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Comment by user_7832 | Hacker News Reader

Most of the issues mentioned in the article and the included email are concerning, however they also oddly seem to be common in many places across the globe. The surgeon mentioned was in Australia, I have seen these issues first hand in the Netherlands and am aware of very similar of the first 2 out of 3 issues (caused by overwork/understaffing/over-fatigue etc) in Belgium, Germany, the UK, India and god knows how many other places.

However, fields like aviation have strict workload limits. You cannot be on call/duty for too long because fatigue kills. Issues like alarm fatigue are studied by agencies, and folks at Boeing/Airbus then implement the findings.

The question is, why is it okay for medical professionals to wear themselves down to the bone (sometimes literally, like in this article), while some other professions take care to avoid it?

(Edit/PS: I added a fairly detailed self-reply below on what I think are some of the common arguments (like on the number/availability of doctors) and why they don't really fly, pun not intended.)

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The answer is implied, right there in the first paragraph: "... I’ve never been diagnosed with a mental illness."

At least in the US, there's a kind of masochistic pride in the physician community, that everything he described in his essay is laudable, noble, to be emulated. Nowhere does he acknowledge the risks to his patients or whether the costs are worth it in the end, or if a different system might be better. And he's holding up the lack of mental illness diagnosis as if it's something to be proud of, as opposed to never being diagnosed with say, cardiovascular disease or cancer. He's proud he's never sought help or tried to change anything. Sure he mentions problems with patient care in passing, but what he's really upset about is "just being another employee".

In the end in his mindset whatever he's complaining about is better than the alternatives, which is ceding over some of the care responsibilities to others or opening up healthcare to a more competitive market so he's not the only provider who could provide those services (note the comment about denying other physicians income). The AMA and physicians union (yes it's a union) basically guarantees this in lieu of having real competition, decreased income, and so forth.

Why is it different in something like aviation? My guess is because the failures are more visible, they're on the nightly news, people are there posting pictures on social media? For whatever reason, I don't think pilot organizations ever managed to remove themselves from scrutiny in the same way as physicians did. We see pilots as highly skilled professionals, but part of a system, with alternatives, and the subject of fair scrutiny from outsiders who are not pilots: engineers, safety experts, investigators and so forth. In my experience when these kinds of issues come up in healthcare though, everyone defers to physician groups themselves, as if no one else has expertise enough to scrutinize them.

I imagine too at some level, part of the issue is that the pilots themselves are subject to their own mistakes: if a pilot crashes a plane, they take themselves out at the same time. If a surgeon makes a mistake and kills a patient, they still walk home and can rationalize whatever they want, all they want.

I'm growing unsympathetic to these types of essays (the one linked). If physicians want me to empathize with them more, maybe they should stop stigmatizing mental unwellness and recognize it in themselves. Maybe they as a professional group should admit that others could take on some of the load, maybe even better in some situations. It feels a bit like they create a mess out of selfish greed or ego and then expect me to feel bad for them.

> Nowhere does he acknowledge the risks to his patients or whether the costs are worth it in the end, or if a different system might be better

c.f.

"...everything is rushed, and mistakes are bound to occur."

"I am realising more and more that what brings me greatest distress is the relentless administrative pressure which take away the meaningful clinical engagement I have with my patients."

"I was burned out and I couldn’t control my emotions at work and at home. I’m not inherently an offensive or rude person, I’m just a person pushed to the limits and set to fail because of the circumstances around my work."

> In the end in his mindset whatever he's complaining about is better than the alternatives, which is ceding over some of the care responsibilities to others or opening up healthcare to a more competitive market so he's not the only provider who could provide those service

This is Australia, which does not have artificial restrictions on the supply of doctors to the same extent. On the other hand, they don't have a surplus of surgeons nor can nurse practitioners do the work

> (note the comment about denying other physicians income).

Yah, he's saying that if he doesn't come in, the backlog gets worse, and other people don't get paid.

> He's proud he's never sought help or tried to change anything.

He says he would like to seek support, but highlights the structural problems that prevent it:

"I know where I can get support, but practically, when and how am I going to get that support?"

"In addition, doctors who scream for help may be formally reported, therefore having restrictions placed on their practice and then incurring higher medical indemnity fees in some situations. Trainees who ask for help may be labelled as underperforming and have to be commenced on probation or remediation. We may not have practical access to the support that are often advertised."

I absolutely am in agreement with you that the things done to artificially lower the supply of residency training in the US are terrible. But those criticisms don't seem to apply to this essay.

> which does not have artificial restrictions on the supply of doctors to the same extent

Yes it does. One of the really interesting questions is actually why the same problems have been created in so many otherwise-different systems.

