
First-year doctors will be allowed to work 24-hour shifts starting in July - finid
https://www.washingtonpost.com/news/to-your-health/wp/2017/03/10/first-year-doctors-will-be-allowed-to-work-24-hour-shifts-starting-in-july/
======
sarreph
I do not personally understand how healthcare — the fundamental preservation
of human life — allows for this kind of risk exposure. Many programmers in the
tech community know that half of the listed time (12 hours) of solid work is
enough to start to slow your decision-making and reasoning ability. When
peoples LIVES are in the hands of junior doctors who are essentially drunk
off'f sleep deprivation[0], how can we trust the system to to its job?

Why are the incentives continuing to be placed in the wrong areas? When will
we remedy this properly?

[0] -
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1739867/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1739867/)

~~~
ianai
As a human, the concept of anyone working 20-24 hours straight...really,
anything over 10 hours straight, infuriates me. I'd rather solve problems
associated with shift change over than force someone to work like that.
Further, life is short. Forcing someone to be so confined for such a period of
time is...wrong.

~~~
sp332
They're still limited in the number of hours they work per week. It's not like
they're working 24/7.

~~~
mithr
Unfortunately, those limitations aren't strictly enforced (the hospitals seem
to care more about their bottom line than about their cheap labor's well-being
-- so I don't see this changing soon).

In addition to that, this stuff accumulates over time, especially in a super-
high-stress environment that frequently requires life-or-death decisions.
Really think about the limitations described in that article -- interns must
have one day off every seven, and cannot work 24h more than one night in
three. So they work 16 hour shifts for seven straight days -- which means they
have to get to and from work, shower, sleep, and eat some meals during that
time -- and that's assuming that handoffs are always performed perfectly on
time (they're not, the hospital is hectic), and that you can always leave
exactly after 16 hours (you often physically can't, given the nature of the
work).

And then you get a single day off. Which you use almost entirely for sleep,
because not only do you barely have enough time to get a full night's sleep
every worknight under "ideal" conditions, but you also have a hard time
falling asleep because you're so hyped up/stressed from everything that's
happened during the day.

And then, somewhere in that mix, you have to work for 24h. That might be ok if
you had some chance to recharge your batteries during the past few
months/year, but you're so overworked and over-stressed that even your two
two-week vacations aren't enough to erase the bags under your eyes.

So, in short: this decision is really, really irresponsible. It caters to
super-alpha types (which are indeed often attracted to medicine, and
especially to surgery) who are willing to sacrifice everything in order to
accomplish their lofty career goals as quickly as possible, and to hospitals
who want more, cheaper, labor. Having been afforded the opportunity to talk
with residents at a couple of the best-regarded hospitals in the country (my
girlfriend is going through this "experience" at the moment), and seeing
first-hand how this affects them, I'm pretty confident in saying that the
handoff problem, while real, is not going to get better by making interns stay
for four extra hours after their already inhumane 24h shift.

------
mabbo
Someone ought to do a study on what the effects truly are.

Take a group of hospitals, randomly assign them to "continue insane hours for
residents", "40-hour work-weeks and no more than 12-hour shifts" and maybe a
third group somewhere in between. Run it for two years, and see what the
effect on patients and doctors actually is.

Then will come the hard questions: if we see that these insane hours are
literally killing patients, surely then it will make sense to end this
madness?

~~~
bryanlarsen
Those studies have been done and the results were counter-intuitive.

Yes, long shifts kill patients. But the other thing that kills patients are
handovers -- one doctor forgetting to note or tell another doctor a crucial
detail at shift change. Longer shifts mean fewer shift changes.

~~~
abakker
Couldn't we just have longer shift-change overlaps? I.e. double staff for 3
hours during handoff and have multiple overlapping 12 hour shifts / day?

~~~
phil21
This is what we do in 24/7 network operations centers - so issues can be
cleanly handed off between shifts.

