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Comment by IB885588 | Hacker News Reader

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..

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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.

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.

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