Rookie Doctors Will Soon Be Allowed to Work Up to 28 Hours Straight
npr.org
npr.org
Doctors apparently don't make mistakes that can hurt people.
They can, but it turns out that the handoff points can themselves be more problematic than the effects of working for 28 hours. They did lots of published research which showed that, which is why this policy change is even happening.
Also, a 28 hour shift doesn't mean that the doctor is working (or even awake) the entire time - they're on-shift, but there are periods of downtime. It's not necessarily 28 hours of constant activity.
That's a good idea. Do you know what those flaws are, and how to fix them?
I'm not being sarcastic - there's a whole lot of money that's been poured into this over the last few decades, and it's not easy.
While we wait for someone to figure out the answer, in the meantime, it's reasonable for providers to go back to the policy that empirically produced lower rates of medical errors, which we know because that's what was standard practice up until a few years ago, and it already is standard practice for all other residents.
But I also think the answer is pretty obvious, if not practical. You need to basically double the number of doctors, and stagger shifts so they have half-shift overlaps and scheduled 8hr (max) shifts to begin with. Then doctors can stay longer through the next shift if needed (and this would be common) to complete the handoffs properly as well as get through critical periods of patient care.
I think that would be far safer than the current model - but also would effectively double your salary costs which is of course a non-starter.
As mentioned in the article, one of the problems they found with the shorter shifts is that it was less effective for teaching, meaning that they would need longer training periods overall to achieve the same results with shorter shifts. So that would mean increasing the costs of residency, which is already an unprofitable program to begin with.
So, doubling the number of doctors without compromising on training would mean increasing the per-resident costs significantly and then doubling them. That's... a hard approach to execute.
Also, that's assuming that having twice the number of doctors caring for each patient per unit time does not introduce any other problems, which is an assumption I'd question.
I would make the argument that the vast majority of scheduled hours for a resident have absolutely nothing whatsoever to do with learning and entirely to do with having shift coverage and are primarily economically driven decisions.
You do make good points about less uninterrupted time with patients, and it's a good reminder of how this is a very nuanced difficult problem to solve. Even in my industry where we can more realistically staff shift overlaps, we have handoff issues due to human mistakes. Nothing is going to be perfect, but I think we can do better for patients as well as doctors.
Come on. You know people are lying out their asses about hours.
Here's an idea. 12 hour shifts. Like nurses. And NPs. And PAs. Who also do handoffs.
People are lying about hours; therefore in peer-reviewed research, longer scheduled shifts led to lower rates of medical errors?
The data from which the peer-reviewed empirical studies is flawed. I know, because I am the data. I -- and almost every other surgical resident I know -- routinely falsifies their work hours. Why we do this is a _long_ topic for another thread.
Please confirm with your local surgical resident; if you can find her. ;-)
Do you really want me operating on your Mom after 28 hours? I wouldn't. I can't tell you the amount of times a fellow resident has got in a car crash, or made a mistake related to patient care because of lack of sleep.
Also, let me clear up the "periods of downtime" part for you. For the last 6 call nights, I got a grand total of two hours sleep.
Honestly, I created a throwaway specifically to reply to many of (what are in my opinion) very misguided opinions on how these types of hours effect quality of care.
No, but I don't want 3 different doctors treating her with that time period either[0] - at least, not with the findings of the peer-reviewed research demonstrating that this leads to higher rates of serious medical errors.
> I can't tell you the amount of times a fellow resident has got in a car crash, or made a mistake related to patient care because of lack of sleep.
Nor could I tell you the number of times critical information has gotten dropped at a handoff boundary, impacting the care of the patient.
Nobody's saying that sleep deprivation doesn't impact medical care. What the peer-reviewed research is saying is that sleep deprivation is less dangerous than frequent handoffs.
[0] which is what 12-hours shifts (as you proposed) could entail.
You'd think, but it's a lot harder than it looks, and I'm speaking from experience.
In the meantime, they're going back to a solution that they know works, because in this case it's literally what they used to do before and what they already do for all other residents, and it has a lower failure rate.
All they're doing here is reverting a failed experiment in response to the measurable, documented problems it introduced.
> a solution that they know works
For what definition of works? My (thankfully few) trips to the hospital have not exactly inspired a lot of confidence in the hospital system. Duplicated questions, minimized interaction with an actual doctor, being kept in the dark about what's going on, waiting for hours between human interactions, empty IV bags which hang for hours... This is questionable definition of "works".
Handoffs are dangerous so longer shifts make sense...but 28 hrs is way too long. People are pretty much walking zombies at that point.
The ACGME is still acting off a model where sign-outs are face-to-face following a checklist (see: https://www.ncbi.nlm.nih.gov/books/NBK43722/). This is the best we've come up with, and it frankly takes a lot of time. It's no wonder 16 hours didn't cut it. What we need is a better way to do sign-outs so that residents can know what's going on even during their days off. The very wording "sign-out" is rather a misnomer. Just because you're leaving the hospital for two days doesn't mean you forget about your patients. What we need is something like a Twitter feed so you can get updates on your patients when you're not in the hospital. Then you wouldn't have to have a full-blown sign-out when you return.
It's too late for you, but I wrote an essay called "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...) to warn people about what med school and residency is really like—and to tell them that there are good alternatives!
Living with someone who went through the process led me to write the essay.
You don't point out one reason some people choose nursing/PA school. They get to move between fields somewhat easily. I think that belies the difference between these professions and physicians; the doctors become specialized in their areas while the mid level providers carry out their plans.
