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Comment by verelo | Hacker News Reader

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?

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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.

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