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Comment by mattjaynes | Hacker News Reader

I recently had a family member in the intensive care unit (ICU) for over a month in Austin, Texas. I quickly learned my main contribution would be protecting her sleep when I saw she hadn't slept in days because of the constant interruptions. She went from reasonable and compliant in taking her medication, to extremely irritated and noncompliant with the doctors. Of course I could see this was due to sleep deprivation, but when I kept bringing this up to the doctors and nurses, they gave me blank stares and didn't seem to believe or care. When they started suggesting another surgery due to her not improving, I nearly lost my sanity. Ultimately, I had to become a very vocal and unpleasant protector of her sleep - if a nurse came in, I quickly took him/her outside the room and asked what they were planning and whether it was absolutely necessary. This annoyed them quite a bit and they hinted that they could have me removed. It was one of the worst experiences of my life. Just being in the ICU for a month with a loved one is hard enough, but having to battle the staff to protect something so basic as SLEEP so she could recover, made it a true nightmare. Something is truly broken if trained medical staff see sleep as optional - the data and science behind sleep is so compelling, and they don't understand these basics? Desperately frustrating...

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You were dealing with doctors and nurses, right?

One group runs a gauntlet of fire by sleep deprivation during pre-med training: with on-call work hours up to 120 hours a week. And the other group are typically on shift rotas so their sleep patterns are permanently disrupted.

I'm going to call it for them being oblivious to the sleep requirements of ordinary human beings, because these professions are self-selecting for sleep-dep survival traits; only people who can work insane hours make it through hospital medical training, and only people who can take shift work in their stride make it as hospital nurses.

(Also, my observation of hospital doctors is that anyone you see on a ward outside core office hours is relatively junior, i.e. aged about 22-35. Senior consultants and professors work normal hours like everybody else. As for the nurses ... my understanding is that ICU nursing burns them up.)

(Source of observations: former hospital pharmacist here, who just got a refresher course c/o a relative who spent three months on an acute stroke ward this fall.)

>One group runs a gauntlet of fire by sleep deprivation during pre-med training: with on-call work hours up to 120 hours a week.

I would argue this is the source of injury and death to the patients that needs to be addressed rather than powered through in some sort of macho hazing ritual. Anecdotally a very tired doctor is allegedly how my wife lost her mother.

I've always assumed that the failure rate for handing off care to another person and the rate because of long hours must go in favor of long hours. I don't have anything to back this up except the MCAT being designed to check how you perform when tired. Now with electronic records I've been wondering if long hours are still be necessary, assuming I'm right about the failure rates.

I'm sorry about your mother in law regardless.

This is the claim, but if you look at the experiments supporting it, they’re all bonkers. For example, care is no worse from doctors on 28 hr shifts vs 24. I would argue that both of these are so far from a well-rested baseline that they’re meaningless.

We know from lab experiments that performance craters way, way before that, which is why pilots, truck drivers, cops, and every other profession work shorter shifts.

All this talk is insane. I have like maybe 4 top-performing hours on my best days. The idea of working more than 8 in a life safety critical situation boggles the mind.

Super intersting to see people discussing this! As someone that holds a pilots license and talks with a lot of commercial pilots about their jobs, sleep is often a hot topic of discussion. It would be illegal, not just irresponsible, for a pilot to try pull off a 120 hour work week. Why do we treat doctors differently? Their macho behaviour in my opinion is unacceptable, and likely reduces positive patient outcomes, yet it goes on?

Medicine has different concerns than piloting, though. Pilots don't have to ensure continuity of care for their passengers, and can accomplish their work in reasonable chunks. Doubling the number of patient handoffs, on the other hand, significantly increases the risk of one of the more common sources of error.

But could the increase in errors from increased hand-offs be smaller than the increase in errors from sleep-deprived doctors, nurses and patients combined with the increase in disease spread and disease progression from the effect of sleep deprivation on the immune systems of doctors, nurses and patients? Additionally, could there be benefits from getting more eyes on a patient's condition?

