
No Doctor Should Work 30 Hours Straight with No Sleep - BDGC
https://www.theatlantic.com/health/archive/2016/12/no-doctor-should-work-30-straight-hours/510395/?utm_source=nhfb&amp;single_page=true
======
snowwrestler
A friend of mine is a PA who works in emergency medicine, which means he pulls
30 hour shifts sometimes.

I challenged him about how, with what we now know about sleep deprivation, he
could defend that schedule.

He pointed out that much of medicine, especially emergency medicine, requires
deep complex analysis of a wide variety of symptoms, some of which might seem
unimportant or unrelated at first. We've all seen shows like House where it
takes a genius to diagnose the root cause of a set of weird symptoms. While
that is obviously exaggerated, the reality is that diagnosis is often
difficult and in an ER, happens continuously with treatment.

He said there is no way that a doctor or PA can fully hand that mental flow
state off to another one. So the scariest thing to him is handoff--what if he
forgets to document or mention some seemingly minor detail that ends up being
crucial??

Long shifts give medical personnel more continuous time with each patient,
reducing the chance that handoff will come too early in treatment, when
mistakes or misses have a greater impact. It also permits long periods of
overlap between shifts.

"Being sleep deprived is bad for care," he admitted, "but so are handoffs." He
feels that as long as the total time per week does not exceed too many hours,
long shifts are good for care.

~~~
amorphid
That's a really interesting point. I wonder if it'd be practical to address
the handoff problem with rolling start times. So if average ER patient takes 3
hours to treat from start to finish, for an 8 hour shift, you stop taking new
patients at the 5 or 6 hour mark. That being said, if an ER doc is in the
"graceful shutdown" part of their shift, and a spike in patients rolls in the
door, it'd be hard to say no to helping out.

~~~
mjevans
I had similar thoughts, except with 4s.

For the first 4 hours they take patients (and shadow some of the persisting
cases from other doctors).

For the next 4 hours, they're purely cleanup/handoff... EXCEPT in the case
that a major crisis happens. Things extend 4 hours at a time in that case.

This would, however, mean staggering the doctors in 6 different shifts that
could each handle the ingress load for their ramp up period.

Naturally doctors that are 'morning' or 'evening' people should be binned in
to shifts compatible with their biological schedules.

~~~
Spooky23
Where do you get the 5-6 doctors to make up the difference since you're
working a short shift plus pairing with another doctor for half your shift?

~~~
mjevans
Think of the 'doctor slots' as cutting blades with overlap.

The first four hours (half shift) the doctors are taking in new patients. In
the next four hours they aren't taking them in, they're finishing processing
and starting to pass them off to the next shift if they appear to be complex
cases.

------
jseliger
The culture of medicine, at least at the physician level, is completely
insane; it's so insane that describing its insanity is part of the reason I
wrote "Why you should become a nurse or physicians assistant instead of a
doctor: the underrated perils of medical school"
([https://jakeseliger.com/2012/10/20/why-you-should-become-
a-n...](https://jakeseliger.com/2012/10/20/why-you-should-become-a-nurse-or-
physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-
school/)). Residents in particular have no power, and even physicians
themselves frequently feel they have no choice but to match the death-march
pace set by administrators or their most deranged colleagues.

~~~
pdxandi
My wife's a second-year resident and it's pretty unbelievable how hard and how
much they work. She's on her 18th straight day of working long days during the
week and long nights during the weekend. Legally there's an 80-hour per week
cap, but no resident would ever complain. They do 24 hour shifts, but never 30
hour ones, though other programs at her hospital do.

I felt upset about her hours all through medical school only to discover
residency is worse. There are no fellows in her program either so the
residents handle it all. I feel I've just accepted her terrible schedule at
this point. I'm most saddened that we won't be able to have children for
another five years until she's completed her fellowship, especially because
I'm in my mid-30s.

Writing this comment makes me realize how painful it feels at times that her
medical training runs our lives.

~~~
rileyteige
I can definitely relate with you on this story.

My wife is getting ready to start an OB/GYN residency next year (lasts 4 years
for those who don't know). She just wrapped up interview season and each
program had just about the same scheduling for their residents: 5 12-hour
shifts at a minimum if you're lucky with one 24-hour shift per week on top of
that. Often times I heard "one weekend off every six weeks". Then there's
call.