However I don't think the additional staffing costs will fly, you're talking a
hugely substantial increase if you were to enforce this - more than 25%, since
current staffing levels are so thin.

~~~
pfranz
(not sure who would fix this) but that still sounds like a problem with the
cost structure. In other businesses, after 8 hours you get paid 1.5x, after 12
hours 2x. If those were the incentives here, it'd be cheaper to overlap and
pay two salaries (I'm ignoring benefits here).

It's a balance of what people are willing to pay, the risk we're willing to
accept, how ethically we treat workers (doctors). Unfortunately, like many
places in the economy, there aren't rational actors on each side to negotiate
these things.

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carbocation
This doesn't return things to the pre-duty-hours era. However, it does roll
back specific limits that were created for first year residents (interns).
When eventually studied, the interpretation that most of us had was that there
is not a significant difference in patient care with these shorter hours. This
is due to, we think, the tradeoff between a tired doctor who knows your
current condition well, and better rested doctors who are handing off
responsibility more often.

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thatoneguy
How is this not a form of hazing?

"I did it so the young people have to do it, too."

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pmarreck
Cruel and unusual punishment?

Sleep deprivation has some pretty serious negative side effects

~~~
Arizhel
What's really bad is that the American medical establishment, including these
doctors, seem to be defending this practice.

It'd be really interesting to see a good study comparing the rate of medical
errors and resultant patient deaths/injuries in hospitals in the US and in
other industrialized nations, and to also compare the hours worked between
them.

Another thing that came up in the article is the problem of hand-over between
doctors and medical teams, and that having ridiculously-long hours seems to be
a patch to avoid all the problems that come from that. That sounds like an
organizational and procedural problem: doctors and nurses aren't properly
writing things down, or if they are, they're not writing them in a legible
way.

I had a recent experience where I had to accompany a friend on an ER trip.
Different doctors and nurses kept asking her, over and over throughout the
lengthy visit, what she was there for, and to describe the symptoms. It was
eerie; there seemed to be absolutely no information recording and usage by
these people, it was like everything was all-new every time some new person
came on the scene. It was also really strange how they kept telling her
totally different and contradictory things: one nurse says she's not allowed
to have any food or water (despite being parched), another nurse says this is
wrong, etc. (She ended up drinking water out of the bathroom sink because she
was so thirsty, and was there for a possible cardiac problem so electrolyte
depletion certainly can't help.)

American ERs seem to be very scary, incompetently-run places.

~~~
JshWright
As a paramedic, I understand your frustration with answering the same
questions repeatedly. There is absolutely information being recorded and
tracked, and it's very likely the provider walking into the room has already
read the notes written by those who were there earlier.

However, much like debugging a technical problem, a systemic approach is
necessary for patient assessment. Everyone has their process which they have
developed over the years... The pattern and flow to their questions, the order
in which they assess various body systems, etc. Jumping around in that process
to cover the handful of questions they couldn't find the answers to in earlier
reports is a recipe for skipping something.

I'm not saying there isn't room for improvement here. My wife recently spent
two months in the hospital, and there were several times where we had to
'educate' a provider about what the plan was (i.e. we would discuss something
with the attending, but they didn't chart it well, so the senior resident
wasn't up to speed on the changes, etc...)., however, when it comes to those
assessment questions being asked repeatedly, there is a method to that
particular madness.

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jgamman
love the orwellian way this is spun as to how it is letting doctors do another
4 hours on top of the current pathetic 20. no @%^@%#$ way i'd let myself be
diagnosed by someone 23 hours into their shift, let alone do a procedure
requiring basic hand eye co-ordination.

~~~
JshWright
How many times would you want to be passed off from one "primary" provider to
another over the course of 24 hours? Those handoffs are where things falls
through the cracks...

Allowing doctors to work fewer, longer shifts is correlated with increased
happiness for the docs (they end up with actual days off), and no increased
risk for patients.

[http://www.absurgery.org/default.jsp?news_trial0216](http://www.absurgery.org/default.jsp?news_trial0216)

------
hhw
My father is a urologist trained at McGill in its heyday back in the 60's, and
they often worked much longer shifts than 24 hours. It was part of the
training to be working while sleep deprived. In real life, a doctor often has
to take calls in the middle of the night, and it was important for the medical
school to either train students to be able to work under such conditions or be
failed out if they couldn't hack it.

Mind you, they also had other traditions like working with cadavers with their
bare hands only, out of respect for the people who had donated their own
bodies.