I've always wondered if the problem might be in the handoff procedures. Those studies about mortality in the event of a handoff always make it sound like obviously handoffs are an inherently dangerous thing, but perhaps the modern way of doing them is just poorly implemented? It feels extremely unlikely to me that absurdly long hours are the only solution.

I think this is a rational question to ask! Often people will jump to conclusions "handoffs cause errors", and while errors are a symptom of handoffs executed poorly, it seems uncommon for people to often ask for improvements to these processes.

There's just no way efficient way to capture, log, and communicate every single little detail a doctor observes while diagnosing and setting treatment for a patient. First impressions are often wrong, and little details can become significant later. Early treatment might be designed not only to address symptoms but to exclude other diagnoses.

In a plane in level controlled flight, there is very little to hand off between two type-rated pilots. Both folks understand the machine, and the machine is working the way it is supposed to. Humans work the same way! Parents "hand off" their healthy kids to schools or babysitters or relatives every day.

But imagine a plane that is in the process of crashing; it's in a dive, controls are not responding as expected, one of the engines keeps turning off. A pilot is fighting to regain control... how comfy are you with THAT pilot handing off the aircraft to another pilot in the middle of that situation?

It's a little silly as an analogy, since plane crashes tend to be resolved pretty quickly one or the other. But conceptually, just imagine a plane that is in the process of maybe crashing for 12 hours. There's a good argument for a pilot to just see that through instead of "clocking out" at 8 hours.

> Pilots don't have to ensure continuity of care for their passengers, and can accomplish their work in reasonable chunks.

Are you aware that on long haul international flights pilots do in fact rotate who is actively "flying" the plane? Flying is in quotes because most of the work is done by automation these days. I won't draw any analogies between the autopilot doing much of the work for pilots and nurses doing it for doctors because I can't actually support the statement with any data.

Yes, but that's the whole point: there's little risk in rotating pilots, whereas rotating members of the care team carries a substantial risk of key information falling by the wayside.

I see your point, but i'd love to see a peer reviewed study to back up the claim that "it's better to have over-worked doctors and nurses than to introduce more handoffs".

There's no error in hand offs. Attending doctors are detached and spend just a little time with a patient during their stay. Nurses and PAs do most of the work.

Flying a plane is way less complex than medicine. A pilot can hand off a flying plane way, way, way more easily than a doctor can hand off a patient with a complex set of symptoms and treatments.

I should also point out that the vast majority of doctors don't work 120 hours a week continuously, rather, they experience higher-than-usual clusters of working time vs. not working time. That is, they might be on rotation for 36 hours straight but then off for 36 hours or more. And some of their shifts might only be 8 hours. Residents work longer hours, but are supervised by doctors.

I know several ER docs and they all cite the dangers of patient hand-off as the main reason they continue to support long shifts.

Medicine is a conservative field - unfortunately that also includes ignoring anything harmful to their cult aspects even if it is trivially obvious like "wash your hands" after doing a damn autopsy before delivering a baby. Or yes infants can feel pain - not using anesthesia because the control isn't fine enough to not have a better chance of killing them is a grim but justifiable thing initially but inexcusable once it becomes possible to do so safely.

And the sleep deprivation and hazing "I did it so everbody else must too!" is definitely a cultic thing.

I use cult very deliberately to point at the reasoning being entirely irrational and social as opposed to underlying value. And also because actual cults use slerp deprivation.

Peter Attia (MD) had a podcast episode where he talked about being a resident and how it almost killed him (asleep while driving) and was bad for patient.

Also explained that the guy who created the residency program was a cocaine addict who rarely slept, and since then all doctors have to try to follow his crazy schedule for no good reason..

Yeah. I mean, I get that hospitals are 24-hour operations that need doctors & nurses available at all times. So some people are going to get the crap end of that stick and have to do night shifts. But is it really necessary for them to work 80+ hours while they're at it? It seems like there's enough people trying to be doctors that you could cut that down to a healthier 40 hours+ 15 hours on call if it's really necessary to. Heck, even 50 hours.

