
Rookie Doctors Will Soon Be Allowed to Work Up to 28 Hours Straight - happy-go-lucky
http://www.npr.org/sections/thetwo-way/2017/03/10/519662434/rookie-doctors-will-soon-be-allowed-to-work-up-to-28-hours-straight
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maxerickson
Dupe of
[https://news.ycombinator.com/item?id=13840429](https://news.ycombinator.com/item?id=13840429)

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PeterisP
If a truck driver is working 28 hours straight, we consider their decision
making capability so impaired that they endanger others and we take away their
licence if they dare to do 28 hours without rest.

Doctors apparently don't make mistakes that can hurt people.

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chimeracoder
> Doctors apparently don't make mistakes that can hurt people.

They can, but it turns out that the handoff points can themselves be more
problematic than the effects of working for 28 hours. They did lots of
published research which showed that, which is why this policy change is even
happening.

Also, a 28 hour shift doesn't mean that the doctor is working (or even awake)
the entire time - they're on-shift, but there are periods of downtime. It's
not necessarily 28 hours of constant activity.

~~~
karzeem
I'd say that's a good argument for fixing whatever the flaws are in the
handoff process that make it even worse than 28-hour shifts.

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chimeracoder
> I'd say that's a good argument for fixing whatever the flaws are in the
> handoff process that make it even worse than 28-hour shifts.

That's a good idea. Do you know what those flaws are, and how to fix them?

I'm not being sarcastic - there's a whole lot of money that's been poured into
this over the last few decades, and it's not easy.

While we wait for someone to figure out the answer, in the meantime, it's
reasonable for providers to go back to the policy that empirically produced
_lower_ rates of medical errors, which we know because that's what was
standard practice up until a few years ago, and it already is standard
practice for all other residents.

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phil21
I agree with this assessment having only briefly paid attention to this topic
while a friend was going through residency. This is not something that is
being ignored - I would say the exact opposite is true, it was probably one of
the most discussed topics of residents at the time.

But I also think the answer is pretty obvious, if not practical. You need to
basically double the number of doctors, and stagger shifts so they have half-
shift overlaps and scheduled 8hr (max) shifts to begin with. Then doctors can
stay longer through the next shift if needed (and this would be common) to
complete the handoffs properly as well as get through critical periods of
patient care.

I think that would be far safer than the current model - but also would
effectively double your salary costs which is of course a non-starter.

~~~
chimeracoder
> But I also think the answer is pretty obvious, if not practical. You need to
> basically double the number of doctors,

As mentioned in the article, one of the problems they found with the shorter
shifts is that it was less effective for teaching, meaning that they would
need longer training periods overall to achieve the same results with shorter
shifts. So that would mean increasing the costs of residency, which is already
an unprofitable program to begin with.

So, doubling the number of doctors without compromising on training would mean
increasing the per-resident costs significantly _and then_ doubling them.
That's... a hard approach to execute.

Also, that's assuming that having twice the number of doctors caring for each
patient per unit time does not introduce any other problems, which is an
assumption I'd question.

~~~
phil21
I again don't completely disagree, in the event real learning is going on.
That's why I feel the "scheduled" shifts should be rather short and double-
staffed, with the expectation residents stay as long as it takes to "get the
job done".

I would make the argument that the vast majority of scheduled hours for a
resident have absolutely nothing whatsoever to do with learning and entirely
to do with having shift coverage and are primarily economically driven
decisions.

You do make good points about less uninterrupted time with patients, and it's
a good reminder of how this is a very nuanced difficult problem to solve. Even
in my industry where we can more realistically staff shift overlaps, we have
handoff issues due to human mistakes. Nothing is going to be perfect, but I
think we can do better for patients as well as doctors.

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aabajian
Oh great, I come to HN for tech news and see this. As a graduating medical
student doing a surgical prelim, I'm certainly not looking forward to 28 hour
work days. I think what many don't realize is that day-to-day medicine is
super low-tech.

The ACGME is still acting off a model where sign-outs are face-to-face
following a checklist (see:
[https://www.ncbi.nlm.nih.gov/books/NBK43722/](https://www.ncbi.nlm.nih.gov/books/NBK43722/)).
This is the best we've come up with, and it frankly takes a lot of time. It's
no wonder 16 hours didn't cut it. What we need is a better way to do sign-outs
so that residents can know what's going on even during their days off. The
very wording "sign-out" is rather a misnomer. Just because you're leaving the
hospital for two days doesn't mean you forget about your patients. What we
need is something like a Twitter feed so you can get updates on your patients
when you're not in the hospital. Then you wouldn't have to have a full-blown
sign-out when you return.

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aswanson
That Twitter feed sounds like a start up opportunity. Would it be easy to
maneuver around hippa?

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FLUX-YOU
HIPAA's probably the least of your concerns. Any feed like that would have to
integrate with whatever EMR/Surgery information/Scheduling/HL7 Interface
solution(s) your hospital uses, none of which are the same or even remotely
resemble each other. Your system would become yet-another-password to remember
unless hospital IT would be willing to let you join the domain or group, which
likely means you'd need to support on-prem installations.

