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

It's not uncommon for EMS workers to work shifts > 24 hours. That includes companies where you aren't at a specific station, but the crew is "posted" with their vehicle somewhere in the service area (gas station parking lot, etc...).

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

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

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

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

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

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

And they're probably, still, making worse decisions after 10 hours than before 10 hours on the shift.

Hopefully automation can help free up time for doctors.

How would automation help? Is it not a supply/demand issue already (an increase in doctors alleviate things)? Was it worse before we had electronic records and fancy medical equipment?

Maybe it's because of cost (and automation will drive that down)? We're willing to pay fewer doctors at the expense overworking and low supply? If so, I don't see that fixing anything. It would keep status quo, but drive down doctor's salaries or the demand of doctors.

I mean how else does automation help in life. I'd think we're far from an AI making the tough life or death decisions but if their potential work load of 24 hours could be decreased with automated systems performing specific tasks. What exactly is automated? I don't know maybe the pre-checks/questionnaires screening patients.

I realize a doctor is not the same as a burger flipper/dishwasher so their tasks would be harder to automate.

Fancy medical equipment haha. Throw that x-ray imaging away let me just touch your bones and see if it's broken or not.

A tumor did you say? We'll I don't see it.

It was just a thought of my part I'm not a doctor, or a 'leading analyst's just the usual forum BS on my part.

As has been mentioned throughout this thread, in the studies so far conducted (e.g. FIRST), longer shifts are non-inferior for patient safety compared to shorter shifts with more handoffs. There is no such thing as a free lunch, nor is something that is facially obvious safe to treat as true in medicine unless you test it. The changes that were made due to assumptions (not measurements) about safety were found not to be supported when the evidence became available.

Is there any good research into improving the handoff process?

It seems it would be beneficial regardless of how well rested the doctors were.

Active area of research. Take a look at IPASS.

But at some point sleep deprivation must cause issues.

12 hour days I could buy, not 24

> Many programmers in the tech community know that half of the listed time (12 hours) of solid work is enough to start to slow your decision-making and reasoning ability.

I don't think it's fair to compare doctors who have a rigorous medical school and academic path to 'programmers' which includes a wide group of people some of which haven't even graduated college. This is simply a different group of people at the core. And even within that group there are those (in medicine) that choose what appears to be an easier path (let's say psych or family medicine) vs. surgery which might involve standing in an operating theater for 9 to 12 hours and having to be attentive. Along the same lines it is a bit different to make the grade to fly a small single engine airplane (get training) and be able to fly and land fighter jets on an aircraft carrier.

Not taking away from your point of slowing decision making and reasoning but quite honestly not everyone is built from the same bolt of cloth and is impacted the same.

One small example. My wife would take call overnight, get woken up regularly, and easily get back to bed and be fresh the next day at the hospital. If I get woken up (and I am not a programmer) I can't fall back to sleep and would be a wreck the next day. People are different and in some cases the career path and training separates the type of people that end up being in the profession.

I think you overestimate the abilities and knowledge of doctors and nurses. Healing is an art not a science, and it will likely always be so. Bodies are not necessarily understandable, especially as the person can tell you lies, is forgetful, or does not speak your language or understand your version of English words, and you have to do this in sometimes small time windows. The idea of a 'good' doctor is not attainable for most patients, it is a 'good enough' doctor that we are aiming for. So, stress testing docs in the field is looked highly upon by many of the elder docs, they then know that they can depend upon that doc when called for. I know that is not something that a patient necessarily wants to have happen to them, but that is the truth. We live in a world of limited time, money, information, planning, etc, more so in a hospital than anywhere else. Life is risky and will always be so.

Having been through residency myself, I'm actually in favor of this change back to 24 hrs. As background, when I was an intern, the "16 hr rule" was not in place, but I did have to manage interns as a senior resident with the rule in place.

Four points that I'd make on this subject. The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts. In fact, in many cases the doc would have more of a chance to get a nap in on the 24 hr shift than the 16 hr. Basically, I'm suggesting (with zero evidence except my own experience), that I'm not sure there's a significant difference between 16 and 24 hr shifts' effects on a doc's ability to function well--both can be fine under the right circumstances and both can be equally terrible. Also related to this is the fact that nurses, doctors, respiratory therapists work as a team in hospitals ... most critical decisions are checked on a number of levels.