Edit: a post giving details on the Australian medical training constraints https://www.aph.gov.au/About_Parliament/Parliamentary_depart...

> > to the same extent

Your source says that the government sets (indirectly) a limit on the number of places at most public universities, but there are private, full-fee universities that are not so limited.

Internship slots, in turn, are set by disparate government agencies. They've climbed, but probably not climbed enough.

Compare to the US, where congress basically directly controls the number of residency slots and has failed to increase them really at all to keep up with increasing population and increasing need for medical services.

This is just wrong. The supply is absolutely artificially capped, particularly for positions like surgeons. This is controlled by the Royal Australasian College of Surgeons in combination with government funding. There is no “private, full-fee universities that are not so limited” alternate path; don’t make stuff up. Source: Brother in law who is a surgeon.

> This is just wrong. The supply is absolutely artificially capped, particularly for positions like surgeons.

I feel like you don't understand the distinction about positions at universities for initial medical training vs. internship and residencies, which I believe I discussed fairly above.

see

> > Internship slots, in turn, are set by disparate government agencies. They've climbed, but probably not climbed enough.

"Disparate agencies" isn't great phrasing, though, as what I really mostly meant was "each province".

To start with, you’re overestimating the role of full fee paying university places, Australia doesn’t have provinces, and the intern year is not equivalent to an American internship - that’s the registrars, and there are fewer of those than internships. (This is the position you need to get in order to begin any specialty training, such as surgery. They are very explicitly managed and funded by the federal government. https://www.anao.gov.au/work/performance-audit/administratio...)

More generally, Australia does have states and territories, but the federation model is far more centralized than the US: for instance, public hospital funding is a shared pool coordinated by federal agreement. https://www.publichospitalfunding.gov.au/victoria-basis-nati... While the vast majority of internships are at public hospitals, the federal government also pays directly to create a relatively small number of internships at private hospitals.

But of course this is all largely irrelevant because about one third of doctors in Australia completed all of their training in another country, and were then awarded a visa based largely on their profession being listed as a national priority under the system managed by the federal government.

> At least in the US, there's a kind of masochistic pride in the physician community,

But the question is why does the rest of society insist that pilots be properly rested but not doctors? I'm sure a lot of pilots would also work crazy amounts of overtime if allowed.

Pilot failures are really visible, and kill hundreds atll at once. Bad medical decisions lead to more deaths overall, but it's far less likely the public will hear it, and even if they do, it's one person at a time.

Far more people die from car crashes than airplane crashes too: It's not even close. And yet, people who have no business behind a wheel drive, and the penalties for being a poor driver are typically minimal. Same difference.

And the pilot is quite likely to die in any fatal pilot error, so there's an element of self-interest in preventing pilot error.

When a pilot or a truck driver fall asleep, it’s easy to see the cause and effect. When sleeping, they can’t control the vehicle.

With other professions, the people are awake, their brain just isn’t functioning properly, so it’s easier for people to ignore the true cause, since well rested people can make mistakes too.

Not only pilots. Truck driver resting time is heavily regulated to the point the need to record start and end or they will be fined at best. Their employers will also be on the hook if drivers are non compliant.

A truck driver! But doctors? No… they are Uberhuman and can make life or death decisions after 24 hours on call and awake. Ridiculous. It is a topic that angers me a lot.

This happens in Portugal as well as Poland, it indeed feel universal. I think the reason is that doctors are kind of like gods: in the hour of your biggest need it is them that can help, therefore they are highly respected and have huge influence over a wide cross section of society. Everybody will eventually need a doctor in their life.

Another pet outrage topic related to doctors is the amount of time they need for training. They train almost 12 years after high school before they are qualified. What a wasteful training. They learn lots of generalities to the specialize in the end. With a 10 or 12 year higher education you are speaking about phd or post docs for a profession that requires 1 for every 1000 citizens. Imagine that ratio of phds and post docs. Is being a GP really requiring such training? I don’t think so and agree with above posts that their duties should be broken down, opened and delegated.

Because when there is no pilot, the airplane simply does not fly. Nobody dies, there is just an economic damage. But if there is no doctor, people still get ill, and then people die. Which makes it ethically easy to impose the one but not the other. And which is also the reason why pilots can go on strike, while the same is much more limited for any kind of (medical) care job.

I would also add the famous Bert Cooper line, "I never heard the word client in there." He mentions patients, but they are all wrapped up in a woe-is-me section I work so hard and yet I haven't been diagnosed with a mental illness.

He sounds like the kind of person that brags about being mentally sound but is secretly addicted to benzos. Always advocate for yourself!

