No Doctor Should Work 30 Hours Straight with No Sleep | Hacker News Reader

No Doctor Should Work 30 Hours Straight with No Sleep

theatlantic.com

324 pointsBDGC197 comments

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.

Yeah there is lots of literature on this issue and some ongoing studies trying to determine how to reduce medical error during the hand-off. For example: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD...

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.

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.

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?

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.

I think that is how it works, but with longer periods of time. Instead of an 8 hour shift with overlap of 2, it's a 24 to 30 hour shift with overlap of 8 to 10.

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.

I experienced this twice, when my baby daughter was in observation after two episodes a week apart.

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.

My pregnant wife was bounced between clinics a few years back and subsequently spent several weeks in a hospital bed. We had the same experience of having to repeat the story every shift change (at least for the first week) and ultimately became incredibly frustrated with doctors doing rounds who would directly contradict the information provided by other medical staff or what was written in her chart.

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!)

Yes, sorry for the cliffhanger, it turned out to be allergy to cow's milk protein (most probably as it's difficult to confirm). She was 5 month's old, and the treatment was the withdrawal of cow's milk for a year, then she was able to consume it normally.

Did he have statistics on the typical amount of time he spent caring for patients?

Like, how many people are in the care of an ER for 10 hour stretches in a given week.

1. That's weird, what the heck ED do they do 30 hour shifts in? Non-US? My wife is an ED physician in the US and that does not ever happen in any ED she's been in.

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.”

and

> 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

What, with your knowledge, could be done with technology to solve this problem of handoff?

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 don't know what the exact process would be, but I think that the key would be to focus on process. Start treating each patient mishap like the FAA treats every airline mishap, take steps to ensure that each doesn't happen in the same way again, and I think you could improve things a great deal.

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.

I doubt it would scale. The FAA regulates one thing (flying planes) and there still are a ton of checklists and regulations, presumably if you tried the same thing with medicine it would collapse under it's own weight with all the different edge cases

General AI will make all of this irrelevant. A General AI doctor never needs to sleep and would never forget anything relevant.

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.

Devices of uncertain possibility and certainly no timetable certainly will make such a thing irrelevant.

Meanwhile, we're discussing the world that exists.

>>Devices of uncertain possibility

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.

overlap the shifts by 2 hours.

Why is that not an acceptable solution, outside of economics?

Who wants to start the AM 2 hours earlier or finish the night 2 hours later?

people who get paid really well and don't want to kill other people?

Who wants to pull 30 hour shifts?

My brother just finished his residency. His opinion is they do it for cultural reasons and it's a terrible thing. I'm curious what percentage of doctors think the way they do it is a good idea.

Sounds like there's a need for pair-doctoring.

- Always have 2 doctors for everything

- Stagger/overlap the shifts

- double the cost of already expensive medical care

No, because 100% of your medical expenses surely don't go to payroll for doctors' salaries.

If handoffs were really the reason, a few seconds thought suggests ways to deal with that. For example, assign fewer patients per doctor, and let the doctor grab short bursts of sleep in between seeing patients. Yet somehow, I feel confident in predicting that if you start suggesting those solutions to the authorities, you'll find they are utterly uninterested.

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...). 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.

But nurses are no different.

We need to start addressing the leading cause of medical accidents - physicians/nurses sleep deprivation.

they are completely different. Where I work in cali nurses are full time working 3 or 4 twelve hour shifts a week. Overtime optional and highly compensated.

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.

I was forced to do 100 hours a week for a company that had a sadistic culture of over work, you never get anything done, under those kind of hours unless you're doing stimulant drugs your brain just shuts down. I wonder how many doctors are also drug addicts just to make this kind of work intensity physically possible even?

I'm surrounded by doctors and I don't know any that abuse drugs, other than alcohol and maybe weed. I believe they are just so busy and so overworked that they are constantly moving around / doing paperwork. The demands of the job keep them going.

You must have never met psychiatrists then; never seen otherpeople take drug usage so lightly.

You don't know any doctors that use drugs, but you do know of some that do weed.

I'm laughing...

Is weed a kind of tea, or is that an energy bar?

He said abuse, not use.

In my experience, you are absolutely correct. I dated a nurse for a while and later married a doctor, and it was completely different. Physician training is absolutely, terrifyingly demanding.

I know of no nurses that work this schedule, even voluntarily (overtime, swaps).

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).

I do. Nurse midwives, and other mid-level providers are often subject to similar hours and work schedules.

A friend of mine had to become his wife's driver, because after working double shifts across two hospitals, she could barely keep her eyes open.

There you have it: she was working agency at a secondary hospital. That is due to a decision of her agency or herself; it has nothing to do with hospital administration or nursing in general.

Many hospitals are based across multiple locations, so it's not necessarily agency work.

