First-year doctors will be allowed to work 24-hour shifts starting in July

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.

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.

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.

> 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.

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.

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.

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.

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.

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.

And will lead to mistakes with fatal consequences

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.

So if you are bleeding profusely you are going to ask?

And then refuse stitches if there is no other doctor available?

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

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?

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).

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).

or we can just import foreign doctors like NHS does.

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