I write this as I read more through your comment... the statement on the kids,
medical training running your life... all true.

The other part, that I'm sure you can personally relate to, is "The Match".
The "sorting hat" algorithm that all 4th-year med school students have to go
through. For those unaware, the match dictates the program that a doctor
candidate (MD or DO) must attend for residency. Given where my wife attended
medical school, we already know that we're going to have to pack up and leave
the home that we've established over 4 years since there are no residencies in
our region. But since everything is done through "The Match", it's really a
toss-up where in the country we end up (she applied to every program in the
country since competition mandates that everybody do absolutely everything)...
we'll be finding out in about 6 weeks where we will live come summertime.
"Runs our lives"... so accurate.

I do what I can to support my wife through this endless process, but boy is it
exhausting for everyone involved. I have no clue how she does it.

It truly is an enormous sacrifice of - really - some of the best (at least
youthful) years of your life. Want to become a doctor? Say bye-bye to your
20s.

Edit: drawing context from another person who also commented on your post,
we've also heard kids during second-half of residency can be a good route to
go. We're thinking 3rd year ourselves.

~~~
pdxandi
Can relate to all those points.

The Match was especially brutal on us because there were only a handful of
programs within 2000 miles of our home (West Coast) so we said goodbye to our
lifelong friends and family and moved out East.

It's a bit late for you, but I created a website
([https://medmap.io](https://medmap.io)) to help with The Match process. I
have plans to improve it and make it more community driven, but it at least
helps visualize your options.

~~~
rileyteige
That is a really cool website. I have some comments, and let me preface them
with the fact that my wife is going to be a DO so I'm always looking for
"Where is the love for DOs?":

\- I don't see a way to differentiate between DO and MD programs. Along the
same lines, several of the programs she applied to (like Grandview in Dayton:
[http://www.ketteringhealth.org/grandviewmeded/residencies.cf...](http://www.ketteringhealth.org/grandviewmeded/residencies.cfm))
don't appear on this map (though some do, but again no indication of DO). What
is the datasource for the map? Is there any way it could be enrichened?

------
minimuffins
Learning about new ways that our medical industry is totally dysfunctional is
baffling and infuriating. It seems to be an inexhaustible well of misery for
workers and patients alike. These conditions are like something out of a 19th
century factory town. One more way the US healthcare system is a ridiculous
anachronism.

My first questions are

1) Is sleep deprivation and the generally toxic work culture for doctors and
healthcare workers a uniquely American thing? Like does a doctor in Denmark or
the UK or Mexico have such a brutal work regime?

2) What's the solution to this? I'm inclined to think healthcare workers have
to organize themselves to oppose it and demand new policies because who else
will? It seems no one in hospital administrations, regulatory bodies or
government has any incentive to push for change here, in fact they're doing
the opposite by expanding allowed hours worked.

~~~
trowawee
The problem is that doctors are never going to organize against this, because
A) most have been thoroughly inculcated in a culture that worships that kind
of work ethic and B) the limited number of physicians is the reason they make
absurd amounts of money. The median ER doc in SF makes $328,047[1], and ER's a
relatively low-paying specialty. The solution is regulation with teeth,
similar to the rules governing pilots.

[1]: [http://www1.salary.com/CA/San-Francisco/ER-Doctor-
Salary.htm...](http://www1.salary.com/CA/San-Francisco/ER-Doctor-Salary.html)

~~~
arikrak
I wonder what would happen if instead of adding more regulations, they took
away some of the power that medical schools have in restricting people from
practicing medicine. E.g. nurse practitioners and physician assistants sound
like a step in the right direction.

------
djsumdog
I remember hearing about sleep deprivation in the medical field before;
especially for people who work in the ER or as surgeons. The demand in the US
for nurses and doctors is very high, and so are the education costs which can
be prohibitive to people getting into medicine.

There's a whole system of failures, from the cost of education to the student
loan systems to medical insurance and billing, that has led directly to
overworked doctors. Many med students today feel that they can't become GPs
because they simply won't make enough to pay back their student loans.

~~~
devoply
The issue is that of management. The management profession has taken over
hospitals and it runs those according to management practices. Overworked
doctors are a result of (bad) management, and nothing else.