It's different in aviation because the pilot dies too when the plane crashes.

The understaffed healthcare system works with overworked doctors on the basis that having a tired and overworked doctor is a lot of the times better than having no doctor at all, because (s)he most likely can end up saving more lives than taking with their tired brain. If your operations have a 90% survivability rate it could still be considered a success despite those 10% they end up killing, because 90% is a lot better than 0%.

Meanwhile a tired pilot is more binary, it either can have 100% passenger survivability if things go well or 100% fatality if things go tits up, meaning the risk are too high to take chances.

It's basic game theory.

Good point, and you can turn it around: Doctors are never "finished". They could always do more to help patients. So in contrast to aviation, where there is a clear corridor of things to do, doctors have no natural upper bound on their work.

but the alternative isn't having no doctor at all, but to get more doctors, so the "basic game theory" is about why the limits on more doctors stay in place despite the higher risk of death etc.

> but to get more doctors

Have you found that magic fountain of endless doctors?

Sure, it's very easy! Just do things that prevent burnout (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8834764/) and the job gets more attractive, drawing more students and producing less attrition:

- Valuing work gives meaning (money, appreciation)

- Autonomy gives feeling of control

- Managing burden prevents overwork, exhaustion and fatigue

> Sure, it's very easy!

I have issues when someone says a complicated issue can be solved easily…realistic expectations…

The answers to some problems may be easy to know but difficult to implement, due to political/financial will etc. For eg we know how to reduce emissions, but it's still a challenge. In such cases advocacy and raising awareness can be helpful.

"Easy to describe" is very different from "easy to do".

It reminds me of the famous "just eat less and exercise more", the alleged simple solution to the global obesity epidemic.

Sounds good, but healthcare already constitutes 17% of US GDP. And with an aging population, spending has been growing faster than the rate of inflation. Most of the funding ultimately comes from governments, self-insured employers, and individual patients. Those groups have no appetite for spending more.

https://savegme.org/

The entire medicare residency slot system seems a bit self inflicted, why hasn't an alternative system popped up?

Also this is a global problem, not just the USA. You look at videos of student doctors in the UK for example and there are similar abusive schedules. https://www.youtube.com/watch?v=KE1XwEMGm0I

Read Adam Kay's "This is going to hurt" [1]. It was made into a miniseries. I read the book and it was so horrifying that I couldn't face watching the dramatisation.

It doesn't seem to be such a big problem here in Norway where things like working time directives are taken much more seriously.

[1] https://en.wikipedia.org/wiki/This_Is_Going_to_Hurt

Yeah it’s called correct incentives - I look at the over work, and insane stress levels that doctors suffer and I say “NO THANKS”

I am definitely not the only one

The AMA only allows a fixed number of seats in medical school.

There also can be tiers of medical doctors. Most doctoring work is routine, and can be handled by a more of a medical tech.

False. The AMA has no regulatory or accreditation authority over medical schools. Schools can admit as many students as they want.

The bottleneck right now in producing more US physicians is lack of Medicare funding for residency slots (graduate medical education). Every year some students graduate from accredited medical schools with an MD but are unable to practice because they don't get matched to a residency program. Congress hasn't significantly increased funding in years. At one point the AMA did lobby Congress to limit the number of slots but they have since reversed that stance and are now lobbying for higher residency funding.

https://savegme.org/

There are already tiers of clinicians. Much routine care can be delivered by Physician Assistants or Nurse Practitioners working under a Physician's supervision. Specific limits on their services are set at the state level.

Why do residency programs require subsidies, are resident doctors each a large net financial loss to a hospital? I can't think of many other career paths where someone out of school is so underprepared for the job that the business could not employ them without someone else footing the bill, doesn't seem like a reasonable system that will sustain itself in the long term. I suppose pilots are a bit like this but they typically take the financial risk on themselves to some degree or get the taxpayer funded training via the military.

Hospital accounting is always messy. There's no simple way to determine whether a particular program is profitable or not; it comes down to how the accountants allocate overhead costs. But the fact that publicly owned and non-profit teaching hospitals aren't voluntarily expanding their residency training programs is strong evidence that they operate at a loss.

Very few other career paths have such an extensive body of knowledge, licensing requirements, and low tolerance for errors. Law is maybe a bit similar in that new associates in most firms are worse than useless, and training them sucks up a lot of time from senior associates and partners. But law firms aren't subject to price fixing, so they have more freedom to raise their rates in order to cover those costs.

Do residency slots mandate public funding?

Aren't they doing actual useful work same as regular doctors? (albiet with a higher error rate)

So they could be funded through via charging for services rendered.