You would likely have to extend residency based on everything that you need to learn for a given specialty. Med school graduates have an average of over $180k in student loan debt - from med school alone - and resident salaries in the 2-4 year programs are mid five figures.

Given the choice, I'm not sure someone whose 4-year earning potential is capped at $60k with $200k in student loans would want to extend that to 5/6/7 years.

I believe the GP is talking about increasing the number of doctors, not their years in residency.

You learn how to do your entire specialty during residency. If you cut the number of hours, you have the same amount to learn in less time.

That's on the assumption that amount learned per hour remains constant as hours worked increases.

And that sleep deprivation has no effect on learning ability.

>You would likely have to extend residency based on everything that you need to learn for a given specialty.

I would challenge that assumption because I don't believe there's any consistent number of hours worked by residents in rotation, is there? I mean there are published schedules and then there are actually the number of hours worked which at least according to the other posters is even more than scheduled. So if there's already an element of randomness here and different doctors are getting different numbers of in-rotation hours then it's plausible hours could be made consistent and reduced, isn't it?

You may want to look into why med school is so expensive, compared to other majors.

Here in the UK, the way I heard it from a friend who was doing their pre-med, is that there was a built-in cost incentive: hospitals paid doctors who were on-call at one third of their regular hourly rate for out-of-hours on-call coverage. (That's not regular hourly rate plus a third; that's one third of normal wages for hours after the first 40.) So the hospital administration had a solid reason to work their interns and house officers into the ground rather than hiring extra junior doctors.

The original rationale was that the "on call" hours were not supposed to be busy and the duty doctors could spend most of them sleeping in a bunk or studying: but by the late 1980s (when I heard about things) they were working more or less constantly through their shifts.

The EU Working Hours Directive was supposed to fix this by banning workers from putting in more than about 50 hours a week without very specific protections being enforced, but one of the first things the UK's Conservative government did in 2010 was to stop enforcing this.

I wonder how much of it is financially motivated in this way and how much is the inertia of this hazing-style culture. From what you've said, I'm sure hospitals would object to a change out of financial self-interest, but it seems the ingrained culture stops the issue from getting a big push to begin with.

I know labor unions (sometimes rightfully) get a bad rap, but it seems this is exactly the type of abuse they were designed to stop. There are some [0] but the rate is low, less than 15%, and there's a sort of self-censorship style of pressure against pushing harder for them.

[0] https://www.theatlantic.com/business/archive/2017/02/doctors...

But Doctors have a very strong labor union, which tends to advocate FOR this system. Probably even though the AMA represents residents, doctors who have succeeded in the residency system have more sway within it.

I'm in the US. After some searching, I can't find any information about most doctors having unions. I found one that appears to mostly work with California doctors, but that was about it. Either way, I was speaking about residents, who don't have particularly strong or ubiquitous unions. Again, that's in the US. Other countries may vary.

I was being tricky here but I mean the AMA.

It controls a great deal about doctor's education and working conditions. It does not collectively bargain, so it's not strictly a union. But it's more powerful than most unions at this point. So a glib, "maybe doctors should get a union to represent them" answer to poor working conditions for residents doesn't really make sense. They already have a powerful organization that should represent them.

I think that there is at least some group of physicians who really think that poor working conditions for residents improves patient outcomes and doctor training.

That is very true, the AMA is not formally a union, but it does exert a significant level of control and influence in standardizing the practices of doctors.

As for patient outcomes, I'd love to see a study of them for the roughly 15% of residents that have a union and very modest work place improvements, compared to outcomes for the rest of residents. You're right, many doctors do seem to "feel" the traditional method is superior, but I'd like to see hard data.

I know I've seen some before, I think The Atlantic had an article about it in the past year.

I found this paper: http://www.acgme.org/Portals/0/PDFs/Position%20Papers/Commit...

