group).

Of course, it's a different story if she will be in a more sane line of work, such as hospitalist, ER doc, etc.

She's sub-specializing in intensive care, unfortunately. We've discussed having children toward the end of fellowship for the reasons you state. It's a tough decision for us because I'll likely carry the brunt of the parental workload, but we also depend on my income for living expenses and loan repayment.

We waited until my wife was done with residency and fellowship, and it has worked out well for us. We have our second child on the way shortly, feel free to message me if I can help in any way.

My wife's in her final year of residency, so I know what you mean. I work from home in part to be around when she's off, but the demands of the lifestyle are especially clear when you see neighbors pulling into driveways at 5:30pm, friends enjoying a full weekend, vacations, and having several days off around the holidays.

Residency, by not granting you those things that people normally take for granted, helps you appreciate them!

I'm in the exact same boat. I work remotely and even though I've had a few job offers, one last night actually, I feel it's more important to have my flexibility here so I can see my wife when she's home. I find it especially helpful when she's on night shifts when her at-home time is <8 hours; I can move my day around hers to make meals and help wake her with coffee.

I can definitely relate with you on this story.

My wife is getting ready to start an OB/GYN residency next year (lasts 4 years for those who don't know). She just wrapped up interview season and each program had just about the same scheduling for their residents: 5 12-hour shifts at a minimum if you're lucky with one 24-hour shift per week on top of that. Often times I heard "one weekend off every six weeks". Then there's call.

I write this as I read more through your comment... the statement on the kids, medical training running your life... all true.

The other part, that I'm sure you can personally relate to, is "The Match". The "sorting hat" algorithm that all 4th-year med school students have to go through. For those unaware, the match dictates the program that a doctor candidate (MD or DO) must attend for residency. Given where my wife attended medical school, we already know that we're going to have to pack up and leave the home that we've established over 4 years since there are no residencies in our region. But since everything is done through "The Match", it's really a toss-up where in the country we end up (she applied to every program in the country since competition mandates that everybody do absolutely everything)... we'll be finding out in about 6 weeks where we will live come summertime. "Runs our lives"... so accurate.

I do what I can to support my wife through this endless process, but boy is it exhausting for everyone involved. I have no clue how she does it.

It truly is an enormous sacrifice of - really - some of the best (at least youthful) years of your life. Want to become a doctor? Say bye-bye to your 20s.

Edit: drawing context from another person who also commented on your post, we've also heard kids during second-half of residency can be a good route to go. We're thinking 3rd year ourselves.

> My wife is getting ready to start an OB/GYN residency next year (lasts 4 years for those who don't know). She just wrapped up interview season and each program had just about the same scheduling for their residents: 5 12-hour shifts at a minimum if you're lucky with one 24-hour shift per week on top of that. Often times I heard "one weekend off every six weeks". Then there's call.

How does this work out in the long term?

In the places I've seen that (not medical). It stops after a while because either the rhythm got back to normal or people burned out.

Well I can't say for sure about post-residency, but during the programs the shift scheduling was consistent all four years (some months you work the day 12-hour shift, other months you work the night 12-hour shift). The only thing that changed was during 3rd and 4th year, the call schedule was a bit more relaxed (after all they have to prep for another round of board exams).

As for burnout, alcoholism is relatively high among many medical specialties: https://www.sciencedaily.com/releases/2016/03/160314111353.h...

Can relate to all those points.

The Match was especially brutal on us because there were only a handful of programs within 2000 miles of our home (West Coast) so we said goodbye to our lifelong friends and family and moved out East.

It's a bit late for you, but I created a website (https://medmap.io) to help with The Match process. I have plans to improve it and make it more community driven, but it at least helps visualize your options.

That is a really cool website. I have some comments, and let me preface them with the fact that my wife is going to be a DO so I'm always looking for "Where is the love for DOs?":

- I don't see a way to differentiate between DO and MD programs. Along the same lines, several of the programs she applied to (like Grandview in Dayton: http://www.ketteringhealth.org/grandviewmeded/residencies.cf...) don't appear on this map (though some do, but again no indication of DO). What is the datasource for the map? Is there any way it could be enrichened?