Of course their effective pay may be close to zero, after malpractice insurance, but it will still attract some number of med school grads who can't get in otherwise.

Residency slots don't mandate public funding. The majority of funding comes through the Medicare program but private foundations also contribute some. Private payers (insurance companies) also indirectly subsidize residency slots by paying teaching hospitals higher rates.

Some services performed by residents are billable, especially the more experienced ones. But the programs as a whole run at a loss after accounting for overhead so hospitals won't add more slots without a matching funding source.

Presumably it will only happen in hospitals that charge high enough rates to fully cover the cost of overhead, I.e at one of those luxury hospitals

What "luxury" hospitals? I've never seen the word "luxury" used to describe the teaching hospitals which train most residents. Most of them have high proportions of Medicare/Medicaid patients where rates are set by the government and hospitals have zero ability to charge more. I don't think you understand the reality of healthcare economics; this isn't a free market where sellers can change prices and supply to meet customer demand.

Colloquially, from the folks I've spoken to, luxury refer to those hospitals that offer high-end rooms, fancy furniture, concierge service, and so on, for a higher fee. I.e. Places where the differences are immediately obvious to the layman

If it's indeed the case that most hospitals can't cover their overhead then by default it must be limited to the high end, if it ever does happen.

> The bottleneck right now in producing more US physicians is lack of Medicare funding for residency slots... Congress hasn't significantly increased funding in years. Much routine care can be delivered by Physician Assistants or Nurse Practitioners working under a Physician's supervision

We should all accept a lower standard of care because hospitals can't find more funding to train doctors? What are all the $20 aspirin paying for? How does every other profession manage to train new members without needing a literal act of Congress?

Where would you suggest that teaching hospitals find more funding? Most of them are non-profits, or operate as part of state or local government agencies. They have no ability to negotiate higher rates with Medicare/Medicaid and only limited ability to negotiate higher rates with private payers (typically set as a multiplier to the Medicare rate). Voters generally haven't been willing to raise taxes. There is probably some waste that could be trimmed but it's tough to figure out where to cut without impacting patient care quality. Much of the administrative overhead is forced upon them by unfunded government mandates around reporting, quality, security, credentialing, and interoperability.

Private donors are always welcome. If you have a few million to spare then you can personally fund a residency program expansion at your favorite teaching hospital.

I won't attempt to defend ridiculous charges for certain basic medical services. Hospital accounting is a funny business, and almost entirely artificial. The teaching hospitals tend to deliver a lot of charity care (including writing off a lot of bad medical debt) and some Medicare/Medicaid reimbursements don't even cover their costs. So, they attempt to close the gaps by jacking up other prices as high as they can.

You should accept a lower standard of care because as a society we have limited resources and can't afford to waste them. If you have a boo boo then a NP can clean the wound and apply a bandage. That's what happened to me when I crashed my bike last year and it was fine. Physician time should be reserved for more complex cases.

Are you talking about the same hospitals that tripled the administrators to doctors ratio in the last 50 years (don’t remember exact numbers)? Is that why we need to accept a lower standard of care?

P.S. wait, you went to a hospital to apply a bandaid after you fell off your bike? Are you serious? Perhaps that’s the real problem…

The AMA doesn't have direct control over it, I was wrong about that. But they heavily influence it:

https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...

That's a straw man. We do not need "endless doctors" just more (or some way to use them more efficiently).

The number of doctors are limited by the pipeline to educate them.

Most countries I know, the number of people admitted to study medicine exceeds the number people wanting to study medicine vastly exceeds the positions to do so, and admissions are highly competitive. To a point, I'd say, that it is becoming ridiculous.

So, there is not a lack of people wanting to become doctors, but a lack of people allowed to even start to study to become one.

If you didn't cut the "limits" from the quote, you might've found a hint on how to answer your question without any magic involved. For such a small profession the general talent pool is endless indeed unless you... limit

Sorry, that is bollocks. That is the story most people believe, and makes for a convenient story for those people actually to blame. Funnily, it is also the story most doctors themselves seem to chose to believe in.

First, those are not the only choices. There is also the the option of training and hiring more doctors. 2

Probably, there is also an option of making more efficient use of doctors time, but that one is more complicated.

Most of the work of doctors is not life-saving.

I think, you see a standard problem of pushing shit down or up. Government lowers budget, pushes quotas down, which gets pushed down further until it reaches the bottom rank and file, the doctors.

They have to "do more with less" (Not limited to public sector, see Boeing), and that works for a while, until it doesn't.

> Most of the work of doctors is not life-saving.

Yes, but working out which parts are and aren't critical is the $64,000 question.

