16 Hours
| Wed Dec. 3, 2008 9:20 AM PST
16 HOURS....A new report has — once again — stated the obvious: it's insane to require doctors to work long shifts without sleep. And — once again — not everyone agrees:
The report, produced by the Institute of Medicine, an arm of the National Academies, recommended that medical residents ideally should work no longer than 16 consecutive hours, considerably less than the 30-hour shifts now allowed.
....Dr. Mark I. Langdorf, medical director of the emergency department at UC Irvine Medical Center and associate director of the residency program, called the recommendations "nuts."
"The problem here is balancing the need for patient safety, which I acknowledge, with the need to have the training in medicine be an apprenticeship," he said. "It sells the educational process short to make training so intermittent that you don't really get continuity."
"Continuity of care" has been the excuse for 30-hour shifts forever, but I've never seen a single person actually make a coherent case for objecting to a five-hour nap in the middle of a shift. They just chant continuity like a mantra and expect the rest of us to believe that 30 hours is some kind of talismanic number even though it really doesn't make any sense. Hell, I don't think I could even blog intelligibly after 30 hours, let alone make subtle and potentially life-saving diagnostic decisions. This may be an ancient practice, but so was bleeding patients until we figured out better. It's time to stop being idiots about this.
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Comments
Kevin, with all due respect I think this is the main reason your blog writing has stagnated. I frequently notice your posts gain nuance and sophistication into the late evening only to be replaced the next morning with a droll post about windows software.
I suggest a 72 hour blogothon with the spell checker turned off. Perhaps focusing on the health policy and the medical profession.
Imagine how good our air traffic controllers, train engineers, and crane operators would get if they had a similar training regimen.
BTW, if you see Langdorf today, kick the moron between the legs.
Submitted by Carl Nyberg (not verified) on Wed Dec. 3, 2008 9:42 AM PST.
It's hazing of residents.
Physicians are asked to give the best years of their lives 20s and early 30s to live a very demanding lifestyle.
This is done so that at the end of the process they are onboard with the idea that the world owes them big paychecks.
Older physicians know the system helps keep their pay high, so they fight reform.
I work in a seasonal industry and long hours are the norm. However, thirty hour shifts are nuts. I can say that having pulled a couple and my work is much less significant than that of an ER doc. I try to limit shifts to fourteen hours and that's tough to work day after day. Lack of sleep makes even smart people stoopid.
A full thirty hours, PLUS, of OJT for "Continuity of care", cause nothing says "patient safety" like a groggy red eyed intern desperately juggling a load of patients while the chief resident strokes his epeen about "When I was an intern, we never slept!"
Submitted by Annie (not verified) on Wed Dec. 3, 2008 10:05 AM PST.
Well, physicians don't write orders and make decisions solo. Professional nurses are charged by ethics and statute with assuring patent safety, and it's usually a nurse who catches the error (a near miss where the error doesn't reach the patent). However - the great majority (about 70% of those who are surveyed)nurses are also exposed to harassment, intimidation, threats and assaults by physicians, and that resulting intimidation results in nurses NOT taking action to adequately protect patients, and then "never events" happen. The bad stuff - wrong site surgery, medication overdoses or wrong medications administered, wrong treatments or no treatment, etc.
THe answer is to remove nurses and physicians from being employees, where they are controlled by non-professional employers, and transmogrify into self-governed professional practice groups (SGPPG), where the members contract directly to provide their respective professional services to groups of patients, groups of businesses' employees and dependents and patient care institutions' patients.