A family member is the administrative director of a demanding internal medicine residency program here in Canada, and I can say from experience nearly all the residents take maternity or paternity leave during their residency. The program is incredibly accommodating to new parents, partially driven by Canada's strong parental leave laws, but mostly because they recognize doctors are people too. From what I hear US based programs haven't come to the same realization.

If you're worried about the effects of your age on your child, why not freeze her eggs and your sperm?

yeah, why not? nbd.

smh. "freezing eggs" is not a trivial solution.

https://www.theguardian.com/commentisfree/2015/oct/21/women-...

IVF is no walk in the park.

If you don't have the time to have sex and give birth, you sure as hell don't have time to go through IVF retrieval cycles!

So what happened? Was there a massive disaster that created an overwhelming flood of patients, that everybody needs to work overtime?

Because under normal circumstances, a competently run hospital should be able to function with normal 8-hour shifts. If that's not possible, then management fucked up. Accepting these kind of hours as standard is completely unreasonable and dangerous, especially in hospital, where lives depend people being awake enough to do their job safely. People responsible for that should not merely be fired, but locked up.

The AMA enforces an arbitrary limit on the number of medical school spots and therefore doctors in the US. They create a shortage of doctors in order to keep doctors' pay high.

I was unaware of the medical school cap, but there is a residency cap set by congress in 1997 that also aggravates the issue: http://www.medpagetoday.com/PublicHealthPolicy/MedicalEducat...

>Medicare already funds a bulk of the residency training in this country -- to the tune of about $9.5 billion a year. But its support was capped by Congress in the Budget Control Act of 1997.

The medical system has billions of free cash flow. Big hospitals could fund lots more residency spots.

Exactly. The "limited federal funding" canard is a brazen excuse by the AMA to deflect attention from their own role, and to lobby for more free money. No one ever argues against more free money for themselves.

Can the AMA prevent hospitals from creating residencies with their own funds? I'm ignorant about this, but at first blush it seems like doctors must be a top expense and most companies enjoy employing workers with cheap wages and long hours. Hospitals should be happy to hire as many residents as possible (even if they got 60 hours from them instead of 100). What am I missing?

They can encourage their members to avoid those hospitals.

Most doctors don't work for the hospital. That's one of the many reasons behind the strong opposition to Obamacare the creation and consolidation of regional medical systems is making more doctors salaries employees and reduces their bargaining power.

My understanding is that their control to the end of limiting the number of doctors is exerted way back in the part where they have to approve new medical school seats.

So they're basically DeBeers for doctors?

A doctor friend of mine claims that the benefits of doctor-patient continuity outweigh any downsides of sleep deprivation. That sounded like a rationalization or cop-out to me, though. I can't imagine how that could be true, or that they're aren't other ways to solve the continuity problem that don't involve zombie doctors.

Even then, finishing with your current patient and then going home should still not lead to regular 12 hour shifts.

Different patients need differing amount of times. We're not talking about doctors who work in private practice and have business hours. We're talking about doctors who work in hospitals and work prearranged shifts and have on-call time.

A doctor can't necessarily predict how much time a patient will need. If a doc is on an 8-hour shift (hypothetical; I doubt any docs are so lucky!), and gets a new patient at the 6 hour mark, it might not be known if the patient will only be in the hospital for an hour, which would be fine, or 4 hours, which would push the doc to 10 hours.

As the argument goes, that patient is safer staying with the doc into his/her 10th hour on the job, versus being transferred to a different, fresher doctor midway through. I think there's enough truth there for it to be persuasive, but 1) there are limits to how effective a doctor is going to be after a certain amount of time, and the benefits of patient continuity must start dropping as the doctor has been working longer, and 2) there seems to be little attention paid to improving the process of handing a patient off between two doctors, which could further reduce problems related to lack of continuity to the point where a doctor who has been working 10 hours will cause more bad outcomes than shifting patients to fresher doctors would.

> If a doc is on an 8-hour shift (hypothetical; I doubt any docs are so lucky!)

But that's a big part of the problem already. It shouldn't be luck to have an 8 hour shift, it should be standard. And of course there may be times when circumstances demand you deviate from that standard, but if you start with 12 hour shifts, you already start wrong, and it can only get worse.