It's citations have some hard data. Maybe the most interesting part for me was this:

"There exists instead a widespread belief that physicians can be trained to defy the biology of sleep and that safeguards are in place so that patients and residents are not harmed by work schedules that are unheard of in any other workplace, let alone a hospital. That belief is most evident today in the FIRST and iCOMPARE studies that set out to prove that there is no difference in patient outcomes from residents who work 16 or 30 hour shifts. The principal investigators were so convinced that no harm would come of these experiments that they determined it wasn’t necessary to obtain informed consent from either patients or residents in the hospitals where the studies were conducted. This determination has been widely disputed and is now under investigation by the Office of Human Research Protections."

> It seems like there's enough people trying to be doctors

Not in the US. The doctor per pop count is very low.

https://www.nationmaster.com/country-info/stats/Health/Physi...

I think the key word in the sentence is trying to be doctors. The doctor per pop count in very low because med schools have super low acceptance rates[1]. That would probably be the best place to implement some sort of reforms if we want more doctors.

[1] https://www.accepted.com/medical/med-selectivity-index

There are plenty of people trying to be doctors, but there aren't enough programs to train them at the moment.

I imagine if med schools made it easier to get through their programs, the end result would be a significant lowering of the average pay for their profession, as more doctor's hit the job market. It sounds like it's in the best monetary interest of doctors to keep their professional supply low, allowing the demand for them to be high.

The counter argument that I have heard is that patient handoffs are where a disproportionate number of errors occur. Increasing the number of shifts means that more patients in the ED or on the floor will have care fragmented between providers, making it more likely that results will not be followed up or that changes in a patient's status will not be recognized.

I don't know at what point the errors from sleep deprivation exceed the errors from patient handoffs. People seem to take different views depending on what side of the work hours debate they fall on.

This would be easy to do a controlled experiment to compare.

My girlfriend is a second-year OB/GYN resident (which is a 4 year program) and while that field's residency is less insane than some other specialties like ER, she still works 12 hour shifts Mon-Fri (6a-6p on paper but generally 6-7:30), one 24-hour weekend shift a month, and one 12-hour weekend free clinic shift a month. This is on top of the "extras" that are not work but are required to graduate the residency programs. Weekly rotating presentations to the rest of her group (4 other second-year residents so one ~45 minute presentation every 4 weeks), research, generally keeping up with the state of the art in her field, etc.

So she's only "scheduled" for ~67 hours a week averaged throughout the month, but realistically it is in the 85-90 range.

It's easy to see how a more demanding or emergent field could seriously select for folks who are more able or willing to work on less sleep.

I used to work in hospital IT at a level 1 trauma center from 2004-2006. While I was there, an article was released which studied the relationship between time on shift and errors made by staff. As I recall (and it has been 10 years) the findings were:

* Through roughly 9 hours, the error rate was about the same. Say, x%

* In the 10th hour, the error rate increased. Say x + y%.

* In hours 11 and 12, the amount the error rate increase doubled the 10th hour's increase. So x + 2y%.

* In hours 13 and 14, the amount the error rate increase quadrupled the 10th hour's increase. So x + 4y%.

* In every subsequent hour studied, the error rate increase doubled again. x + 8y% in hour 15, x + 16y% in hour 16.

I want to say the study went to 18 hours, but I don't recall if it was 16 or 18 at this point. The paper made the recommendation that shift lengths should be limited to 10 hours maximum.

Every health care professional I spoke to about the article (resident doctors and nurses, maybe 10 overall, mostly in the ER) said the same three things:

1. They had personally witnessed someone make an error they could attribute to tiredness.

2. They themselves had never made a mistake due to tiredness.

3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.

2. They themselves had never made a mistake due to tiredness.

3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.

I think those two items and the tribal knowledge that handoffs are more dangerous to the patient helps the overwork model persist. Sounds like it's past time the medical industry prove that handoffs are more dangerous to patient outcomes. Doctors are trained to be problem owners and problem solvers, but that doesn't make them good team players. And lowering handoffs also limits oversight and prevents second guessing which is great if you're convinced you're always right, but clearly doctors are not always right and patients often pay the price.