By combining nurses and physicians' numbers, the SGPPGs can increase their negotiating power, the members can s/elect their own leaders who are accountable to their colleagues and patients instead of to employers and external third parties, and practice autonomy and authority which has been usurped and abused by employers and third parties can finally be returned to the respective professionals so that they can control their work hours, work conditions, patient case loads and can get back the satisfaction of developing and nurturing real and authentic therapeutic relationships with patients. Another benefit is that when physicians and nurses collaborate to address patient care and health managment, they can dentify and capitalize on their differences to boraden their service reach and can use their overlap to deepen patient service provision with resulting improvement in targeted patient outcomes. They can also recruit university-based nursing and medical faculty into joint appointments and thus can mentor and recruit stellar students into the group practices, a la a Cleveland Clinic and Mayo Clinic model. This would bridge the nursing faculty salary gap in particular, and it could be used to grow a larger cadre of nursing faculty, who are now in critically short supply.
Having been a new graduate nurse immediately placed in charge of a medical teaching ward, I can't tell you how many times a bone tired intern "almost" made a mistake but didn't because "just a nurse" was there to protect him or her from doing patient harm. They learned, all right, but at what expense?
Creating safe work schedules which use the best research available to protect the health and wellbeing of night shift workers should be the sole standard by which to schedule all healthcare providers who interact directly with patents. Anything less is inviting preventable harm and preventable patient deaths. That's not acceptable by any measure.
Truck drivers are limited to no more than 11 hours in a row, at which point they must take 10 hours off.
They're also limited to 70 hours in any 8 day period, at which point they must take 34 hours off.
Actual regs here: http://tinyurl.com/6rqu86
Why do we require this for truck drivers, but not for doctors? Anybody got an answer that doesn't rely on the super-human capabilities of people who've gone to med school?
I think Carl Nyberg nailed it: it's hazing. And, as is the case with so many other forms of hazing, those who've successfully passed through it become emotionally committed to the idea of maintaining the institution as it currently exists.
Doctors tend to be a bit smarter than the average half-drunk fratboy, so they can manage a more cogent defense of hazing than normal. But it's still pretty weak stuff. It might be one thing if their rose-colored glasses were simply driving them to ship their kids off to some abysmal summer camp, but in this case the practice is actually endangering lives. It shouldn't be tolerated.
I Am Not (That Kind Of A) Doctor, but I do know a thing or two about organizations and processes. If you require staff to take 16+ hour shifts because you can't reliably hand off care to another person, that means your organization and its business processes suck. You should fix that, maybe.
This shouldn't be news to anyone in the medical field. Medicine is rampant with the "hero" model of organization, where it relies on specific kick-ass individuals to get anything done. From the outside, it looks like medical professionals are generally good at working in small teams, but don't respect the larger organization. Anything that inconveniences them personally but benefits the environment as a whole is a hard sell.
There's a nugget of truth to this "continuity" business--there's always a potential for mistakes at a "hand-off" point since you can't really hand off your brain and memories to someone else. But then again, you can't have one person working for 36-48 hours (the kind of continuity you'd need for a typical patient's hospital stay)
Obviously better communication methods and systems at a hand off would help, but from a human angle, why not make doctors work with a buddy or as a team? Let's say there are 2 people who "share" the job and each take 12 hour shifts. They'd become familiar with each other, and hand offs between them would be smoother than if you were handing off to someone you weren't as used to working with.
I'm a management engineer at a major academic medical center, so I know a little bit about this.
In practice, this new report doesn't change very much. It still allows an 80 hour work week and it's very, very rare for a resident to work more than 16 consecutive hours. Additionally, a good portion of that time is not spent delivering patient care. They spend some of the time in an "on call" room waiting and, depending on how advanced they are, much of it just shadowing faculty members and learning.
There are two crucial points to consider here. Most importantly, a BIG reason why residents are worked like dogs is because they have to balance the amount of training they receive with quality of life. Basically, the need to be a resident for X amount of hours to be prepared for independent practice and those hours can be distributed over a either a small number of years or a long number of years. If the residents worked 40 hour weeks all the time, it would tack on multiple years to the length of their residency, prolonging the already long process of medical education. This is desirable for neither the residents or the health care system.