I think we're deviating from the point I was trying to address. The length of the shift isn't relevant, what's relevant is that different patients need different amount of times, and can arrive at any time during a doctor's shift. Based on both of those variables, a single patient can easily require care beyond a single doctor's shift, so saying "getting done with your current patient and then leaving should never lead to a 12-hour shift" doesn't really make sense, since that "current patient" could have arrived during hour 6 of your shift and then required a 6 hours of attention before being discharged. If you believe that doctor-patient continuity is more important than a doctor's rest, then you can easily justify any shift length up to the point where the doctor falls over.

I would agree. In extended hospital sessions that my wife and I have experienced, having continuity was huge, especially as the nurses swap out every 8-12 hours.

In my case, I suffered from this issue after a back surgery when some dumbass hospitalist read my chart wrong and told the nurse to cut off pain medication 10 hours after a spinal fusion. I asked the nurse for meds after she woke me up at 3 AM (to take my blood pressure and ask if my birthday had changed) and she refused and essentially accused me of shopping for narcotics.

When my surgeon checked in on me at the start of his day (5AM), he was shocked and got things fixed.

> some dumbass hospitalist read my chart wrong

But couldn't this also be explained by said person lacking enough sleep?

> and ask if my birthday had changed

Er, why? This reeks of a pretty serious administrative fuck-up.

Around here, every interaction with a hospital employee involves a recitation of your birthdate, allergy status and other crap.

When my wife was having our baby, the nurses had to log into three different systems -- an OBstetrics system, the hospitals charting/EMR and the pharmaceutical system. That meant going through the ritual 3 times.

Why can't you have children? Would it completely throw her off her eventual completion of her residency or just delay it?

All women deal with it differently, but most are able to function within their normal bounds until at least the six or seventh month.

> Writing this comment makes me realize how painful it feels at times that her medical training runs our lives.

s/runs/ruins/?

Post-birth is a consideration as well. Assuming the parents intend to breast-feed, the child will need the mother every hour or two for several months after birth. After a few month the interval widens, but not by much -- at least, not by enough to allow the mother to take on anywhere near a regular doctor's workload. So it's not just the last few months of pregnancy that are a concern.

But nurses are no different.

We need to start addressing the leading cause of medical accidents - physicians/nurses sleep deprivation.

they are completely different. Where I work in cali nurses are full time working 3 or 4 twelve hour shifts a week. Overtime optional and highly compensated.

medical residents will routinely do back to back 24 hour shifts with no sleep and even the ICU attendings will do a week of every other day 24 hour shifts.

The 16 hour rule only applies to interns. Once you reach second year the rule is 80 hours a week averaged over four weeks. This means that 100 hour weeks still do happen.

I was forced to do 100 hours a week for a company that had a sadistic culture of over work, you never get anything done, under those kind of hours unless you're doing stimulant drugs your brain just shuts down. I wonder how many doctors are also drug addicts just to make this kind of work intensity physically possible even?

I'm surrounded by doctors and I don't know any that abuse drugs, other than alcohol and maybe weed. I believe they are just so busy and so overworked that they are constantly moving around / doing paperwork. The demands of the job keep them going.

You must have never met psychiatrists then; never seen otherpeople take drug usage so lightly.

You don't know any doctors that use drugs, but you do know of some that do weed.

I'm laughing...

Is weed a kind of tea, or is that an energy bar?

He said abuse, not use.

In my experience, you are absolutely correct. I dated a nurse for a while and later married a doctor, and it was completely different. Physician training is absolutely, terrifyingly demanding.

I know of no nurses that work this schedule, even voluntarily (overtime, swaps).

Nursing in many states is challenged by unsafely high patient:staff ratios, excessive documentation requirements (on extremely slow user interfaces), and the need to vigorously double-check physician's orders (dangerous drug interactions, over-dosages, etc).

I do. Nurse midwives, and other mid-level providers are often subject to similar hours and work schedules.

A friend of mine had to become his wife's driver, because after working double shifts across two hospitals, she could barely keep her eyes open.