There's been some study(s) which suggest that medical error is the 3rd leading cause of death. This may have been debunked so if wrong please correct me.

https://www.cnbc.com/2018/02/22/medical-errors-third-leading...

Many sane minds would argue that, but the ACGME is actively arguing otherwise. They are actively building rules that allow residents to work longer shifts (up to 28 hours straight) while claiming these rules improve patient safety.

Patient hand-offs between shifts tends to introduce errors. Instead of finding ways to improve hand-offs, the ACGME is simply trying to have fewer of them.

These are supposed to be some of the "top minds" in medicine and that's the best they can come up with.

That's no really addressing the problem, it's just doubling down on the mistaken notion that the treating physician is the best one to tend to the patient under any circumstance. Doctors need to learn to be team players.

Nurses are a lot more than just shift change workers, and their nursing school requirements are a lot higher than you seem to believe.

I don’t think (s)he was commenting on education. I read their comment as only people who can do 12 hour shifts that may be required to occasionally be overnights followed by days, completely disrupting their sleep schedule, can make it as ICU nurses.

"Works on a shift schedule" is a shared trait between nurses and shift workers. "Has one thing in common with" is not the same as "is the same thing as".

Parent to that reply edited their post after my comment, and I can no longer edit my reply.

To be clear, you're saying that people whose job is to - quite literally - understand, diagnose, and treat hundreds (thousands?) of medical issues that they personally haven't experienced, don't have the capacity to understand that not everyone is on their same sleep schedule?

Yes.

Doctor's are notorious for not understanding their patients' experiences, and how that impacts them.

I've just witnessed this with my partner's recent bout with cancer. While her oncological surgeon completely understands, her reconstructive surgeon had no conception of what she was going through.

Those people spent many years learning to understand, diagnose, and treat thousands of medical issues. During that entire time, they were continuously sleep deprived as a matter of culture. Those that could not handle this environment dropped out. They're probably still sleep deprived. They may have learned about sleep's medical effects, but the personal experience of those who survived the selection process who work 120-hour weeks and have been waking patients up once an hour for years has a blinding effect on this diagnosis.

It's a bit like bringing someone from south Florida to northern Michigan this winter for some ice fishing. I understand that it's cold here, I intellectually know about, have observed the effects of, and can treat frostbite and other problems resulting from this cold - but all that would make it hard for me to intuit the problems of a visitor who was unable to control their fingers when they removed their gloves and dipped their hands into a minnow bucket to bait a hook. My fingers work fine in that bucket, everyone else on the lake is doing it, you're just going to dry them off in a few seconds and put them back in warm gloves...what's the issue?

People whose job is to treat human bodies should have enough sense not to constantly wake them up.

The mind does funny things. They also understand that exercise and good nutrition are fundamental to health. When I worked in a hospital I normally ate in the cafeteria. The physicians had horrible diets, including the cardiologists.

Let's not even get started on how many nurses smoke.

As someone with a father and a wife who are both physicians, yes. In both cases they started working to get into medicine in high school, pushed hard in college, and then had med school and residency.

That alone is 16 straight years of normalizing sleep deprivation. Time spent studying and working is regularly 80+ hours per week, certainly from med school onward and certainly the year spent studying for the MCAT.

If they start at 16 and finish their residency at 30 or 32, that's the only life they've ever known for all of their formative years. They cannot relate to people with a normal schedule because they have not experienced it.

A lot of people don't do their job perfectly.

It's my job to create applications and diagnose problems with software, but even though I've used the software in development and testing, I do not understand the experience the same way a daily user understands the experience.

Similarly, doctors and nurses do not have significant experience in being a patient, especially one who isn't around hospitals all day.

Why do doctors not get sleep? It is still the most ridiculous thing I've ever heard. Start up founders? Fine. Grocery store bagger? I don't care. BUT A PERSON IN CHARGE OF TOUCHING (inside) MY BODY? I want their Fitbit sleep records for the last month showing a consistent 7 hours of sleep.