For people who have been in the hospital, the best argument to being a doctor over PA/nurse/etc is that, at age 60, you could be teaching, seeing patients, doing research, building biomedical devices, conducting community outreach, and doing what you were trained to do. Notably, for doctors, that doesn't include dealing with bodily fluids, angry family members, an arrogant boss 30 years younger, etc.
Like in every profession, doctors need to work to get paid. But, if you want to be in charge of your own work day when you're at the middle to end of your career, be a doctor.
Sounds a lot like "dev-ops."
Good luck getting all of the signoff and political buy-in required to get set up with that.
You could spend 18 months running around to convince someone to do ten minutes of work to bring you online, and I'm not exaggerating.
Aren't our medical professionals the people we least want to be dangerously fatigued?
Hasn't anyone read the literature on how sleep deprivation interferes with learning?
Or how being up for 24 hours straight is equivalent to a blood alcohol level that would disqualify a person from driving?
And we want people in this state while they're responsible for the health of people sick enough to be hospitalized?
What the actual fuck?
Regardless, after your first year, no matter what program or specialty, 28 hour calls become the norm. As a second year surgery resident for example, you can plan on taking a 28 hour call two or three times a week. This is just how it is. For two main reasons:
1) There are not enough of us for everyone to get 8 hours of sleep a night. People can debate why or ways we should fix this, whether it's widening scope of practice for nurse practitioners or decreasing our pay so there is more of us, but logistically there are not enough residents to keep everyone well rested.
2) There is physiological relevance to a 24 hour cycle in many diseases. For example, if a patient comes in with a bowel obstruction, the process of observation, lab evaluation, imaging, +\- surgery takes sometimes 24 hours. 12 is sometimes not enough to appreciate the full evolution of acute disease.
Big topic here. My experience is anecdotal and limited. Why they did a big study to see what was best. Still, it only applies to first years.
As other people mentioned, this really seems like treating the symptom (poor continuity of care), not the problem (ineffective ways of communication and training).
We are doctors. Society demands highly trained and skilled physicians to take care of them. It takes many years to produce one. And there are many hours in the day.
Basically what you're saying is that the system is so broken that the best care relies on young adults fresh out of college working in a condition that has been shown to be just as bad as being legally drunk. I'm saying that, if that is the case today, we need to fix the system.
The argument returns to a lack of man power. There are simply not enough residents for us to work 40 hours a week and get 8 hours of sleep a night. Call that broken, or what you want, that's just how it is.
Should we lower standards? Lower quality of care? If the answer was easy we would have already implemented something.
Don't promote/require undergrad before med school. As in premed is not an actual degree anyone would ever get. Don't require multi year residency's, if the goal is education then 12+ hours days actively block that goal by inhibiting memory formation.
Shockingly both of those require zero money and would add up to 4+ more years of practice and lower education costs. However, US doctors don't want that as it would lead to lower pay just like every other country.
But no multi-year residencies? You are misinformed. It takes years to learn how to take care of the sick and dying. We don't just punish ourselves with lengthy training programs for fun.
No no, this is not at all how to go about this. Every cog in patient care needs to be replaceable within minutes or the whole system is just headed for disaster. Whats the policy? Whats the procedure? Wheres that evaluation?
(No need to comment on the smallest violin of the world playing for the business owner of 1) who would rather exploit residents to get more work out of them instead of stopping to admit patients)
If you design things for people to be horribly incompetent due to sleep deprivation, then going through the same process while awake probably produces similar results. However, a shorter work day would mean you could use different processes.
As you well know, everyone lies through their teeth when it comes to hours violations.
Does this policy increase medical industry revenue?
With the exception of instant death to the patient, medical errors always increase revenue.
I for one would rather my doctor worked 8 hours, went to bed for 8, and returned for the third (or 4th) 8 hours than that they be on their feet trying to keep their eyes open for 24 hours straight and remember everything that I and 20 other patients have said to them or undergone in the last 24 hours.
Would you rather have your surgeon hand the scalpel off to another doctor, or have them proceed while so fatigued as to be drunk?
And in case you didn't notice, the article also points out the dangers of fatigue, just with the journalistic integrity that suppresses the expression of the outrage that those of us who aren't journalists should all be responding with.
According to empirical research, that is actually more dangerous for you, because the handoff points are most likely to introduce errors.
It's counterintuitive, but that's something that both providers and peer-reviewed medical journals agree on.
If that's true, I think it's kind of fascinating. I'd certainly like to know that there is someone who is taking enough interest in me as a patient that they consider themselves ultimately accountable for providing or coordinating a professional standard of care. But I don't need that person to be the personal face of that care all the time, and frankly, it's ridiculous to assert the system behaves that way now. And I definitely want to know that person is operating without cognitive impairments, and definitely don't think "continuity" means "one person."
I'm sure there's realities of actually doing the work that I don't understand, and I also know that handing off information and coordinating people is far from trivial (I know that we're really not all that good at it in software, a profession where for anything to work at all you have to pass around carefully encoded instructions). I just don't understand the given argument.
Also, I see at least one professional counterargument in the article.
I come from the UK but live in Norway and am impressed by the health system here.
It did. And they did the research, and they found that frequent handoffs introduce more errors than longer shifts do. So, they're taking action to address that.
I would be pretty annoyed at that, but I also probably wouldn't report it just to see it through. Seems weird they'd suddenly get honest about it.