Additionally, residents do provide valuable work in a teaching hospital. If their work week was reduced from 80 to 40 hours, hospitals would have to take on twice as many residents to perform the same amount of work. Or, they would have to hire in enough NPs and PAs to make up the differences at $100,000+/yr a pop. We did some back of the envelope math and figured that a 60 hour week would cost our institution a minimum of $10 million a year in additional labor costs, which is a large chunk of change and, in these economic times, would put us much deeper in the red than we already are since revenues would be unaffected.
It's really not as simple as doctors trying to haze residents. They need to be trained, they want to be done sooner rather than later, and the hospital needs their labor.
The 30-hour shift thing seems like hazing to me as well, but there is something else to consider.
Doctors are like soldiers in that both will have to perform their duties in the most extreme sorts of circumstances. Soldiers will have bullets and bombs whizzing by them. Doctors will have someone's liver in their hands and literally two seconds to make a life-or-death decision with a patient. One of the obvious ways to prepare folks for those kind of extreme conditions is to expose them to extreme conditions during their training. Special forces guys don't go through all that crap for the heck of it.
I'm not sure 30-hour shifts are the answer but you've got to do something to prepare doctors for when the crap hits the fan, because their crap and their fan is considerably different and more dynamic than most jobs.
Mike
Submitted by Annie (not verified) on Wed Dec. 3, 2008 10:30 AM PST.
@ ericblair:
That's an interesting observation. Perhaps part of that comes from physicians never having practiced in ethical and patient-focused organizations. I inherited a dysfunctional critical care unit where almost all of the physicians which ranged from trauma surg, pulmonary, oncology, anesthesiology, cardiology, gen surg to internal medicine and ID were unhappy and were not taking call for the unit reliably. Nurses were unhappy and turning over rapidly. There were patient safety issues all over the wazoozle.
I spent time in making walking rounds with every nurse and every physician every day. I went out to the waiting room and listened to families. I went to the ER and the OR and talked to the nurses caring for my unit's patients.
Then I invited them all into the unit to participate in problem solving, in which I got out of their way and just assured that the resources they needed were n place so they could all do what they do best.
Within just a few months, nursing positions were all filled with a wait list, physicians all showed up to meetings (even when food wasn't available - the true sign of commitment *g*)and participated, and unit morbidity and mortality rates declined significantly. However, senior hospital administration, instead of celebrating, instead acted threatened and they came after me in full force. Without my knowledge, the pres. of the medical staff, VP of medicine, chief of surg, chief of trauma, and acting chief of the ED all went to bat for me and the processes I had instituted. Administration still won, and I resigned since mine was a voice that was ineffective in advocating for the interests of the professional staff and patients. But with competent administrators, it can be done quickly and with demonstrable positive results in patient safety, desired patient outcomes and nurse and physician satisfaction. That's why I (and countless other nurses and physicians)was in the rat race in the first place.
Just consider what could be accomplished if only the unethical rat-f*ckers could be removed from the healthcare system equation.
With all due respect to the fine doctors I have met in the medical field, perhaps if the hours that they worked were sinificantly shorter, they wouldn't come across as such incredible bastards and jackasses. Moreover, perhaps if they were trained for a longer, less stressful period, they might become better healers.
I'm sure this idea comes across as truly repulsive to most of them. Most of them come across as repulsive to me
Cheers,
Alan Tomlinson
Zach:
Is it really "very, very rare" for a resident to work more than 16 consecutive hours?
I'm not in the medical field, so I don't know. But I do have two good friends who are both residents. And they have routinely worked 24- and 30-hour shifts. Sure, it's not every day, but it's often enough that I wouldn't call it "rare," let alone "very, very rare."
Do you think their experience is anomalous?
We should have every doctor in support of the 30 hour standard fly in a plane from LA to NY with a pilot that's been up for 24 hours*. If any of them object. They have to change their vote.
* Only the pilot knows there's a backup co-pilot that's well rested. No pilot would take a suicide mission like this.
MBunge: Doctors are like soldiers in that ...