Regarding the U.S., the reality is that it's mostly the students (med students, residents and fellows.. you're called Doctor by residency) that are sleep deprived. After that most doctors are on normal to normal-ish cycles. But because residents and fellows are such solid profit earners for hospitals and the hospital owns their life they opt to over-work them and charge you max dollar for their time. Once the doctor is board certified (post residency or fellowship) then the power shifts back towards the doctor and they can get more normal lives.

Exceptions are specializations that are essentially emergency/urgent but even most of them are on rotations like another poster mentioned where they've shifted their own sleep patterns to match their hours.

Since watching my friends become doctors (psychiatrists, uroligists, neurointerventional readiology) and my wife become a surgeon I have started telling friends and family "If your doctor looks under the age of 35 then you should ask them the last time they slept before they start treating you.

tl;dr : hospitals straight up own the futures of their med students/residents/fellows .. so they overwork them while paying them $40-55k year, and when they aren't working they have to study for their exams.

Also apart from the Doctors, the military is also notorious for their practice of having too little sleep.

Yes! Sleep deprivation played a role in the two Navy crashes in the last few years.

This is because their job absolutely requires performing on insufficient sleep. Combat isn't shift work.

I think (without much data here) that medical training pushes insufficient sleep on doctors due to on-call schedules. While hospitals have doctors, many of their specialists come from private practice or multi-specialty clinics, which rotate being on-call between then (often in 12 hour shifts). The other cause of insufficient sleep is that if a patient under care of doctor has complications, they will often be called, even if just for a consult.

Economically, this is likely efficient compared to having hospital specialists (which may end up with nothing to do many nights), but causes docs to train for worst case scenarios sleep-wise.

According to my doc cousin, it's to limit the number of patient handoffs between providers. Apparently error rates are around 5-10% per handoff, so the idea is that if the error rate from sleep deprivation is less than that, it's better to have sleep deprivation.

I get terrible headaches if I sleep less than 8 hours and I'm 27. Always wanted to have more time in my day but I get no time if I can't focus or function.

I'd hope someone doing something as high risk and important as surgery would be getting as much as they need regardless of how much that is.

> during pre-med training: with on-call work hours up to 120 hours a week.

Can someone please tell me why they still put medical students through this institutional hazing?

Saying that "pre-med training" (whatever that means) consists of 120 hour work weeks is not accurate but it's probably just because we're using the wrong words.

Pre-med = college, and aside from the highly scientific work load is no different than any other college experience.

Medical school (no longer called "pre-med" by anyone) is typically 2 years of classes and 2 years of clinical rotations. The rotations are not going to be 120 hours a week but may be 60-80. But unless you go to a teaching hospital and consent to student contact (which may or may not be a requirement of treatment) no med school student is touching you.

Residency is after med school (they're full doctors now) where you train your specialty, and at least in the 4 year program I'm familiar with, their title is intern, resident, resident, senior resident for each of the four years. They have increasingly high levels of responsibility as they progress and by the 4th year they are basically oversight/management of the other residents who assist on complex cases and bring in at attending physician(s) for big stuff. Hours are typically 80+ and I'm sure you could approach 100 for very demanding or emergent specialties but it's certainly not "pre-med training" and 120 is pushing it for sure.

After you graduate residency you move to an attending, fellowship, or research position and the hours drop back down to the 60-70 range and decrease as you gain seniority.

And on top of those 60-80 hours per week you need to add all the time prepping for exams and boards, correct? That study time is work too, and that pushing up to 120 hours per week.

In medical school, 120 hour weeks really only exist for 4th year med students who are on sub-internships in surgical specialties like neurosurgery, orthopedic surgery, general surgery, etc. Students in those fields do 3 or so month long sub-i's at hospitals they want to do residency at. They basically function as month long interviews for those programs, and are also used to get letters of recommendation from prominent faculty in the field. People who are interested in those fields know about the hour requirements on sub-i's and in residency, and self-select in a way.