I think, that is a bit besides the point I wanted to make.

Yes, it is very hard to know a priori, what is life-saving, and what not. No, I do not wanted to suggest that the work of doctors it is not important.

The common understanding of doctors (their self-understanding included) is, that their work is very important, to the point that they exploit themselves. Or allow themselves to be "exploited".

In this forum, more commonly you have people here working on productive systems, which can empathize with the feeling the responsibility for the operations and not wanting to drop the ball.

People with that mindset think, they may safe a patient / the system, but working oneself to exhaustion won't solve those problems. And on the contrary, the exhaustion may be a contributing factor of making things worse in various ways. One directly by your actions, the other indirectly by covering up systemic problems.

Indeed. Is that weird mole just a weird mole, or is it skin cancer?

>They have to "do more with less" (Not limited to public sector, see Boeing), and that works for a while, until it doesn't.

Yes, which brings us back to the point I made about it being a numbers game. IF you start cutting back pilots sleep and planes' QA to boost profits, you'll reach the "it doesn't work" phase (planes dropping from the air killing everyone) much sooner and at a steeper rate than with overworked doctors where the decline is a lot slower and gradual hence why this issue gets ignored more easily by those in charge, because it's so slow that people keep getting used to this as the new normal.

IF a few Boeings fall from the sky, people might stop flying Boeings, but people won't stop going to the doctor just because some people get killed from malpractice (which is statistically more likely than dying in a plane crash).

It's easier for the public to recognize and be outraged about 237 dead airline passengers compared to 237 dead patients even if both are caused by overtired pilots or "providers" (I hate that word for it's vagueness).

I think having more physicians is the core thing.

The US stands out in having so few physicians per capita (per 1000 it's 3.6 in the US, here in Sweden it's 7.1, in Germany 4.5, Spain in 4.6). This has been discussed before here before, and I don't think it was controversial that a sensible solution was to simply have more physicians.

I think one major thing that the US is doing wrong with that which is not so well known is that the training starts rather late in life. Thus you get less out of the physicians you train. Here in Sweden a physician has a MSc in medicine and is ready to meet patients and be trained when he's 23, and I think this has the benefit that there's no need to overwork them.

By the time they're 30 they'll have all the experience the need without having been overworked, and not sleeping enough kills intelligence, memory, drive, all mental qualities one may have.

I think these two policies, ensuring that people graduate earlier-- removing the pre-med and having people start right away with a medicine program, and graduating in 5.5 years, that's the right approach.

Physicians would earn less, but they'd have substantially better lives. Being able to start younger also means success younger, and happier families.

This was in Australia (4.1).

Ah, thank you.

What about the meta-game, where doctors get burnt out or suicide, and that increases pressure on the remaining doctors, in a negative feedback loop.

We should impose work limits on doctors, just like pilots.

What I don't understand:

Say I'm a doctor, and I declare I will only work my 40 hours (or however much a full time is where you are). I will literally leave when my time is up. Oh, and I don't pick up phones outside of work. Or read emails.

What will anyone else do about it? Fire me? Then they have even less doctors...

It seems to me doctors do have the power to change things, even without collectivizing. But for some reason I don't understand, it doesn't seem to work out.

They would earn less money.

> the power to change things, even without collectivizing.

Not really it's a sort of prisoner's dilemma. The one who refuses to work stupid hours gets fired and someone else has their job. If they stood together then it might work.

But there is no one waiting for their job. In most places there is a shortage of doctors.

> Not really it's a sort of prisoner's dilemma. The one who refuses to work stupid hours gets fired and someone else has their job.

Is this relevant in a profession that already doesn't have enough practitioners?

I mean, let's say there is a shortage of 100 doctors in a location that currently has 900. If you fire one, wouldn't they easily pick up one of the open 100 slots?

The individual concerned is still fired and has a harder time surviving than the company that fired them.

There's a duty of care* that doctors have. If there's no one else to care for your patient, you're required by law to care for them. (I'm not a doctor, but it's a real thing) It's one thing to risk being fired. It's quite another to lose your profession.

*google "duty of care" for more info

If you don't have your own practice, yes, they might fire you. If you're only working "part time", you're bringing in less in patient associated payments for the owners compared to people who work more.

There's also the fact that doctors might prefer $700k/yr working 80 hour weeks vs $350k/yr working 40 hour weeks. A lot of people who become doctors are workaholics and were behaving in a similar manner throughout their schooling.

I think someone also did the math and figured out that having fewer handoffs side a patient led to better outcomes so now there’s pressure to have two doctors per24 hours instead of three or four.