There you have it: she was working agency at a secondary hospital. That is due to a decision of her agency or herself; it has nothing to do with hospital administration or nursing in general.

Many hospitals are based across multiple locations, so it's not necessarily agency work.

I used to work in a hospital laundry (where we were understaffed, of course), and I spent my lunch hour talking with nurses. Many were actually NAs and had to work second shifts at different hospitals to make a living wage. So even if the hospitals are reporting normal shifts, the personnel are actually working up to twice as many hours.

Nurses cannot leave until relieved. My mom routinely had 12 hour shifts extended when she worked in NYC.

And at considerably worse pay with no overtime, asumming nursing is the same everywhere.

No, we should direct all the hate at lawyers asking for more than 250k for malpractice

So lawyers demanding 250k for malpractice is what's causing malpractice? OK...

Next you're going to be blaming the patients.

Defensive medicine is incredibly expensive and produces worse results, so while I wouldn't blame lawyers solely. there are much better ways of doing things imho. New Zealand's Accident Compensation scheme is one way - far from perfect, but far better.

Doctor amputates the wrong leg. How much in compensation is that worth in your mind? There should never be an award more than 250k? I disagree. My wife is a psychiatrist that works in patient. She got a transfer from another hospital who was on 32 drugs. That's clear negligence and should be a malpractice suit but no lawyer will take the case. It's not clear cut enogh. In recent years the pendulum has swung in the other direction. There isn't enough access to the court system for patients wronged by the medical community.

I'm curious why so many people still put up with it?

I'm a practicing hospitalist and I love it. I spend time on the hospital floor, time in the ED, and time covering patients in the ICU. Yeah, some days suck (I occasionally have to stay from 7 AM to past midnight, though that is quite rare), but overall I can't imagine doing anything else.

Also, I work 7 days in a row and then have 7 days off, which I absolutely love. I have the option of working 5-days every week and having weekends off, but I prefer my current schedule.

I think I'm pretty well-paid, but are there better/easier ways to make money? Yes, of course. My college roommate probably makes more than me and my understanding is that he just sits in meetings and adjusts Excel spreadsheets all day managing someone else's money. But hey, whatever. I could work at night instead of the day, it would be easier (no discharges), and I would make over 430k. But I don't want to do that. Instead, I work with a residency program and get to teach, which is very rewarding.

I think overall it's just a matter of perspective and expectations.

Sounds like you really enjoy what you do!

I hear about doctors like you, but I have never experienced someone like it in real life.

Maybe one day.

Even if there are people like yourself who actually want to work 17 hour days for 7 days in a row (!), shouldn't we as patients be able to have doctors who are not allowed to do that insanity? Medical error is the #3 cause of death in the US. It seems entirely irresponsible to take someone's life into your hands without proper rest.

work 17 hour days for 7 days in a row (!)

They explicitly said 17 hours was rare.

I don't really care how rare it is; I never want to be treated by someone who's been going for more than 8 hours, much less someone who's been going for 17.

Ah, I probably misread the comment a bit. I read it as working 7am to past midnight is rare, making 7am to midnight (or just before) normal. But you're probably right in that what was meant was that there are other, more sane working hours (not defined in the comment) that are the normal conditions.

But yes, to agree with the sibling comment, I'd prefer to never have any doctor in any hospital seeing a patient after they have been working for 17 or more straight hours.

I'm usually in around 0800-0830 and out by 1700-1800

I always wondered why the public puts up with it. Aviation is always provided as a contrast to the medical community: pilots have legally-mandated sleep requirements.

My hunch is that when a plane crashes, everyone freaks because planes aren't supposed to crash. When someone dies at a hospital nobody notices because people die at hospitals all the time.

If the plane crashes, the pilot has a good chance of dying too, if the doctor makes a mistake, not so much.

Air traffic controller then. I hope they have regulated hours in the USA...

Thanks for writing that. I can't remember exactly the process we went through, but I remember your post being a significant part of the information pushing my wife from med school to PA school, a decision we're quite happy about.

> The culture of medicine, at least at the physician level, is completely insane

Is this problem US specific, or global? And, isn't the real problem a scarcity of qualified doctors? Which, if people follow your advice, becomes worse?

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