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Comment by mcv | Hacker News Reader

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.

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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.

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.

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.

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