~~~
dv_dt
Except that management in hospitals are often doctors themselves (or
influenced by the more senior doctors). One problem is that most doctors have
gone through a residency with abusive hours - so it becomes hard to separate
tradition from necessity.

[http://www.latimes.com/business/la-fi-medical-resident-
hours...](http://www.latimes.com/business/la-fi-medical-resident-
hours-20161216-story.html)

~~~
devoply
[http://study.com/hospital_management_career.html](http://study.com/hospital_management_career.html)

------
finid
30-hours of non-stop work is almost 4 days of work, assuming 8 hours per day.

Next time you read that a surgeon left one of his/her tools inside a patient,
now you know why.

~~~
venomsnake
I would probably trust the worst student in a medical class when sober and
well rested more than the even the best doctor after being awake for 30 hours.

Mistakes will be made and people will die. After mission critical all nighter
you also need 2 days at least to be able to recuperate.

~~~
parenteral
I'm a doctor and I dispute this. I'm not advocating for long work hours or
saying that it's healthy/OK. But the "worst students" in my assessment are
people that I wouldn't trust to care for my loved ones at all and I would
definitely take my weary-eyed trusted colleagues over the former any day. It's
a very long discussion, but there are some really bad doctors out there who
get by because most mistakes don't cause obvious harm.

Also, the body that oversees residency programs is going to relax duty-hours
restrictions since they've studied it now and there's no difference in
outcomes or resident satisfaction when they eliminate the 80-hour restriction.

~~~
kelnos
> no difference in outcomes...

I find it hard to believe there's no difference in outcomes. Every study
related to quantity of sleep or sleep deprivation that doesn't have to do with
doctors points to severe cognitive impairment as waking hours increase and
sleeping hours decrease. It's incredibly suspicious that studies that _are_
related to doctors point the other way, especially studies conducted by the
body that oversees residency programs (sure, I expect them to be unbiased,
right). Either patient outcomes are indeed affected by the long hours, or
being a doctor is so comically easy that a drunk monkey could do it. I doubt
it's the latter.

Speaking of drunkenness, being caught drunk on the job is a firing offense for
a doctor, and I believe you can also lose your medical license, right? Sleep
deprivation has been shown to affect judgment, alertness, memory, and reaction
time in a similar manner as alcohol. If it's fine for a doctor to be sleep
deprived, why not let them be drunk while working too?

> ... or resident satisfaction when they eliminate the 80-hour restriction.

Of course not. The residents would never complain, lest they risk being viewed
as slackers.

~~~
wott
> _Speaking of drunkenness, being caught drunk on the job is a firing offense
> for a doctor, and I believe you can also lose your medical license, right?
> Sleep deprivation has been shown to affect judgment, alertness, memory, and
> reaction time in a similar manner as alcohol. If it 's fine for a doctor to
> be sleep deprived, why not let them be drunk while working too?_

Unfortunately, it's not just a rhetorical argument, but it is a true problem
with hospital doctors: alcoholism, drunk at work, and of course abuse of all
drugs that are easily available for them. And everyone covers it up, as long
as there is not a major accident.

There are of course the same reasons as in the general population, but there
are extra ones: the pressure; the stupid work organisation with stupidly long
shifts; the fact that most of the medicine studies are also insanely organised
and insanely competitive (in my country, this is where you find the shittiest
mood and mentality of all studies, except perhaps a few business studies),
thus the habit is taken early to use alcohol and drugs to "perform" or to "put
up with the workload", except that it is 'fine' when you are young, but when
you get older and keep the same habit, you don't recover and the effects
accumulate.

------
dnautics
Didn't they do a study and find that decreasing doctor hours caused an
increase in patient mortality because of handoff errors? And that digitizing
records didn't help because of a combination of inaccurate measurement by the
staff and because of factors that can't be measured (intuitive observation,
etc).