I used to work in a hospital laundry (where we were understaffed, of course), and I spent my lunch hour talking with nurses. Many were actually NAs and had to work second shifts at different hospitals to make a living wage. So even if the hospitals are reporting normal shifts, the personnel are actually working up to twice as many hours.

Nurses cannot leave until relieved. My mom routinely had 12 hour shifts extended when she worked in NYC.

And at considerably worse pay with no overtime, asumming nursing is the same everywhere.

No, we should direct all the hate at lawyers asking for more than 250k for malpractice

So lawyers demanding 250k for malpractice is what's causing malpractice? OK...

Next you're going to be blaming the patients.

Defensive medicine is incredibly expensive and produces worse results, so while I wouldn't blame lawyers solely. there are much better ways of doing things imho. New Zealand's Accident Compensation scheme is one way - far from perfect, but far better.

Doctor amputates the wrong leg. How much in compensation is that worth in your mind? There should never be an award more than 250k? I disagree. My wife is a psychiatrist that works in patient. She got a transfer from another hospital who was on 32 drugs. That's clear negligence and should be a malpractice suit but no lawyer will take the case. It's not clear cut enogh. In recent years the pendulum has swung in the other direction. There isn't enough access to the court system for patients wronged by the medical community.

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.

If she is pursuing a demanding specialty, consider having your kids while she's a resident; I've known a few people that did it and while it's hard, it can be the lesser of evils. Fellowship is just as hard - maybe even harder - than residency, and when you're practicing she likely won't be eligible for maternity leave initially and can face pressure from the group to keep on working (otherwise someone else might end up having those brutal all-weekend calls back-to-back... not a good way for the new person to make themselves popular with their group).

Of course, it's a different story if she will be in a more sane line of work, such as hospitalist, ER doc, etc.

She's sub-specializing in intensive care, unfortunately. We've discussed having children toward the end of fellowship for the reasons you state. It's a tough decision for us because I'll likely carry the brunt of the parental workload, but we also depend on my income for living expenses and loan repayment.

We waited until my wife was done with residency and fellowship, and it has worked out well for us. We have our second child on the way shortly, feel free to message me if I can help in any way.

My wife's in her final year of residency, so I know what you mean. I work from home in part to be around when she's off, but the demands of the lifestyle are especially clear when you see neighbors pulling into driveways at 5:30pm, friends enjoying a full weekend, vacations, and having several days off around the holidays.

Residency, by not granting you those things that people normally take for granted, helps you appreciate them!

I'm in the exact same boat. I work remotely and even though I've had a few job offers, one last night actually, I feel it's more important to have my flexibility here so I can see my wife when she's home. I find it especially helpful when she's on night shifts when her at-home time is <8 hours; I can move my day around hers to make meals and help wake her with coffee.

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.

> 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.

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.

Well I can't say for sure about post-residency, but during the programs the shift scheduling was consistent all four years (some months you work the day 12-hour shift, other months you work the night 12-hour shift). The only thing that changed was during 3rd and 4th year, the call schedule was a bit more relaxed (after all they have to prep for another round of board exams).

As for burnout, alcoholism is relatively high among many medical specialties: https://www.sciencedaily.com/releases/2016/03/160314111353.h...

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) 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.

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...) 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?

A family member is the administrative director of a demanding internal medicine residency program here in Canada, and I can say from experience nearly all the residents take maternity or paternity leave during their residency. The program is incredibly accommodating to new parents, partially driven by Canada's strong parental leave laws, but mostly because they recognize doctors are people too. From what I hear US based programs haven't come to the same realization.

If you're worried about the effects of your age on your child, why not freeze her eggs and your sperm?

yeah, why not? nbd.

smh. "freezing eggs" is not a trivial solution.

https://www.theguardian.com/commentisfree/2015/oct/21/women-...

IVF is no walk in the park.

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!

So what happened? Was there a massive disaster that created an overwhelming flood of patients, that everybody needs to work overtime?

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.

The AMA enforces an arbitrary limit on the number of medical school spots and therefore doctors in the US. They create a shortage of doctors in order to keep doctors' pay high.

I was unaware of the medical school cap, but there is a residency cap set by congress in 1997 that also aggravates the issue: http://www.medpagetoday.com/PublicHealthPolicy/MedicalEducat...

>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.

The medical system has billions of free cash flow. Big hospitals could fund lots more residency spots.

Exactly. The "limited federal funding" canard is a brazen excuse by the AMA to deflect attention from their own role, and to lobby for more free money. No one ever argues against more free money for themselves.

Can the AMA prevent hospitals from creating residencies with their own funds? I'm ignorant about this, but at first blush it seems like doctors must be a top expense and most companies enjoy employing workers with cheap wages and long hours. Hospitals should be happy to hire as many residents as possible (even if they got 60 hours from them instead of 100). What am I missing?