That's a very good point. I think 12 hour shifts aren't necessarily bad, but even EMTs/firefighters (in some places, afaik) have downtime after their shift. Maybe work one on one off, or maybe 2 on 3 off. I suspect that's still much better than the practice of 24 hour shifts.

Did they really study how doctors and other staff work in enough countries?

Not so sure about that. According to a few studies, medical error is the 3rd leading cause of death, behind heart disease and cancer.

Many operations are elective. In such cases, having a tired surgeon or nurse may be worse than delaying the procedure, or even skipping it.

https://www.bmj.com/content/353/bmj.i2139

https://pubmed.ncbi.nlm.nih.gov/28186008/

https://journals.lww.com/journalpatientsafety/Fulltext/2013/...

This has been extensively debunked. Read the original methods of the BMJ article that you linked. They took every single minor error, like prescribing medicine 15 minutes late, and if the patient died, even of an aggressive cancer that they had already, it would be counted in the 'medical error that caused the death' statistic.

https://www.nytimes.com/2016/08/16/upshot/death-by-medical-e...

https://www.medscape.com/viewarticle/863788?scode=msp&st=fpf...

https://sciencebasedmedicine.org/medical-errors-2020/

Of course practicing doctors and nurses are going to swear up and down that it isn't true. They are the perpetrators. Ask any person who has had to spend time in a hospital recently, and watch your "de-bunked" turn back into a "re-bunked." These jokers can't even keep the charts straight. It is fast-food-tier service for a life-and-death commodity.

…but if you postpone a procedure, the medical facility they work at isn’t able to keep up with their revenue targets.

IMO this is doctors acting as enablers of a toxic administration. They need to refuse outright to not work crazy hours and force the system & administration to come to a crisis. The admins are not working those hours and thus do not feel the consequences of their actions and by enabling their bad behavior they are not getting consequences from their bosses, which are politicians and customers.

I think it's a matter of the 'tradinionalist' mindset in doctor education

most doctors will think "well, I went through a hardcore intesnse experience in medical school, therefore that's how it should be"

I'm saying they've normalized overwork as part of their specific subculture of modern medical professionals. they really believe they won't be as good doctors without this arguably abusive overwork system

it's yet another group of people who all belive in some form of the "no pain, no gain" mindset; the issue is these groups don't give nobody anything unless there's some harm or pain involved

> If your operations have a 90% survivability rate it could still be considered a success despite those 10% they end up killing, because 90% is a lot better than 0%.

> Meanwhile a tired pilot is more binary, it either can have 100% passenger survivability if things go well or 100% fatality if things go tits up, meaning the risk are too high to take chances.

This isn't how the math works. A tired pilot either kills or doesn't kill their passengers on a given flight the same way that a tired doctor either kills or doesn't kill their patient in a given operation. In both cases it's 100% survive or 0% survive.

Pilots aside, we also have laws about keeping truck drivers from driving too many hours, and accidents involving drowsy truck drivers are unlikely to have fatality counts measured in the hundreds.

The difference between doctors and pilots/truckers isn't in the amount of risk involved, it's that surgeries are expected to have a non-zero fatality rate. A doctor can do their job perfectly and still lose a patient, so it's harder to prove that the fatality rate would be lower if we gave surgeons more rest. When a truck driver falls asleep at the wheel and kills someone it's obvious because they did something provably illegal or unsafe right before the crash. When a surgeon fails it's a lot harder to prove it was preventable.

It's a little different because an unflown airplane doesn't kill people, but an untreated medical condition does.

Sometimes it can happen extremely quickly, but also be largely preventable with proper and timely intervention (like with a burst appendix).

Thanks for the perspective. I have doctor friends and everyone seems to just blindly accept that some jobs are not jobs, they are identities. You never pause being a doctor. But your comment shows that even in life-critical environments, we do have ways of organizing work so individuals can bear it. Fire brigades are another example.

Time to push for a change. And time to call some people and ask whether they are truly ok right now.

My partner is a surgeon in the UK. She's planning on leaving the profession at the end of the year. We talk a lot about what is wrong with the medical profession.

One issue is the type of person attracted to the profession. They're incredibly academically talented, not driven by money, and desire status and recognition. Surgeons are the most extreme cases of this personality type, as they're harder jobs to get and have a lot of pressure. These people are the types who get their head done, roll up their sleeves, and get on with things. They're not used to asking for help or additional resources. They're the sort of people who care for others! Medicine self-selects for martyrs.

In addition, you have so many hoops to jump through (training, specialisations, etc) with significant time investment that can be lost in moments by pissing off training directors or other senior doctors. My partner ends up working more than her contracted hours because her bosses expect her to, although they would never explicitly enforce stricter rules. If she works her contracted hours she can kiss a consultant job (UK equivalent of attending) goodbye as her bosses won't provide a reference for the role.