~~~
vertex-four
Do most hospitals not have an ADFS instance floating about somewhere?

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chimeracoder
> Do most hospitals not have an ADFS instance floating about somewhere?

Good luck getting all of the signoff and political buy-in required to get set
up with that.

You could spend 18 months running around to convince someone to do ten minutes
of work to bring you online, and I'm not exaggerating.

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cauterized
Who thought this was a good idea, and why?

Aren't our medical professionals the people we least want to be dangerously
fatigued?

Hasn't anyone read the literature on how sleep deprivation interferes with
learning?

Or how being up for 24 hours straight is equivalent to a blood alcohol level
that would disqualify a person from driving?

And we want people in this state while they're responsible for the health of
people sick enough to be hospitalized?

What the actual fuck?

~~~
surgeryres
I am a surgery resident. This "rule" only applied to first year residents, and
was started in 2011. There in fact is a study being conducted where one arm of
first year residents follows the 16 hour max and another follows the 28 hour
max. It seems the results from this trial suggest the 16 hour max is
detrimental to learning, hand-off logistics and scheduling.

Regardless, after your first year, no matter what program or specialty, 28
hour calls become the norm. As a second year surgery resident for example, you
can plan on taking a 28 hour call two or three times a week. This is just how
it is. For two main reasons:

1) There are not enough of us for everyone to get 8 hours of sleep a night.
People can debate why or ways we should fix this, whether it's widening scope
of practice for nurse practitioners or decreasing our pay so there is more of
us, but logistically there are not enough residents to keep everyone well
rested.

2) There is physiological relevance to a 24 hour cycle in many diseases. For
example, if a patient comes in with a bowel obstruction, the process of
observation, lab evaluation, imaging, +\\- surgery takes sometimes 24 hours.
12 is sometimes not enough to appreciate the full evolution of acute disease.

Big topic here. My experience is anecdotal and limited. Why they did a big
study to see what was best. Still, it only applies to first years.

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verroq
Solution: allow more people to become doctors.

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surgeryres
Ok, but what exactly do you propose? funding to support residents comes from
the federal government, and this funding is already strained.

Should we lower standards? Lower quality of care? If the answer was easy we
would have already implemented something.

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Retric
If you really want simple solutions to more doctors:

Don't promote/require undergrad before med school. As in premed is not an
actual degree anyone would ever get. Don't require multi year residency's, if
the goal is education then 12+ hours days actively block that goal by
inhibiting memory formation.

Shockingly both of those require zero money and would add up to 4+ more years
of practice and lower education costs. However, US doctors don't want that as
it would lead to lower pay just like every other country.

~~~
surgeryres
Limiting under grad education - sure, that is reasonable, that is how non-US
countries do it. You get fast tracked to medical school after high school. But
you still need some amount of undergrad education before medical school.

But no multi-year residencies? You are misinformed. It takes years to learn
how to take care of the sick and dying. We don't just punish ourselves with
lengthy training programs for fun.

~~~
Retric
It takes years for the sleep deprived to do so. That does not mean it must
take years. As you know actual doctors continue to look things up, so you
don't need them to memorize every edge case, just know when something could be
an edge case.

~~~
surgeryres
Yea, well. I just don't think we can continue this argument.

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kwhitefoot
Strange how some countries expect doctors to work ridiculous hours and justify
it on the grounds that not doing it would increase the risk of medical errors
and yet other countries seem to manage without excessive hours, see this study
about Norwegian doctor's working hours
[http://bmjopen.bmj.com/content/4/10/e005704](http://bmjopen.bmj.com/content/4/10/e005704).

I come from the UK but live in Norway and am impressed by the health system
here.

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chris_7
This should just be generally illegal from a labor law perspective, not even
something specific to doctors.

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kwhitefoot
You'll have to join the EU to get that, look up the European Working Time
Directive.

~~~
chris_7
It could be implemented at the state level here (Republicans would never allow
a pro-labor law like that to be passed federally). If New York, California, or
Massachusetts passed a law like this, it could be a competitive advantage in
attracting top talent in fields that treat their laborers terribly (like
medicine, apparently).

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sebringj
Medical errors are the 3rd leading cause of death. Didn't that wake them up to
make it less error prone, not more?

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chimeracoder
> Medical errors are the 3rd leading cause of death. Didn't that wake them up
> to make it less error prone, not more?

It did. And they did the research, and they found that frequent handoffs
introduce more errors than longer shifts do. So, they're taking action to
address that.

~~~
sebringj
That would make sense I guess but in a "lesser evil" type way.

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FLUX-YOU
>the cap would occasionally prevent doctors from seeing a treatment or surgery
through from beginning to end

I would be pretty annoyed at that, but I also probably wouldn't report it just
to see it through. Seems weird they'd suddenly get honest about it.

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dbg31415
"Allowed" is a nice way to put it.