The reason resident physicians work so much is because residents make $60k working 80+ hour weeks, and the PAs or NPs who would be willing to cover the floors at night would make $150k+ working 40hrs/wk. Residents also have no collective bargaining power because of the residency match system. You can't easily leave one program and go to another because you don't like the working conditions, for example. If you want to leave, you're more or less blackballed unless you're switching fields. And you don't want to speak up about the conditions because you've got $300k in debt and a degree that's useless until you finish residency.

So they are being taken advantage of then.

Sounds like they should just legislate away the "Residency match system."

Ironically, congress passed a law in 2004 to give the NRMP, the organization that runs the match, immunity from antitrust legislation. https://en.wikipedia.org/wiki/National_Resident_Matching_Pro...

I'm currently in my 4th year of medical school, and I have to clarify your comment on the hours worked. We're held to the same hours limits as residents, which is 80 hrs/week averaged over 4 weeks and an average of 1 day off per 7 days. We most often come near these hours on surgical specialty rotations (like the ones you noted). However, these are completely voluntary rotations. I'm not interested in surgery, and I have no surgery rotations scheduled at all during this year. Most of this year is actually spent on residency interviews. I've been traveling to different cities in the US about twice per week since October, and will continue through the end of January with breaks for the holidays. I have no hospital duties from September–January.

The 3rd year of medical school is much tougher since we spend about 10 months of that year on rotations in the hospital. While some rotations are much lighter, others like surgery again get close to the hours limits. This is complicated by the shelf exams we take every 8–12 weeks. These require an additional ~2–3 hours/day of studying and most of a weekend day as well. Obviously, this study time is not counted towards the hours limits, but it definitely factors into fatigue and burn out.

Where do we go to change that 80 to 32? This thread is making me feel unsafe.

So the other side of this problem is resident education. The ACGME in conjunction with medical specialty boards govern the requirements for graduating from residency. There are hard requirements on how many and which kinds of procedures you need to do and patients you need to treat over the course of your residency. Residents meet those requirements with the current average 80 hrs/week and ~3–5 years of training. Moving from 80 to 32 hrs/week would likely require an expansion of training time to ~6–10 years, which residents would be absolutely against (I know I would be). I've been in school forgoing a "real job" with a salary for nearly a decade, and I'll be in my mid-30s before I become an independently practicing physician under the current system. Although the work hours are abhorrent, I don't want to add more years to my training in exchange for better hours.

My mom was an ICU nurse for over 20 years, and yeah, the burnout is real. My mom always said that ICU is made up of a very small number of surgery recovery patients (who quickly get moved to a different section once they're past the critical part of their recovery), and the rest is people who are just there to die (especially here in Florida, where there are a large number of elderly).

She eventually had to switch to another position, because it became too much. She said she lost a lot of her empathy for the people who had spent 60-70 years abusing their bodies, and now were just here to slowly die under her care (regardless of how good that care was). She also hated that so many people were kept alive on machines long past the point of having any life left, just to keep the families happy. She said after a while, she could tell the difference... that whatever made a person a person (the soul or whatever you believe in) was gone, and all that was left was a pile of meat being kept "alive" by the machines.

> intensive care unit (ICU)

There are only two reasons for someone to be in an ICU: they require a therapy no other floor will administer, or their condition/therapy requires very frequent administration/titration/observation. These two reasons frequently overlap.

Sleep isn’t optional in general. It’s optional in the ICU, because the premise is “if you don’t need this level of attention to survive, you absolutely shouldn’t be on this unit.”

I think it is absolutely standard in that situation to at least take vitals every couple/few hours, no way around it. It's annoying to be woken up so often, but it's done for good reasons.

First observation every few hours is fine, but their is little coordination between hospital workers so people are often interrupted multiple times an hour which cuts the time for the next interruption.

That’s cost effective for the hospital but simply not viable longer term. To be clear waking someone up every 2.5 - 3 hours is very different from waking them up every 2.5 hours and another 2+ random times during the night.

