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.
2. She's also boarded in internal medicine, where she did have to do 30 hour shifts. They are terrible for patients and physicians, and I've been in heated arguments with physicians because I think the primary reason they exist is as hazing.
3. Handoffs are a legit problem; much more in other fields than in the ED. (Though handoffs do exist in the ED). It is a balancing act for that reason, though physicians could do a lot better with the handoff process IMO.
4. http://mef.med.ufl.edu/files/2010/01/Resident-and-Attending-... :
> Handoffs, the transfer of patient care from one health care provider to another, are known to be vulnerable to communication failures8 and have been called “remarkably haphazard.”
> When looking specifically at malpractice cases with communication breakdowns, 43% involved handoffs.
5. It's my belief that patient-centric design and communication could eliminate nearly all of these issues while reducing the need for long shifts, but there's a big [evidence needed] tag on that
A notepad app probably wouldn't cut it, but is there any way to move the complex thoughts in a doctors mind into a database somehow?
I think doctors focus on, and are very good at, doctoring. A little more focus on process and the totality of the hospital experience could bring big gains relatively quickly.
That's just an outside opinion though, my wife would probably disagree with me.
She recovered quickly so she was released from ER to observation for 48 hours. In those 48 hours we would see new doctors and nurses every 8 hours, explain everything again, so they wouldn't miss any details from the history, and every now and then a doctor would come up with a new theory and order studies without first consluting with a specialist in that area.
One of this theories was epilepsy, after that we went to see a neuropediatric and dismissed the theory inmediatly, even before seeing the study.
All of this was in a stable condition, I can't imagine going through the same in critical condition. So, altough I think 30 hour shifts are excesive, I can understand why long shifts are important.
One of the biggest lessons we took away from the whole experience was the need to be your own medical advocate (understand the health issues, pay attention to what doctors tell you, and don't be afraid to ask for clarification or challenge them if they say something that contradicts other information from a reputable source) - doctors work long hours and see many patients - it's not really surprising that they make mistakes and may miss critical information when scanning similar data sets hour after hour. Unfortunately for patients can be serious consequences to these errors.
(I hope your daughter is doing ok now!)
On rounds, a doc might only see each patient every hour or two... even longer for specialists.
ER docs also work some shorter shifts. So in a week he might work one 24 or 30 hour shift, and one or two 8-hour shifts. The shorter shifts provide arms and legs for simple cases, and the longer shifts provide continuity for more serious cases. The docs take turns holding down the long shift.
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.
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.
- Always have 2 doctors for everything
- Stagger/overlap the shifts
Like, how many people are in the care of an ER for 10 hour stretches in a given week.
Why is that not an acceptable solution, outside of economics?
Who wants to pull 30 hour shifts?
That is, if the government allows it to be used in consumer products. It would make a potent military weapon. Probably more potent than any military weapon invented so far.
Meanwhile, we're discussing the world that exists.
It is certain. 100% certain. It will be simpler than the brain and way more powerful.
>>no timetable certainly will make such a thing irrelevant.
Yeah, not sure when this will happen. But it will happen. It'll happen within my lifetime.
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.
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.
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) 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.
- 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...) 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?
How does this work out in the long term?
In the places I've seen that (not medical). It stops after a while because either the rhythm got back to normal or people burned out.
As for burnout, alcoholism is relatively high among many medical specialties: https://www.sciencedaily.com/releases/2016/03/160314111353.h...
Of course, it's a different story if she will be in a more sane line of work, such as hospitalist, ER doc, etc.
Because under normal circumstances, a competently run hospital should be able to function with normal 8-hour shifts. If that's not possible, then management fucked up. Accepting these kind of hours as standard is completely unreasonable and dangerous, especially in hospital, where lives depend people being awake enough to do their job safely. People responsible for that should not merely be fired, but locked up.
>Medicare already funds a bulk of the residency training in this country -- to the tune of about $9.5 billion a year. But its support was capped by Congress in the Budget Control Act of 1997.
Most doctors don't work for the hospital. That's one of the many reasons behind the strong opposition to Obamacare the creation and consolidation of regional medical systems is making more doctors salaries employees and reduces their bargaining power.
In my case, I suffered from this issue after a back surgery when some dumbass hospitalist read my chart wrong and told the nurse to cut off pain medication 10 hours after a spinal fusion. I asked the nurse for meds after she woke me up at 3 AM (to take my blood pressure and ask if my birthday had changed) and she refused and essentially accused me of shopping for narcotics.
When my surgeon checked in on me at the start of his day (5AM), he was shocked and got things fixed.
But couldn't this also be explained by said person lacking enough sleep?