They can encourage their members to avoid those hospitals.

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.

My understanding is that their control to the end of limiting the number of doctors is exerted way back in the part where they have to approve new medical school seats.

So they're basically DeBeers for doctors?

A doctor friend of mine claims that the benefits of doctor-patient continuity outweigh any downsides of sleep deprivation. That sounded like a rationalization or cop-out to me, though. I can't imagine how that could be true, or that they're aren't other ways to solve the continuity problem that don't involve zombie doctors.

Even then, finishing with your current patient and then going home should still not lead to regular 12 hour shifts.

Different patients need differing amount of times. We're not talking about doctors who work in private practice and have business hours. We're talking about doctors who work in hospitals and work prearranged shifts and have on-call time.

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.

> If a doc is on an 8-hour shift (hypothetical; I doubt any docs are so lucky!)

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.

I think we're deviating from the point I was trying to address. The length of the shift isn't relevant, what's relevant is that different patients need different amount of times, and can arrive at any time during a doctor's shift. Based on both of those variables, a single patient can easily require care beyond a single doctor's shift, so saying "getting done with your current patient and then leaving should never lead to a 12-hour shift" doesn't really make sense, since that "current patient" could have arrived during hour 6 of your shift and then required a 6 hours of attention before being discharged. If you believe that doctor-patient continuity is more important than a doctor's rest, then you can easily justify any shift length up to the point where the doctor falls over.

I would agree. In extended hospital sessions that my wife and I have experienced, having continuity was huge, especially as the nurses swap out every 8-12 hours.

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.

> some dumbass hospitalist read my chart wrong

But couldn't this also be explained by said person lacking enough sleep?

> and ask if my birthday had changed

Er, why? This reeks of a pretty serious administrative fuck-up.

Around here, every interaction with a hospital employee involves a recitation of your birthdate, allergy status and other crap.

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.

Why can't you have children? Would it completely throw her off her eventual completion of her residency or just delay it?

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.

s/runs/ruins/?

Post-birth is a consideration as well. Assuming the parents intend to breast-feed, the child will need the mother every hour or two for several months after birth. After a few month the interval widens, but not by much -- at least, not by enough to allow the mother to take on anywhere near a regular doctor's workload. So it's not just the last few months of pregnancy that are a concern.

I'm curious why so many people still put up with it?

I'm a practicing hospitalist and I love it. I spend time on the hospital floor, time in the ED, and time covering patients in the ICU. Yeah, some days suck (I occasionally have to stay from 7 AM to past midnight, though that is quite rare), but overall I can't imagine doing anything else.

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.

Sounds like you really enjoy what you do!

I hear about doctors like you, but I have never experienced someone like it in real life.

Maybe one day.

Even if there are people like yourself who actually want to work 17 hour days for 7 days in a row (!), shouldn't we as patients be able to have doctors who are not allowed to do that insanity? Medical error is the #3 cause of death in the US. It seems entirely irresponsible to take someone's life into your hands without proper rest.

work 17 hour days for 7 days in a row (!)

They explicitly said 17 hours was rare.

I don't really care how rare it is; I never want to be treated by someone who's been going for more than 8 hours, much less someone who's been going for 17.

Ah, I probably misread the comment a bit. I read it as working 7am to past midnight is rare, making 7am to midnight (or just before) normal. But you're probably right in that what was meant was that there are other, more sane working hours (not defined in the comment) that are the normal conditions.

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'm usually in around 0800-0830 and out by 1700-1800

I always wondered why the public puts up with it. Aviation is always provided as a contrast to the medical community: pilots have legally-mandated sleep requirements.

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.

If the plane crashes, the pilot has a good chance of dying too, if the doctor makes a mistake, not so much.

Air traffic controller then. I hope they have regulated hours in the USA...

> The culture of medicine, at least at the physician level, is completely insane

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?

Thanks for writing that. I can't remember exactly the process we went through, but I remember your post being a significant part of the information pushing my wife from med school to PA school, a decision we're quite happy about.

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.

1) It seems pretty bad in France too, judging from the few friends I have in medicine.

2) Like everywhere else. Do your hours and leave. If the business fails, too bad for it.

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...

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.

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.

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.

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://study.com/hospital_management_career.html

I suggest you talk to some older doctors. If you did you'd discover that these insane schedules of work and training have been standard since before either of your parents were born.

The cost of education isn't a obstacle to people getting into medicine, except indirectly by slowing down the opening of new medical schools or expansion of existing ones--otherwise we'd be seeing lots of open spots in and reduce competition for admission to medical schools, which certainly isn't the case. Moreover, new medical schools with a total of 1000+ seats have opened in the past few years. The real bottleneck is in the number of residency slots, which hasn't changed in 20 years.

> The real bottleneck is in the number of residency slots, which hasn't changed in 20 years.