~~~
vorotato
Who is this they?

~~~
TJSomething
That would be Desai, et al. Though I can't access the paper right now, they
say that the 2011 regulations have tripled handoffs, increasing handoff risk.
It also turned out that the average amount of sleep per week was not increased
by much after instituting the regulations.

[1]
[https://www.sciencedaily.com/releases/2013/03/130325183819.h...](https://www.sciencedaily.com/releases/2013/03/130325183819.htm)

[2] Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 Duty Hour
Regulation–Compliant Models on Sleep Duration, Trainee Education, and
Continuity of Patient Care Among Internal Medicine House Staff: A Randomized
Trial. JAMA Internal Medicine, 2013; DOI: 10.1001/jamainternmed.2013.2973

~~~
chewymouse
The article is here:
[http://unmhospitalist.pbworks.com/w/file/fetch/65758972/desa...](http://unmhospitalist.pbworks.com/w/file/fetch/65758972/desai_dutyhours_2013.pdf)

------
finid
The interesting part of this is that truck drivers are heavily regulated, as
they should. They are forced to take breaks after driving a certain number of
hours. Not sure exactly, but I think it's about 8 hours.

The same treatment for doctors won't be a bad idea.

~~~
rileyteige
While I agree with you, I have two words: Doctor shortage.

~~~
finid
If that ever becomes a direct result of regulating doctors in that way, then I
don't see why we can't solve that problem the same way we solved the shortage
of nurses decades ago. In this case instead of importing filipino nurses,
we'll just import doctors from wherever.

Who know, India or China might have a surplus of doctors too.

Or maybe that's the kind of problem that telemedicine will solve.

~~~
rileyteige
I agree that telemedicine has the potential to be revolutionary, at the very
least in the primary-care field. Not sure what it could do about in-patient
care, however. The other issue that telemedicine does not solve as far as I
know is there are diagnostic tools doctors use beyond sight/sound - what can
be palpated, what is the smell? Perhaps that's where nurses could step up?

------
throwaway2016a
I know what my code looks like after 30 hours of coding with no sleep
(unfortunately)... it's not pretty and takes days to recover from. Thank
goodness no one's health depend on my code.

------
noskillz
My wife was a surgery resident when we had our first child. It was tough with
her working 30 hour on-call shifts. Plus the normal 80+ hour (sometimes it
would be as much as 130) work weeks. She eventually decided that instead of
killing herself for a job she would stop being a doctor and focus on the kids.
This worked out for us but it took some guts to call it quits after 10 years
of training to get where she was at. We have a ton of debt because of it as
well.

Besides the tough work schedules I find it kind of crazy we require
20-something year olds to choose a speciality and stick with it. Very few
people can do this and not have some regrets. On top of the insane work hours
they also put up with people dying on them and delivering the bad news to
family members (at least for surgeons this happens a decent amount).

------
diimdeep
In the US alone, the Association of American Medical Colleges (AAMC) estimates
a shortage of 91,500 physicians by 2020 and up to 130,600 by the year 2025.
[https://en.wikipedia.org/wiki/Physician_supply#Global_View](https://en.wikipedia.org/wiki/Physician_supply#Global_View)

~~~
tjic
Note that the AMA, run by doctors, is required by US law to give their
approval before a new medical school may open, or an existing medical school
can expand its program.

The doctors who would see their salaries fall if supply increased have
complete control over supply.

This is complete regulatory capture, and it's terrible.

~~~
themantalope
While this is true, the real bottleneck is the availability of training
positions. Other commenters have pointed out that these positions are
generally increasing in number, but not nearly at a rate large enough to make
up for the shortfall.

One positive argument to having a body like the AMA leverage some control over
medical schools is that it helps to ensure that schools only open/expand if
the AMA thinks that their students will have reasonably good chances of
getting residency positions. It helps to avoid the sort of situation that is
currently going on in law school and PhD programs where there are no where
near enough positions available for all the students who are graduating from
those programs.

And I do generally agree with you that there are some significant regulatory
problems regarding training and residency positions, especially since
residents have basically zero leverage at all.

~~~
mattkrause
It's confusing to me that there are not more programs that "convert"
biomedical PhDs/postdocs into MDs. The PhDs and postdocs have some relevant
background and are clearly fairly clever and motivated.

