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Comment by astro- | Hacker News Reader

In healthcare, the workers are in high-stakes situations with personal liability for the care they provide. When you make a mistake, your license can be taken away. Licensing is important to prevent malpractice, but it does enable a form of worker exploitation.

When you’re on a severely understaffed ward, you have to get the work done whatever it takes. If the next shift fails to turn up, you can’t just go home. People’s lives are at risk. You’re responsible until you can hand the care over to someone else.

Like this, things can be stretched to unhealthy or even dangerous levels for a long time before there’s any accountability for the management. The front line staff have to get the work done, often at great personal expense.

Honestly, I don’t know how people do it.

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I also get somewhat scared when I hear about things like shift lengths or "on call" times from my doctor friends, even on "well staffed" shifts.

If you're on your feet and working for 14 hours straight with no rest, you will make more mistakes. It's just being human. Pretending that isn't the case and punishing those mistakes won't reduce them.

Staffing enough people for regular 8 hour work days with regular breaks should be the norm. At the lowest bar, any mistakes that happen on shifts longer than that should be held accountable to any management of the hospital or government agencies making policy, not the nurses and doctors. These are preventable situations, so the people creating the situation in which this occurs should be liable.

Plus good time overlap to hand over ongoing issues - there's a reason why there's an uptick in deaths at shift change time...

The problem is we are collectively not willing to pay for this quality of life, so we operate various systems near the breaking point. As long as said systems don't fail, they will continue to operate as is. Teacher shortages, nurse and doctor shortages, bus driver shortages, air traffic controller shortages, and so on.

Agree with your point that the people creating these situations should be held accountable in some form, although I'm unsure if the will exists for accountability. America runs on "maximum extraction minimum liability" as a philosophy.

https://www.axios.com/2023/08/27/labor-shortages-air-traffic...

https://www.axios.com/2023/10/26/health-care-doctor-shortage...

https://www.axios.com/2024/03/08/aging-health-care-labor-sho...

https://www.axios.com/2023/05/08/us-labor-shortage-older-wor...

At some point it was determined that working longer hours was safer than increasing the amount of mistakes caused by handoffs where new staff takes over and can make errors, miscommunicate, or just lose information. I'm still skeptical fatigue is less dangerous than handoffs.

3x 12-hour shifts would be 36-hours/week, and would be fine. Doctors work a lot more than that though, and that's where the fatigue comes from.

Yeah this is the wrinkle. I do wonder though, whether there might be a situation reversal effect if you moved far enough in the other direction. If you instead had handoffs extremely frequently, say for example, every 6 hours, or perhaps a staggered system where there are people shifting off every 3 hours, you could/would build better process, habits, and culture potentially even to the point where it's no longer a significant liability, or even a benefit (fresh eyes).

It's somewhat similar to how having a handful of remote individuals in a mostly in-person company can lead to significant communication issues, but a fully/mostly remote company builds and leverages tools and processes to reduce these issues significantly.

Not that I'm fixated to this idea just a passing thought following this line of reasoning, but..

There might a world where if we lower the bar of medical school, it turns out at the end it results in fewer mistakes because of the increased supply.

A good bit of the required education for MDs is tangential to providing care. It may not even be a question of "lowering the bar" per se, but of streamlining the curriculum.

That said, you can accomplish a lot by leaving MD education alone and allowing the "technician" type health care workers like PAs and NPs to do more.

When you’re on a severely understaffed ward...

You're being exploited by someone who should face legal repercussions for the situation that they have negligently created. But they won't be.

That's the problem. That's all it is. There's no corrective mechanism from the legal system in play so the problem festers.

Make the caregiver's pay rise the longer they work. Take a rising chunk of that extra pay out of the management's pay, right to the top to help incentivize them. As the rate's rise, rise them higher for the higher-level managers.

Direct Supervisor of 10 staff. Ward supervisor of 50 staff. Hospital manager of, say, 500 staff.

  An extra 1-2 hours, +5% pay/hr, manager -1%/10, ward -1%/50, hosp man -1%/500
  2nd extra 1-2 hours, +10% pay/hr, manager -2%/10, ward -3%/50, hosp man -5%/500
  3rd extra 1-2 hours, +20% pay/hr, manager -5%/10, ward -10%/50, hosp man -20%/500
  4th extra 1-2 hours, +35% pay/hr, manager -10%/10, ward -20%/50, hosp man -40%/500
  ...

While this allows a few overworked people without hurting management much, if it's widespread, it hurts management a lot, especially at the top. You may choose to introduce a cut-off where management starts getting hit hard, without the staff divisor, to really disincentivize working anyone longer than that cutoff point.

License revocation for making a mistake is exceedingly rare.

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