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.

http://www.mdedge.com/internalmedicinenews/article/107413/pr...

> 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.

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).

>Many med students today feel that they can't become GPs because they simply won't make enough to pay back their student loans.

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.

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.

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.

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.

Working over 80 hours in a 7 day period is just insane in and of itself, unless there is a major crisis you shouldn't be working more than 40hrs a week.

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?

There are basically no children with enough experience to be doctors.

https://en.wikipedia.org/wiki/Doogie_Howser,_M.D.

Your counter example is a fictiona character? Or is this one of those joke things I keep hearing about?

Yes, it's one of those 'joke' things. Stay cool :)

That's even worse, you know. Not only you are working people to the brink of exahustion. You are failing to cull the idiots in your midst and then work those idiots to the brink of exahustion. What could possibly go wrong.

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.

> 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.

And sleep deprivation is a well-known torture technique.

The kind of doctors who are working 30 hours straight probably have a degree of difficulty level in what they're doing approaching the drunken monkey.

> 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.

Uh, why would residents report dissatisfaction when it would hurt their opportunities down the road? Would you have? I don't think so. I don't think you are being skeptical enough about these "studies".

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).

Who is this they?

Here is a bit of survey on the topic from April of 2013: https://psnet.ahrq.gov/perspectives/perspective/140/are-resi...

Key finding: "In summary, the literature still does not definitively tell us whether limiting duty hours improves patient safety."

I would argue that the literature is basically worthless here, because they're mostly looking at modulations around an absolutely ridiculous baseline. The 2003 changes dropped hours DOWN to 80/week and 16 or 28 per shift.

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.

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...

[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

The article is here: http://unmhospitalist.pbworks.com/w/file/fetch/65758972/desa...

This study [0] concluded that reduced duty hours for surgical residents actually had no significant difference in patient outcomes.

[0] http://www.nejm.org/doi/full/10.1056/NEJMoa1515724#t=abstrac...

That's not really what that study says. The paper finds no difference between a "flexible" schedule and the standard duty-hour one.

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)"

I wonder if they could work in a napping system that compensates for the lost sleep. Several 45 minutes naps can do a lot if they are working 30 hours straight.

There are certainly handoff errors, but the vast majority of these can be avoided with a well structured handoff with safety-checks built in. The problems that make handoff bad include:

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

Proposal: Have doctors always work in pairs like we do when pair programming. The shifts of each partner consists of 8 hours but are shifted by half a phase. This way the maximum time of sleep deprivation is 4 hours and the handoff is also a process that takes 4 hours giving maximum information transfer and always a fresh mind to catch errors.

We don't have enough doctors to do that.

By design.

Or doctor/nurse practitioner pairs, since training and paying a NP is far cheaper.

Failed handoffs are a process issue and working doctors and nurses harder is just a bandaid on a broken process. I'm viewing this from a manufacturing quality system perspective and while manufacturing a product is far different from treating a patient in a hospital, at the core they are both processes.

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.

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.

It's 11 out of 14 hours, then a 10 hour break.

https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Dri...

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).

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

Yes, and preventing health problems by preventing medical errors would go a long way towards easing up the demand for medical care.

So you want to bring up the problem that over medication causes...

I am not sure what the point of your cryptic reply is, but as someone who has gotten off all medication for my condition, I have no problem saying that there is certainly room for improvement in that regard.

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.

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?

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.

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).

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

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.

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.

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.

Perhaps the US health care system should be focusing more on preventative care. I hear that reduces demand for doctors.

Oh wait, that doesn't make the insurance companies as much money, so that's a bad idea.

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.

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

Especially in the US with the Affordable Care Act.

What did ACA change about reimbursement?

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-...

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.

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...

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.

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?

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.

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

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

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

Because nothing bad enough has happened yet.

No: https://en.wikipedia.org/wiki/Libby_Zion_Law

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

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.

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

Cocaine abuse was rampant around the turn of the 20th century, since it was used as an anesthetic.

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.

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.

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.

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.... :)

Has anyone tried this service?

http://circadienhealth.pagedemo.co/

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

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.

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

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.

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

Never say never

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

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.

Even though I've suggested other motives in play elsewhere, you are probably on to something.

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...

A very soldier-worthy attitude to be admired.

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

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.

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

Sounds a little like startup culture. If you don't work 80 hours per week you are not a real startup.

Most startup employees aren't in a position to accidentally kill someone due to sleep deprivation, though.

(Not saying startup culture is good in that regard. Just saying it has less of a life-or-death impact on others.)

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.

Exactly. And it's not just airline pilots. Truck drivers have hours of service rules, too. So do railroad engineers.

I work in a heavy industry in Australia. There is a 16 hour shift limit - after which you are required to take an 8 hour break before you are able to operate any heavy machinery again.

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.

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.

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.

Wouldn't blame them!

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

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.

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