Er, why? This reeks of a pretty serious administrative fuck-up.
When my wife was having our baby, the nurses had to log into three different systems -- an OBstetrics system, the hospitals charting/EMR and the pharmaceutical system. That meant going through the ritual 3 times.
A doctor can't necessarily predict how much time a patient will need. If a doc is on an 8-hour shift (hypothetical; I doubt any docs are so lucky!), and gets a new patient at the 6 hour mark, it might not be known if the patient will only be in the hospital for an hour, which would be fine, or 4 hours, which would push the doc to 10 hours.
As the argument goes, that patient is safer staying with the doc into his/her 10th hour on the job, versus being transferred to a different, fresher doctor midway through. I think there's enough truth there for it to be persuasive, but 1) there are limits to how effective a doctor is going to be after a certain amount of time, and the benefits of patient continuity must start dropping as the doctor has been working longer, and 2) there seems to be little attention paid to improving the process of handing a patient off between two doctors, which could further reduce problems related to lack of continuity to the point where a doctor who has been working 10 hours will cause more bad outcomes than shifting patients to fresher doctors would.
But that's a big part of the problem already. It shouldn't be luck to have an 8 hour shift, it should be standard. And of course there may be times when circumstances demand you deviate from that standard, but if you start with 12 hour shifts, you already start wrong, and it can only get worse.
Residency, by not granting you those things that people normally take for granted, helps you appreciate them!
All women deal with it differently, but most are able to function within their normal bounds until at least the six or seventh month.
> Writing this comment makes me realize how painful it feels at times that her medical training runs our lives.
smh. "freezing eggs" is not a trivial solution.
If you don't have the time to have sex and give birth, you sure as hell don't have time to go through IVF retrieval cycles!
We need to start addressing the leading cause of medical accidents - physicians/nurses sleep deprivation.
Nursing in many states is challenged by unsafely high patient:staff ratios, excessive documentation requirements (on extremely slow user interfaces), and the need to vigorously double-check physician's orders (dangerous drug interactions, over-dosages, etc).
medical residents will routinely do back to back 24 hour shifts with no sleep and even the ICU attendings will do a week of every other day 24 hour shifts.
The 16 hour rule only applies to interns. Once you reach second year the rule is 80 hours a week averaged over four weeks. This means that 100 hour weeks still do happen.
Is weed a kind of tea, or is that an energy bar?
Next you're going to be blaming the patients.
Also, I work 7 days in a row and then have 7 days off, which I absolutely love. I have the option of working 5-days every week and having weekends off, but I prefer my current schedule.
I think I'm pretty well-paid, but are there better/easier ways to make money? Yes, of course. My college roommate probably makes more than me and my understanding is that he just sits in meetings and adjusts Excel spreadsheets all day managing someone else's money. But hey, whatever. I could work at night instead of the day, it would be easier (no discharges), and I would make over 430k. But I don't want to do that. Instead, I work with a residency program and get to teach, which is very rewarding.
I think overall it's just a matter of perspective and expectations.
They explicitly said 17 hours was rare.
But yes, to agree with the sibling comment, I'd prefer to never have any doctor in any hospital seeing a patient after they have been working for 17 or more straight hours.
I hear about doctors like you, but I have never experienced someone like it in real life.
Maybe one day.
My hunch is that when a plane crashes, everyone freaks because planes aren't supposed to crash. When someone dies at a hospital nobody notices because people die at hospitals all the time.
Is this problem US specific, or global? And, isn't the real problem a scarcity of qualified doctors? Which, if people follow your advice, becomes worse?
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.
2) Like everywhere else. Do your hours and leave. If the business fails, too bad for it.
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.
Aren't you just refering to the 20-year freeze on the number of medicare-financed residents? I believe the number of residents is still increasing through other funding. Or is there some other way to square your statement with this?:
> Medical school seniors scored a record number of available first-year slots in this year’s Main Residency Match... Continuing a 4-year growth trend, the number of available post-graduate year 1 (PGY-1) positions rose to 27,860 in 2016, 567 more spots than in 2015, and a record 18,668 U.S. allopathic medical school seniors registered for the match, 221 more than in 2015, according to data from the National Resident Matching Program (NRMP). Family medicine residency programs offered 3,238 positions in 2016, up from 3,195 in the 2015 match. Internal medicine experienced similar increases, with residency programs offering 7,024 positions this year, up from 6,770 positions in 2015.
I'm at a private (but good) medical school and this is definitely a problem. My tuition (not including living expenses) is about $50,000 per year. And to be honest, there isn't a huge difference in tuition between most private and public medical schools. I'm from NYS, which does a pretty good job subsidizing its state schools. When I was applying to medical school, the in-state price was around $35,000 per year. However, just over the border in Pennsylvania the price at Pitt (which is public) was around $48,000 per year, for out of state students, and maybe 40 or 42k for in state students.