As long as somone is only in the ICU for 72 hours it’s not a huge deal, but start talking a week and it’s a significant issue.

So, my partner had the option of either going home directly after surgery or spending the night in the hospital. The hospital staff wanted her to go home. She wanted to stay. (She has issues with post-surgical pain.)

If the hospital staff had sent her home, she would not be woken every two hours. The medical staff were fine with that.

It would have been perfectly reasonable for them to let her sleep; it would have been no more risk than they were advocating for.

Clearly it was optional.

> Clearly it was optional.

Unless there was some regulatory, legal, or hospital requirement that she receive a certain standard of care. They may have been fine with her sleeping through the night at home, but if she's in the hospital they need to take care of her.

It would not be an easy sell in a courtroom to explain that while you checked everyone except her every 3 hours, you let her sleep through the night and there was an issue that cost her life.

Not that the physicians and nurses should have been taking that into account but the folks crafting the regulations or hospital policy very well may have.

Clearly there was an organizational reason, but those reasons had nothing to do with what she actually needed according to her physicians, which was rest and painkillers.

What you've just said supports the article's argument that hospitals are designed to prevent people from sleeping.

Yes and there is an added benefit to frequent interruptions: despite all the monitoring equipement, a human assessment can go a LONG way in detecting trouble. My wife used to be an ICU nurse and her first code (CPR) in her career was when she was doing some routine stuff for the patient and noticed the color of their skin "looked different". When the patient's heart stopped beating, she was already there to get it back going, saving some precious delay.

For non-ICU stuff, yes there could be some better coordination around sleeping time, but again there's so much non-verbal stuff going on in just a physical assessment.

What would really be useful is having cleaning services and admin/billing services come at the same time (well, right after) a nurse comes, to take advantage of that interruption.

Agreed, but even the medical services aren't coordinated. I was in for 4 days earlier this year -- in addition to being woken for blood draws, I was woken on a diff schedule for meds and still a third for breathing treatments..meaning every 2 hours I was woken up 3 different times...then early am they'd come to get a breakfast order.

Nor are they going to be coordinated, because each of these services addresses a number of different units in the hospital. In order to have all of these services available for each patient in concert, we'd need to multiply the staffing by four or five fold. That holds as true for coordinating physician visits as it does for the other services.

I don't want to make it sound like it's impossible. It's not. But it is incredibly inefficient - which is why it doesn't happen - and the answer to "How can we make it happen?" is "Pay for it."

That is a fair point, but if, as this story implies, by the end of the process sleep deprivation was the main impediment to the patient's recovery, and might have led to additional procedures and the problems they bring, then there would be an issue here.

I also wonder if, like 'emergency room', 'ICU' has lost some of its meaning in some places.

Wife recently spent a couple of days in hospital for surgery/recovery. She was in a normal double-occupancy room for recovery (i.e. not ICU), yet was still woken every couple of hours by someone taking vitals, drawing blood, doing respiratory checks, bringing food, etc. And the room was hardly ever really quiet because if someone wasn't there to see her, someone was attending to the person on the other side of the curtain that divided the room. She said she hardly slept.

There is a fantastic book, "The Circadian Code," which describes this exactly. I don't know what I would have done in your situation, it sounds absolutely infuriating. It is amazing how ignorant some of the best educated people can sometimes be (including myself, I'm sure)!

To get up to speed on how dramatically sleep affects our cognitive performance, listen to this excellent interview with Matthew Walker (Professor of Neuroscience and Psychology at UC Berkeley, and Director of the Center for Human Sleep Science)

https://www.youtube.com/watch?v=pwaWilO_Pig

https://podtail.com/en/podcast/the-joe-rogan-experience/-110...

I’m always sleep deprived (typing this up at 1:30am) but I’ll watch that tomorrow. Just wanted to say, as a chronically sleep derived person I typically feel like crap, everything aches. One day I got 9 hours of sleep and I felt amazing. No aching, total clarity, just felt like a new person. I’ll probably drop dead soon, off to bed now but will watch the video tomorrow! Thanks.

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