Because the stakes in medicine are literally life and death, meaning that it is heavily regulated. There are horror stories around the GMC, the UK regulator, and doctors are terrified of being investigated. They adopt a legalistic mentality where they only treat if they're sure that they won't get prosecuted. It's very different from aviation with its no blame culture.

Finally, another factor that is making medicine so tough is that it is a success story! People live longer, and pathologies that were once fatal can be managed with ever more complex treatments. As demographics lean to older populations, then the demand keeps increasing.

For inpatient hospital care, research has shown that transitions in care are particularly risky for patients. When one doctor goes off shift and hands off a patient to another doctor, sometimes things fall through the cracks. In theory all of the data needed for a smooth transition should be documented in the patient chart, but in practice this doesn't always get done plus there is some tacit knowledge which clinicians build up by observing a particular patient which can't be put into words.

This risk of iatrogenic harm has been used to justify long hours, particularly for residents in teaching hospitals. I'm not saying that it's necessarily a good idea or that there are no better alternatives, just explaining some of the rationale.

Thanks, I commented a bit above already to a similar response. I would say that there's a balance between very short shifts and 24(or more) hour shifts. 12 hours for example is doable occasionally/with breaks in between shifts. Right now the pendulum is at one extreme.

[0] - https://news.ycombinator.com/item?id=40025540

I haven’t read that literature very closely, but will say that I have seen lots of handoffs, and they generally involve someone who has been working 12+ hours, very often 24+ hours, who needs to hand off 10s of patients to 3+ people, all of whom have things to do and can be hard to schedule around, before they can go home.

It is not at all surprising to me that these kind of hand offs result in things being missed, and equally obvious that decreasing the patients per provider and increasing hand off window hours would at least reduce some of those errors, if not outright improve them. Bonus points for putting the peak of handoffs into late morning hours, where much more of the decision making is completed.

Of course, the only way to do that is to either:

1) drag hours out longer, which I think lots of MDs would be fine with if they weren’t expected to turn around and do it again in 18-36 hours, requiring increased staffing

Or 2) increase staffing all around and just maintain more reasonable ratios

I share the same objection about the lack of regulation in the medical profession worldwide.

My best friend from high school became an MD and I witnessed doctors in training being proud of powering through extremely long, back to back shifts with little rest.

Meanwhile, as an engineer I've seen short and strict shift limits on employees operating machinery like trucks and forklifts. Under the obvious principle that insufficient sleep impairs judgement, put lives at risk and creates massive liability.

Compared to aviation, bad outcomes in medicine are a) not news material and also b) taken into account beforehand.

Phobias apart, we simply do not expect to die, when we fly. In contrast, we openly consider % survival rates of medical procedures. These rates have human error already baked in, and would be lower if humans made less errors. And then there is the primal fear of not getting help, if needed, because no help was available, which certainly works on our collective will to action here.

A 50% survival procedure for medicine might work, because it's either that or death. Aviation is always a few plane malfunctions (not even outright crashes) in quick succession away from the entire industry crashing.

The cynic in me says they have bad working conditions since they're public funded: governments, to a large extent, don't want to increase or divert taxes to provide better working conditions since they'd rather give their friends in the private sector a slice of the immovable and highly lucrative pie.

A partly-privatised healthcare system only works when all agree to balance the intangible long-term benefits of universal healthcare with tangible private-sector financial-gain. I don't see this happening when the private sector is seen as the panacea of all social-ills and when universal healthcare isn't seen a means to increase productivity.

> The question is, why is it okay for medical professionals to wear themselves down to the bone (sometimes literally, like in this article), while some other professions take care to avoid it?

I think the answer here is that if you there aren't enough pilots, schedules can be reduced. You can't scale back (in any ethical way, anyway) the demand for healthcare. People will just die at a higher rate and outcomes will worsen.

Thank you for your comment, that's a very good point. I self-replied a bit lower with more discussion on this, primarily to the effect that the "solution" in that case would be to hire more doctors. The concept of a "standby" doctor (like a volunteer firefighter) could be used (more), for eg retired former doctors/nurses.

There is a lot of protectionism & abuse in the doctor system, to the point where I think common tropes are put as fronts to keep up a status quo to hide the reality. You have to look at actions vs. the statements at this point. "The purpose of a system is what it does"

Statement: We need more doctors in Canada.