Back then, it was expected that 2/3rds of students would end up failing out.
Not just from long shifts, but the program was designed to be that challenging
so as to weed out many people, to ensure that only the best would succeed.
Nowadays, medical schools perceive the dollars spent training a medical
student as too great of an investment, and want all their students graduate so
failures are uncommon. Now once accepted, a student has pretty much made it
even though the acceptance criteria is quite distanced from how they actually
perform as a medical doctor. This potentially results in less qualified
individuals becoming licensed.

~~~
tanderson92
But this article is about residency programs, not medical schools. That is,
tho/e stuck with the new hours have already made it through medical school.

Did you read the featured article?

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mnm1
These residents can't even safely drive home after a 24-hour shift, but
they're perfectly fine to practice medicine on others. The "studies" say that,
so it must be true, right?

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droopyEyelids
> said the change will enhance patient safety because there will be fewer
> handoffs from doctor to doctor. It also said the longer shifts will improve
> the new doctors’ training by allowing them to follow their patients for more
> extended periods, especially in the critical hours after admission.

We really need the name of the human being who said that. That quote needs to
be attributed to an individual who has to take some sort of responsibility for
it.

------
kapauldo
The AMA is a cartel that has artificially constrained the supply of doctors to
keep incomes high. It is the most successful union in history.

------
SideburnsOfDoom
The phrase "allowed to" would imply that this is optional, that it is
something that they want. Is that really so?

~~~
carbocation
The first thing we care about is the patients. Most studies that have looked
at longer hours vs more handoffs have shown equipoise in terms of death and
serious adverse events. So, in that setting, most of us feel comfortable to
think about what we want for ourselves as trainees and educators.

From the perspective of a trainee, on the rotations where duty hours even
become a question, I was working 60-80 hour weeks. You can achieve that in a
number of ways. One way is to work 5-6 days per week of 12-14 hour shifts.
This sounds reasonable until you realize, a few months in, that you are at
work from 7a-7-9p (assuming you're working daytime shifts) 6 days a week. It's
monotonous and exhausting.

You can achieve the same by mixing some 24h days into the mix. During my
training, this could only happen starting in our second year and beyond.
Suddenly, I had several days with ample free time to buy groceries, do
laundry, think about the world around me.

Medical training is extremely long and time intensive. Partitioning time into
24 hour chunks can surprisingly be preferable when 80 hour weeks are the rule
(when safe for patients).

~~~
Asooka
But if you do 80 hour weeks and 24 hour shifts, then you will end up doing
Monday, Wednesday, Friday and Sunday, so you have two 24 hour shifts back to
back, resulting in a 48 hour shift? Is that correct? Or do you do 4 days one
week and 3 days the other? Do you get to nap during your shift?

~~~
carbocation
The rule is no more than 80 hours per week averaged over a 4 week period, so
some weeks you pull more, others less. Not every block requires 80 hours/week.
Generally though, 24h shifts are placed into your schedule ("call day"), and
other days you work a usual/shorter shift.

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unabridged
Instead of 1 doctor working 75 hrs, how about 5 doctors working 15 hrs? And
don't tell me there aren't enough candidates, the average acceptance rate for
med schools is about 7%. Also its possible that there are people that would
make great doctors but aren't in the top 10% of memorizing biology.

~~~
JshWright
Longer shifts reduce the numbers of times a patient is passed from one
provider to another. Reducing those "handoffs" is good for the patient (that
tends to be where things fall through the cracks).

~~~
unabridged
It doesn't have to be 15 hrs, it can be 30 hrs. You can have systems like all
patients covered by 3 doctors and only 1 of 3 handoff at a time.

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jason_slack
Wow, 24 hours is insane. I work 10 hour, overnight, shifts at an elderly care
facility and sometimes I have to pull a double or 1.5 shift due to call-ins.
I'm exhausted and I can barely drive home. My work doesn't compare to that of
an M.D.

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jimlawruk
Hopefully future AI can help alleviate the healthcare shortages we seem to be
facing.

~~~
lettergram
Or they can increase the number of people going through medical schools. The
AAMC understands the law(s) of supply and demand and doesn't want too many new
medical doctors, then they would get paid less.

For reference, the number of students graduating from medical school is
dropping:

[https://www.aamc.org/download/321526/data/factstableb1-2.pdf](https://www.aamc.org/download/321526/data/factstableb1-2.pdf)

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squidbot
Does anyone know if doctors on shifts like this are given ample breaks to
peruse polyphasic sleep? A 24-28 hour shift with 3-5 hours of polyphasic sleep
doesn't seem quite as bad as just staying awake for 24 hours+

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pasbesoin
Who is this serving? Because it certainly isn't serving patient health.

So, in that case, stop calling it "health care".

------
gdulli
And the only way that can go wrong is immediately.

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docthrowaway
So now they will be "allowed" to work the hours that they already do. I have
multiple resident physician friends and family members who routinely work 24+
hour shifts once a week, on top of 14-16 hour shifts daily yet if their time
sheet says more than 80 hours/week, they are instructed to correct it.