I went to an in state school for undergrad, and I'm very fortunate to have no debt from that. However, many of my classmates who went to good private undergrad schools (Ivy league etc) will have (a lot) of debt from both undergrad and med school. They literally have no choice - they need to go into a high paying specialty if they ever want to pay their loans off.
There is a "shortage" of doctors and crazy hours in countries with free education, no student loan system and insurance is ensured by the country for all citizens.
So, no, these issues are not the whole story (which doesn't mean they are not issues).
Next time you read that a surgeon left one of his/her tools inside a patient, now you know why.
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.
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.
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.
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.
Also, I am not convinced that the study that found there's no difference in outcomes means what your overseeing board claims it means. As mentioned in the article, they have not measured the performance of individual workerd, but of the hospital as a whole. Most likely it just means that whoever happens to be better rested in the team is catching (and covering up) the fuckups of the ones that are most tired.
People fought and died for an 8 hour workday, and here the AMA and hospitals are shitting all over it, putting everyone involved at risk. Should we bring back child labor while we're at it?
1) Handoff being done at the end of a long shift, so the doctors handing off their patients are tired, sick of working, and desperate to go home
2) Handoffs being interrupted by sick patients (understandably so) - I was once in a handoff that was abandoned half way through because of a cardiac arrest that half the team had to run off to
3) Rubbish handover systems - most hospitals use hand written notes on scraps of paper carried round by doctors; these can be lost, misread, or accidentally forgotten. There are some technological solutions being developed, but few hospitals have employed them so far
There are far more variables involved in successful medical care but the disparity in failure rates is just too large for me to believe that the idea of QA/QC in the healthcare system is anything more than an afterthought.
 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
Key finding: "In summary, the literature still does not definitively tell us whether limiting duty hours improves patient safety."
As an analogy, imagine reducing your cheeseburger intake from 60 per week to 40 per week: it probably won't have a huge impact on physical fitness.
The hand-off issue is also weird because it's at least theoretically improvable, whereas there's no real way (barring go-pills) to reduce sleep-related issues.
Neither one of these schedules is really "reduced" compared to any sort of typical level: they're both ~80 hrs/week (and probably more).
From the paper:
"Programs assigned to the flexible-policy (intervention) group were required to adhere to ACGME duty-hour requirements of limiting work to 80 hours per week, 1 day off in 7 days, and on-call duty no more frequently than every third night, but they were granted a waiver by the ACGME to waive four duty-hour requirements (from the 2003 and 2011 reforms) concerning maximum shift length and minimum time off between shifts (to facilitate continuity of care) (Table 1)"
Most doctors become doctors either as a childhood dream or to fulfill the expectations of others. Lots of pressure at an early age - and it only intensifies from there. Getting the grades, pre-med maybe, certainly biochem, then med school.
Residency is the home stretch to a lifelong commitment, feet don't fail me know, brass ring almost within reach...
Maybe it would be 'better' if that wasn't the case, but it's simply what is.
I agree that not all doctors are like that, but saying that all doctors are what you are describing is false and insulting.
When you have to spend a whole day searching for a terrible doctor in your network, then take a day off only to have said by terrible doctor, "How can I help you." I rage so hard. You aren't helping me, I am your client, now lets get his terrible experience over with.
Also, when you are told you whole life to get your wisdom teeth out only to have part of your jaw suffer from paresthesia for the rest of your life, it makes me wonder why bother.
Death honestly feels like a better option sometimes than dealing with anything in the medical industry
(Not saying startup culture is good in that regard. Just saying it has less of a life-or-death impact on others.)
The same treatment for doctors won't be a bad idea.
There's some additional rules about how many hours can accumulate over a certain period of days (the period is rolling, it doesn't reset).
Who know, India or China might have a surplus of doctors too.
Or maybe that's the kind of problem that telemedicine will solve.
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).
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.
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.
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.
Oh wait, that doesn't make the insurance companies as much money, so that's a bad idea.
Unless you're a field medic in the army or whatever. No thanks.
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.
We also have workplace drug and alcohol testing and there are requirements around disclosing any prescription medication you are on.
Operating heavy machinery is no joke but then again neither is being a doctor.
That would get penny pinching administrators to stop overworking their medical staff.
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.
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...
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.
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?
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.
I remember reading this somewhere, but can't remember where.
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.
It seems targeted towards nurses, but could be applicable to physicians as well.
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.
It's important that the people responsible for our health are well rested and well-rewarded.
Never say never