However, I looked into this after grad school and other than a new program at
Columbia, there's not much. In fact, one person told me that since it was more
than 5(?) years after I took intro bio, I would need to retake those classes--
despite doing bio research for the entire intervening time. It's baffling that
a PhD would quality one to _teach_ a class to medical students, but not
_attend_ it.

------
pmoriarty
Do doctors and nurses get paid by the hour? If not, they should be, with
double or even triple pay for overtime.

That would get penny pinching administrators to stop overworking their medical
staff.

~~~
Tobani
Nurses, quite frequently yes. Physician reimbursement can be incredibly
complicated depending on type of work.

~~~
rileyteige
Especially in the US with the Affordable Care Act.

~~~
bb611
What did ACA change about reimbursement?

~~~
rileyteige
Most of the changes pertain to Medicare/Medicaid. I haven't looked into it in
several years, but this covers it in a nutshell as far as Medicare is
concerned: [https://www.medicare.gov/hospitalcompare/linking-quality-
to-...](https://www.medicare.gov/hospitalcompare/linking-quality-to-
payment.html)

Pay-For-Performance is the key term there. And while it is certainly the more
patient-friendly approach, the problem as I recall is that a lot of patients
re-admit for issues that are their own fault due to them not following through
on the prescribed treatment. The care provider, however, is the one that
doesn't get paid, regardless of why the patient re-admitted.

~~~
themantalope
Yep, a big issue is the metrics that are used to determine performance. I'm at
an upper tier medical school and the doctors here talk (complain) about this
all the time. Not only are many within 30-day readmissions due to factors
outside the control of the hospital, it also disincentivizes institutions to
take on difficult and complicated cases.

If you look at the top performing hospitals, many of them are obscure
hospitals or ones that only offer expensive surgical care that most doctors
would __never__ go to themselves or recommend to their friends/family:
[http://www.usnews.com/news/articles/2015/04/17/only-251-hosp...](http://www.usnews.com/news/articles/2015/04/17/only-251-hospitals-
score-five-stars-in-medicares-new-ratings)

I know the article is a bit old now, but if I recall correctly the rankings
haven't changed much since the metrics are still calculated in the same way.

------
KVFinn
Usually this discussion is around residents' performing worse while deprived.
A big problem no doubt.

But I wonder why people don't bring up another aspect: sleep is essential for
actually retaining and making any learning from practice permanent. Anyone who
has trained or studied anything knows this well and it's clear in the
literature. How can we expect these doctors in training to be actually
learning and improving if they are so often sleep deprived?

------
matryoshka4811
It's hard to comprehend how many hours a doctor can keep going unless you see
them everyday. My mother is an OBGYN. I remember growing up surrounded by MCAT
and medical school books and the residency nights when she wasn't home when I
went to sleep and when I woke up. I don't really remember when the doctor
lifestyle wasn't a dominant part of how my immediately family functioned. (She
had both of my siblings during her residency.)

And now, after she's been in practice for almost two decades, it really isn't
much different. She's the head OB at a hospital/clinic that is the only one
for several counties. She gets multiple cases a year when women show up in
labor that she's never seen before. She's had to report multiple births to
child services because the mother is an addict. On a personal level, it means
that she never makes it to both Thanksgiving and Christmas, sometimes neither,
and she's on call pretty much all the time.

All of this to say that she's inspiring really. I've never known someone who
works harder or more tirelessly. I worry though that she'll work herself to
death. Even then, I know she won't regret any of it.

------
seanwilson
Nobody should work 30 hours straight without sleep whether you're a doctor or
not.

------
chirau
Generally, no one should work 30 hours straight with no sleep. No?

------
dirtyaura
I wonder why sleep monitoring is not used for pilots and doctors and other
people working on mission critical jobs.

~~~
GuiA
Because nothing bad enough has happened yet.

~~~
chewymouse
No:
[https://en.wikipedia.org/wiki/Libby_Zion_Law](https://en.wikipedia.org/wiki/Libby_Zion_Law)

------
squozzer
We shouldn't discount the possibility that the regimen is designed to break
doctors down psychologically.

------
pavel_lishin
Doesn't this level of overwork originate with one medical instructor, who was
a habitual cocaine user and thought nothing of going without sleep?

I remember reading this somewhere, but can't remember where.