Not even close. The extreme conditions that doctors have to deal with (rapidly making critical decisions) are best done by someone who has slept in the last day.
By contrast, soldiers may have to do without sleep because the enemy won't let them sleep. If attending physicians have to regularly go over a day without sleep, then there is a serious short staffing problem. That's a self-imposed problem, not one imposed by the enemy.
Moreover, in those very rare occasions when attending physicians might have to go 30+ hours without sleep (airliner crash, terror attack), they are, by virtue of their greater experience, more qualified than residents to work despite sleep deprivation. The phrase "I know this well enough to do it in my sleep" is not just a figure of speech, and only applies to experienced people.
Most importantly, soldiers train when they're not in contact with the enemy, so that they can perform better when they do meet the enemy. By contrast, residents train on real live people.
Truck drivers and airline pilots are also called on to make life critical decisions. Do you think it would be a good idea to have them during their first few years on the road or in the air operate while sleep deprived? Wouldn't that also be good training?
"A friend" once drove non stop 2,000 miles, with the help of little white pills. By the end, (about 36 hours) the lines on the highway were rippling up into the air, then settling back down. The brain needs sleep, or it goes into dream state while the body is still awake. I don't understand how a resident could possibly could count anything s/he did after 16 hours awake as "learning", never mind the fate of patients in their care.
Interns and residents are incredibly cheap labor, making around minimum wage if you break down their salary to an hourly rate, despite the vast majority carrying massive debt from their medical education. So why not get as many hours out of them as you can? As Zach said, why hire a PA at 100K when a resident with no union and few rights will work 2x the hours for half the money? Who cares if a few patients die, we saved 10 million bucks!!
If you've ever had a loved one in the hospital, you know that this continuity excuse is just that. My father had a heart attack last January and I lost track of all the people who gave him care just in the first 48 hours, never mind over the next four days. He got great care, but the only continuity we had was that we were in the same ICU the whole time. Better knee-jerk justifications for archaic and silly rules, please.
I once worked 130 hours in one week. Burn and Trauma. Most of it wasn't that bad, though, and I learned more and got tougher in that week than in my whole first year of residency. I have to admit it was good for my confidence. Now I know, no matter how challenging the patient or difficult the work environment, I can focus on the patient instead of worrying about myself--I know I'll get through it. This isn't a comment on the general practice, just my experience.
Submitted by Zak (not verified) on Wed Dec. 3, 2008 4:57 PM PST.
It's the money, stupid.
All this talk about "continuity" and "training" is a red herring. The fact is that hospitals use residents (my wife is one) as cheap labor, and without that cheap labor they would lose a ton of money. So, at least part of the solution has to incorporate better funding for healthcare in general.
House Whisperer: I once worked 130 hours in one week. ... I learned more and got tougher in that week than in my whole first year of residency. I have to admit it was good for my confidence.
Why don't you trade notes with Peter VE (4:40 above). His "friend" gained enormous confidence in his skills by driving 36 hours straight with no accidents. Want to know when he's going to be on the road again?
I am a specialist surgeon, and there is just no way for me to avoid working at night for emergencies. I take turns taking call with the other specialists in my town so that we don't get overworked, but there is still no physical way we won't have to eventually work all night after having worked all day.
When you limit doctors to 16-hour shifts, then who takes care of patients at night? I have been at hospitals where we literally had more sick patients than doctors who could take care of them all. People ended up waiting for long hours for needed care, but the critical patients were all cared for by having doctors staying late. Without that, there literally would have been no one to care for them. In some areas like emergency room doctors, or internal medicine or hospitalists, you can argue for increasing the number of doctors, but it doesn't work for every type of problem. You cannot always just get other doctors, or hire more doctors. They are not interchangeable. In some specialties there may be only 2,3 or maybe 5 doctors who can perform certain surgeries or treat certain diseases in an entire town of less than 250,000 people covering multiple hospitals. In smaller towns there might be 1. You can't just have a non-specialist be on call for those doctors, as they do not have the knowledge or training to treat the patients. So for many smaller specialties, including many surgical specialties, there are very few doctors in a given town. I know this is not the problem for major metropolitan areas, but it is a problem for much of the rest of America, and for many city hospitals in the metro areas where doctors prefer not to practice. So with only a few doctors to choose from, what do you do if one leaves town for work or vacation? What happens to the doctor who works a full day of clinic, sees an emergency patient at night, then has to work the next day? What if another emergency comes in? Other doctors can see the patient, but they often cannot diagnose it if it is outside their specialty, and they certainly cannot perform the specialized surgery that may be needed at once.