Actions: It's much harder than 20 years ago to get into med school or a residency (USA medicare). It's even harder to go to med school in Canada than the USA! Doctors from other countries have much higher testing standards than local med school graduates in Canada to get licensed. To the point where they move to the USA because it's easier to start working than it is in Canada itself. Foreign Doctor moves to canada and becomes a taxi driver is a trope in Canada because of the excessively high barriers.

I think it has to do with the cost structure of the good. Healthcare is dominated by labour costs, which means in industrializing economies it lags behind in productivity and labour starts getting squeezed to try and keep prices at a reasonable level. A pilot, despiute being in a highly skilled profession, is only a small part of the puzzle when it comes to the cost of flights.

I've looked at all the other replies and very few mention the obvious: self-regulation is hard.

Hospitals are mostly held as public services, and having more doctors better handled arguably costs more (in training, infra, shift management etc). Gov gets to decide if it wants to pay more, or even change the status quo and bails on it.

It's the same deal for teachers in public schools and other public servants, their mental health management is lagging, their salaries and treatment as well, dispatch and promotions are a PITA etc.

I don't think govs are inherently bad at it, just that there's no check and balances most of the time. Same way private companies are bad at self regulation and need an external force to get regulated. Mandatory unionizing and better avenues to sue for better conditions could be an answer?

My assumption is that is a doctor does nothing the situation will get worse. So therefore them doing anything is seen as a step in the right direction, they will improve things over the base line?

A pilot isn’t in charge of a deteriorating situation, then doing something could make things worse below the base line (a tiredness induced mistake) so therefore make sure the only do stuff when fit to do so?

Note I’ve used questions on both of these examples as it’s more of a half thought and a feeling that a statement or fully fleshed out thought.

I guess the summary is, I’d rather have a tired doctor work on me in an emergency than no doctor work on me. I’d rather not fly on the plane than have a dangerously tired pilot fly the plane.

That’s being said the system clearly needs improving and we need more medical professionals to balance the work load.

It's even worse. In the EU the working week is to be an average of about 48h. ...unless you are an medical professional, then you "may" opt-out and work up to 78h. It's completely legal, and regulated by the law of the EU:)

https://www.europarl.europa.eu/meetdocs/2014_2019/documents/...

Complicated question, on potential factor: maybe because the doctors kill one by one instead of in batches, so the ridiculous artificial entry limits that result in very high workload, but results in artificially high pay, doesn't meet a strong enough force to be adjusted?

(My musings/thinking-aloud): One partial hypothesis/answer is that there are far fewer pilots/cabin crew than there are doctors/medical staff, and hence it's easier to treat pilots properly. But fewer people makes it harder to let someone off if they haven't slept well so I don't really buy that.

Another is that the medical profession is much more "flexible"/fluid in its needs, unlike flights scheduled in a regular manner. However, that doesn't mean it's not possible to give doctors an 8 hour workday, and substitute/bring more doctors for other shifts. In fact, this is exactly what happens in many 24-hour manufacturing plants/operations. Foxconn doesn't let a sleep deprived employee make an iPhone, but it's okay to let a sleep deprived doctor perform life-saving/potentially deadly operations?

Another possibility is that "it would cost more" to have 3 docs instead of 1. Which might be supported by anecdotal evidence on how expensive things (including salaries) are in the medical field. However (especially if you're only familiar with the US healthcare system), this doesn't explain how doctors in say India are overworked.

The "real" reason, I think behind all this? The first part is it's because it's "easy" to compress and push an 8 hour shift to a 24 hour shift, fatigue be damned. The costs are "hidden", it's likely even with fatigue a 99% successful operation is still 95 or 90% successful. Everyone can rationalize it and go about with their day. "Oh, unfortunately people don't always make it".

Not, "there was a 20% chance they wouldn't have made it but an 80% chance it was because the doctor was fatigued."

When an aircraft crashes, 300 people may die instantly. This gets front page coverage on a newspaper. However, a few deaths "here" and "there" don't really show up, even if they tally up to thousands. This is the second factor, that "hides" and normalizes occasional slip-ups.

</End of this wall of text> I unfortunately don't really have a solution. I'm sure there are brilliant UX designers here on HN who could help ease and streamline the admin workload.

I suppose a dedicated politician/presidential candidate somewhere could take this upon themselves to campaign for. (Seriously, the NHS was part of the discussion behind Brexit. Supporting doctors is a brilliant political strategy, the NWA didn't have a song called "Fuck the paramedics".)

There have been many instances of things catching on once found successful somewhere, be it procedures like the Heimlich or concepts like Lean Manufacturing. Therefore I don't doubt that one good Harvard Review paper showing a 20% decrease in all-cause patient mortality, with trials underway in a few hospitals, is all it will take. Question is, who will bell the cat‽

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