~~~
themantalope
I'm a medical student. According to legend, yes, William Osler (one of the
founding physicians at Johns Hopkins Hospital) used cocaine to increase his
energy and focus while working.

[https://en.wikipedia.org/wiki/William_Osler](https://en.wikipedia.org/wiki/William_Osler)

------
Rylinks
This is only one side of the tradeoff. Both tiredness and shift hand-offs
cause bad judgement, and both can kill people. An analysis that only looks at
one is incomplete.

------
tn13
As a rule of thumb I would not recommend anyone working that long without
sleep. A truck driver with lack of sleep can kill more people than a driver.

Even a coder returning home driving might kill someone if he has not slept in
30 hours straight.

For doctor unless he is doign surgeries chances of his mistake resulting into
death might be lower.

------
wenbert
Jesus. 30 hours straight. I know I wouldn't work 30 hours straight in IT - I
think everybody is bound to make expensive mistakes when they're tired. And
how much more for doctors? When what's at risk isn't just money but someone
else's life.

------
ghufran_syed
Should any parent be "allowed" to care for a newborn baby for 30 hours
straight witg no sleep? Perhaps we should ensure that parents do not care for
their children for more than 8 hours in a row, to ensure an appropriate
quality of care.... :)

------
mpcadosch
Has anyone tried this service?

[http://circadienhealth.pagedemo.co/](http://circadienhealth.pagedemo.co/)

It seems targeted towards nurses, but could be applicable to physicians as
well.

~~~
ceejayoz
Misspelling circadian isn't a great sign.

The ICU my wife worked in resisted carrying emergency buttons around on
privacy grounds because they included location tracking. One that tracks
physiological data and presumably analyzes sleep _outside_ of work would've
probably had them striking.

~~~
bb611
It's an intentional mispelling, that's their brand name

------
walrus01
I barely trust myself to do anything with 'sudo' on a production system after
24 hours without sleep, 30 hours without sleep and making life or death
medical decisions is scary as shit.

------
intrasight
No Doctor Should Work 30 Hours Straight with No Sleep - unless it is some
major emergency.

Never say never

------
prodmerc
The medical system will disagree: all doctors should work 30 hours straight
with no sleep, else they're not real doctors and slacking off.

~~~
devoply
You have people that have gone through the ringer to become doctors. These are
the type of people that when you say jump, they ask how high. You can pretty
much get them to do anything you want... because they are self-selected to be
that sort of people otherwise they could have never become doctors. So when a
manager comes to them and tells them they have to work so and so hours, they
do it. And they suck it up, because that's who they are.

~~~
module0000
A very soldier-worthy attitude to be admired.

~~~
realitygrill
You don't think that's kind of questionable?

~~~
module0000
Demanding perhaps, but not questionable. It's just the nature of the industry.
Not an apples-to-apples comparison, but look at combat medics for contrast
during wartime. There are limits to what humans can do, but the 120-hour
workweek in a heated-and-cooled hospital does not bump into those limits.

Maybe it would be 'better' if that wasn't the case, but it's simply what is.

~~~
kelnos
So "simply what it is" is a reason not to strive for something better?

------
edblarney
You wouldn't want your airline pilot to be sleep deprived so why would you
want your doctor to be?

Unless you're a field medic in the army or whatever. No thanks.

~~~
rileyteige
I'll mention the same thing here that I just did elsewhere in the thread to
someone else:

While I agree with you, I have to words: Doctor shortage.

At least in the US, we need more doctors. Many of the doctors with whom my
wife works all see dozens of patients every day, leaving them with mere
minutes for each of them as it is. A 2-minute turnaround is very common,
especially in the internal medicine / family medicine fields. Too many
patients, not enough doctors.

~~~
tspike
I wonder if part of the reason we have a doctor shortage is because people see
the inhumane working conditions and decide not to pursue it as a career.

~~~
maxerickson
There's a (smallish) surplus of medical school graduates, there are as many
people doing residencies as there are residency slots available.

------
acedinlowball
Doctors should only have to work like 5 hours a day but should still get paid
large amounts of money.

It's important that the people responsible for our health are well rested and
well-rewarded.