It is not just residents who occasionally work long hours. Doctors throughout their careers have to, because often there is no one else to do so. You cannot hire a super-specialized doctor such as a urologist or ophthalmologist or nephrologist to just sit around at night waiting for the occasional emergency, not working during the day in case they are needed at night. They have to see routine patients during the day in order to make a living, because 2 or 3 emergency patients a week at night just won't pay any bills, but someone needs to take care of them. Doctors now are often trying to limit their work days and spend more time at home with families, and work less strenuous hours. Sometimes it is very difficult to arrange, even when we try. Working late on call is a fact of life for a specialist. Dealing with problems late at night or with little sleep is unavoidable. And if they have to learn to do it, it is best to learn it during residencies when there is immediate supervision, and someone to watch and make sure the young doctor knows not to push too far and does not start making mistakes.
As for training in residencies, it takes a certain amount of time and a minimum number of patients to gain experience and knowledge in order to become a doctor who is qualified to be independent. By decreasing work hours, you are decreasing the amount of patients the doctor sees and the experience gained. Total training time is already a minimum of 11 years including college, and for some specialties may be as much as 16-18 . If these doctors are forced to go home and not do certain procedures or see rare patients when they come in, no matter what the hour, then they have to stay in training much longer to gain the necessary knowledge, experience and proficiency. You really do need to perform a certain number of surgeries before you get good enough at it to work unsupervised. This could extend the training of certain surgeons by an extra 3- 4 years at least. Would you want to work for more than 20-22 years for next to nothing? Or else we can keep the same number of years of training, but with less experience, fewer procedures, and turn out doctors who are less qualified.
I do think working the insane hours that doctors did in the past is not the right thing to do. They did it then for the same reason we do it now. There was that much work to go around per doctor, and some of that just needs to change. Some reasonable rules need to be in place. But 16 hours is not that long of a shift, and when you are out in private practice and a certain type of emergency comes in, one of the doctors who worked all day and will work all day again the next day is still going to have to come in and take care of that patient at night. Emergency room physicians and hospital doctors are not specialists, and just cannot take care of every type of patient no matter how you arrange their shifts. Someone else is going to have to come in and work late. I would prefer they learn that skill while young and under expert supervision by a teaching institution.
Hopefully these long hours will only be occasional and intermittent. If it is constant, then there ARE ways to change the organization. If they really are happening almost every day, then there are clearly ways to hire more doctors and they would still be busy and everyone could work less. For many doctors, however, it is only intermittent and random, but you still must be prepared for it. In many rural areas it is not possible to get enough doctors to work there already, so hiring more doctors at night to care for people is impossible when you already cannot hire enough doctors for the daytime. And in many small specialties there just aren't that many doctors available, period.
So who takes care of the patients at night then?
Vlad: if they have to learn to do it, it is best to learn it during residencies when there is immediate supervision, and someone to watch and make sure the young doctor knows not to push too far and does not start making mistakes.
I don't completely buy the "immediate supervision" argument. How immediate is immediate? If a doctor is literally standing over a resident's shoulder, then it would be easier for the doctor to do it himself. In the event of a late night emergency then the resident can get his training another time. It also doesn't jive with my late night teaching hospital experiences, when residents are about the only ones around. Specialty surgeon called at 3 AM for a critical case? Let the inexperienced guy practice another time.
