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Comment by cauterized | Hacker News Reader

Who thought this was a good idea, and why?

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?

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I am a surgery resident. This "rule" only applied to first year residents, and was started in 2011. There in fact is a study being conducted where one arm of first year residents follows the 16 hour max and another follows the 28 hour max. It seems the results from this trial suggest the 16 hour max is detrimental to learning, hand-off logistics and scheduling.

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.

1) Is a problem with efficiency not people.

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.

These 28-hour shifts are unique to healthcare in the United States.

Solution: allow more people to become doctors.

Ok, but what exactly do you propose? funding to support residents comes from the federal government, and this funding is already strained.

Should we lower standards? Lower quality of care? If the answer was easy we would have already implemented something.

If you really want simple solutions to more doctors:

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.

Limiting under grad education - sure, that is reasonable, that is how non-US countries do it. You get fast tracked to medical school after high school. But you still need some amount of undergrad education before medical school.

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.

It takes years for the sleep deprived to do so. That does not mean it must take years. As you know actual doctors continue to look things up, so you don't need them to memorize every edge case, just know when something could be an edge case.

Yea, well. I just don't think we can continue this argument.

The problem isn't the number of doctors we produce, but the number of residency spots.

And why is that number so low?

There is limited funding from the government to support residency positions.

Ehh, it's just another part of education, let some people pay their own way. However, that requires fewer years upfront so the costs are more reasonable.

Pay their own way? Residents are already in 8 years of debt after undergrad and medical school education. How could you expect a person to keep paying their way for a total of up to 13 years of education (what it takes minimum to become a surgeon after high school in the US)?

As I said somewhere else, undergrad should be removed. But, if the current system costs X and students pay for 5% now you get more doctors.

You don't get it. The government limits the amount of residency spots. They fund the residency spots. And most students do not pay upfront, they go into debt to fund their education. Having students pay more or go more into debt will do nothing. The amount of residency spots is ultimately determined by the US govt

This is factually incorrect the US government pays for a fixed number of slots, but they don't pay for 100% of the residency slots available. Thus there is no legal limit on slots.

So who should pay for more slots?

So what happens when the resident gets sick or run over by a bus 6 hours into a 24 hour patient?

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)

This 24-hour cycle only works for the small fraction of patients who come in right when your shift starts. For everyone else you're still getting a limited perspective.

As other people mentioned, this really seems like treating the symptom (poor continuity of care), not the problem (ineffective ways of communication and training).

Again, see #1; this is the real problem. There are not enough of us to allow a normal 40 hour work week. The guideline is no more than 80, and we regularly exceed that.

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.

Again, you're missing the root cause. If the problem is not enough doctors to meet patients' needs then why don't MDs and NPs work a little more so the burden doesn't fall entirely on med students? Or conversely, extend med school another year so that everyone gets the same number of hours but it's spread out over more time. Worst case, I would still prefer to be seen by a resident working 6x16 hour shifts rather than 4x24 hour shifts.

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.

There is no burden of patient care placed on medical students in the US. Medical students start clinical duties their 3rd and 4th years of medical school but have little to no actual responsibility. They are not allowed to write orders or perform procedures without resident supervision. Their primary role is to learn. Don't get me wrong, they are very useful and can help a ton doing small tasks and collecting information.

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.

> Why they did a big study to see what was best

As you well know, everyone lies through their teeth when it comes to hours violations.

Especially when reporting duty hours violations is made to seem like the fault of the resident by your bosses. You are incentivized to not report violations.

Any time you see a policy in the medical world (or elsewhere) that appears completely irrational and nuts, ask yourself one question:

Does this policy increase medical industry revenue?

With the exception of instant death to the patient, medical errors always increase revenue.

i mean, reading the article would give you several reasons why they didn't think avoiding fatigue was a good tradeoff.

I see one in the article, which is wanting a single doctor to consistently be available through a course of treatment. But I don't see how 24 hours guarantees that any more than 16.

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.

> 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.

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.

I only see one -- a personal continuity of care argument ("Patients want to know 'you are the doctor taking care of them,' Kothari says.").

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.

As someone who got out of the hospital recently after a couple weeks in, I see the continuity of care argument. I had a lot of doctors in my time there, and the left hand really didn't know what the right hand was doing. I spent an extra 4 days in because one of my doctors thought the other doctor was going to write the discharge order, and vice versa.

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