I also don't buy the "best if you learn from the beginning to do it without sleep" argument. Doing something the first time is much harder than doing it the hundredth time. Do it while you're awake the first few times. After that your greater experience will better let you compensate for the inevitable thinking and skill degradation that comes from sleeplessness.
Total training time is already a minimum of 11 years including college, and for some specialties may be as much as 16-18 . If these doctors are forced to go home and not do certain procedures or see rare patients when they come in, no matter what the hour, then they have to stay in training much longer to gain the necessary knowledge, experience and proficiency. ... This could extend the training of certain surgeons by an extra 3- 4 years at least. Would you want to work for more than 20-22 years for next to nothing?
That's a systemic problem. Only in medicine does one go directly from apprentice (resident) to master craftsmen. While not generally as formal as in medicine, most professions have a journeyman period. Graduate from law school and you get a job paying actual money, even though it will be years before you learn enough to head a major case. Why should medicine be different? I certainly don't believe the accounting that says it costs $X/yr to train a resident, while ignoring the income from services they render. Are even senior residents supervised? Sure. And similarly junior lawyers are supervised by law firm partners. Yet the junior lawyers do actual work for which the firm is paid actual money.
I suspect that this may come from a time when medicine was less specialized and residencies were shorter. It was tolerable then, but nuts now.
P.S. I know I'm ignoring fellowships, but the point still applies.
After working on scheduling pediatric residents, some changes are absolutely necessary in the medical profession. First of all, there simply are not enough doctors. I know in the past that there were quotas on the number of students that entered Med School every year. This was apparently imposed by the AMA and other governing bodies. This has consequences in the type of person that gets to Med School. Some are excellent, many are good and some are assholes - far too many in that category. PreMeds should have a chance to get a life.
The pediatric residency programs simply wouldn't produce enough without MDs from foreign programs, both Americans that go to Caribbean and other medical schools and foreign-born doctors. Part of this problem is that primary care is held in much lower esteem here. The immigration of foreign-born MDs certainly has an effect on care here when communication becomes more difficult and it also drains many of the best and brightest from other countries that need to keep their docs, since most of them never return to practice in their native countries.
Residents in peds have widely varying schedules. On some one month rotations they work far too much, often going beyond their supposed limit of 80 hours in 7 days. About one third of the rotations are this way, about one third are about 50-60 hours and about one third are 49 hours or less. If there were some way to even this out, the situation could be better.
Comparing medicine in the US with the most advanced countries with universal health care: from what I remember France has about 50% more doctors per capita than the US, and far more of them are in primary care - peds, internal and family practice.
In summation, a significant part of the problem comes from the bottleneck at the entrance to medical education. One result of this is fewer residents to use in critical care rotations and more hours for those in those situations.
@ William Schaffer: It's not just that primary care is held in lower esteem, it's that there is less money in it in the long run. When the average med student will graduate with 150k debt (and many, many more will graduate with well over 200k in debt) they look at the quickest way to pay off those loans. Until there is massive reform that pays a family practice doc something close to the orthopedic surgeon or the radiologist, there will always be a massive reliance on FMGs to fill spots except at the top of the top programs.
I'm in the last year of my medical residency. As I'm writing this comment, I've just come off one of the thirty-hour shifts that Kevin mentioned.
The system I am part of is certainly antiquated. It's an undeniable fact, however, that it has prepared me for the long hours, complicated cases, and sticky family conferences that are a central feature of medical practice in this country.
The system should be reformed. I have no doubts about that, and the arguments against reform betray a certain psychological derangement on the part of those making them. But the frequently forgotten counterpoint is that America, despite the horrible system in place for providing and paying for healthcare, actually does an excellent job of educating physicians. I don't think a single colleague of mine practicing in Europe would disagree with that assessment.
It's worth keeping in mind while we reform the system over the next couple years.
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