Secondly, do not underestimate the danger of hand-offs. This is the main reason that I'm in favor of this change. Any time there is major information exchange in a hospital environment, there is increased room for error due to misunderstandings, forgotten information, etc. There have been many efforts to standardize information exchanges and they have become better in many circumstances. But I'll tell you that, in my experience, more hand-offs increased the risk of errors in patients and if I were in the hospital on a medical floor, I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift.

The third point is about how healthcare functions in the country, specifically around large hospitals. Residents and fellows get their training in these places, but hospitals also rely on these trainees to staff their enormous floors. If we were to change the shifts, let's say to a maximum of 12 hrs each, we would likely need significantly more residents in the system overall. Not only does that volume need to come from increased sizes in medical school classes, but the hospital systems would need to be paying the salaries of these trainees. Hospitals with trainees receive some amount of this salary money from the federal government, and some comes directly from the hospital bottom line. Either way, the total cost burden to the system increases, meaning that we will all be paying more in an already overpriced system.

The fourth point is that these work hours rules truly impact the training of residents. There are surgeons graduating after 5 years of ENT training who have not had enough experience to become attendings at the places where they are interviewing. I have spoken with a number of senior attendings about this issue and they all say that they are more and more concerned about whether the trainees coming through these programs are getting enough training. So the option to deal with that would probably be to add on another year of training to fields where competency is not being reached, again increasing the cost to the system and to the overall financial picture of the trainees (many are barely making the equivalent of minimum wage during training and need to start paying on a quarter million USD worth of debt).

Basically, I'm not disputing your concerns, just pointing out that our system will likely cost much more if we move the other direction with hrs rules. I also would not jump to the conclusion that 24hrs is truly worse than 16hrs for patient outcomes. Both are terrible, and maybe not significantly different.

Could the reason handoffs are so bad be because the person doing the handoff has been working for 16-24 hours straight?

I mean in IT i see first hand the notes left by people on pager duty in the middle of the night, and they differ significantly from the same peoples notes after a restful night of sleep.

Has there been any controlling in these studies i see mentioned through this entire thread for sleep deprivation present in people performing the handoffs? If they arent controlling for the amount of rest the people in the handoffs have had in the last 24 hours, im not sure i am willing to put much weight in these studies.

>I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift.

But if you came into the ER at 3am and the doctor you get has been working 23 hours, youre still going to need ot be handed off, and now youve received sleep deprivated care in the interim while waiting for a fresh doctor. Sure, for the guy who arrived just as a fresh doctor arrived, it might be beneficial to have them there for 24 hours, but how many new patients are they seeing in hours 12-24?

> Having been through residency myself

Throwaway because it was so disheartening to read this perspective.

> The first is that 16 hrs is too long of a shift to be working throughout, as is 24 hrs. What I'd tell you is that hardly ever would a doctor be working during the entirety of either of those shifts.

This is very location, hospital, and speciality specific. Most surgical residents would say the opposite.

> Secondly, do not underestimate the danger of hand-offs

Hey, why don't we work on better handoffs. Other fields (even with-in medicine) seem to manage. Maybe we should mine the airlines industry again for good ideas. The dichotomy of 16 vs 24 hours to me is a false choice.

> There are surgeons graduating after 5 years of ENT training... who have not had enough experience to become attendings at the places where they are interviewing.

For what it's worth, surgical sub-specialists like ENTs will do at least 2-3 times as many hours in training as a family medicine doc or pediatrician. Make the training an extra year and pay a better god damn salary if they really aren't trained well enough. Right now the system is designed around cramming as much pain and suffering as a human can withstand in their training to get the most value for the hospital. There's a reason why some ~25+% of general surgery residents leave the field completely.

> The third point is about how healthcare functions in the country, specifically around large hospitals

I mean, I call bullshit and I see this logic all the time from fellow physicians who try to make the cost argument from the floor. We pay NPs and PAs to work exactly these shifts, and hours. Why not residents?

> conclusion that 24hrs is truly worse than 16hrs for patient outcomes

I completely disagree that the late night hours have done anything towards making me a better doctor. And I'm truly sorry if I came off as feisty but the whole discussion is so frustrating to me because I think it misses the big picture. This change by ACGME signals the wrong direction we need to be going in how we treat young doctors.

At some point, the aggregate weight of non-cancellable student loans (~240k on average now?), anti-competitive labor market (that went to the supreme court), inhuman hours (that would be illegal for a pilot or truck driver to do), relatively shitty pay (my SO is in tech and earns 2x what most primary care physicians do in 1/2 the hours) will be too much. They'll quit, and find other ways to "make a difference."

I can't put a pillow in a pillow case after 24 hours. Do you really want me stitching up your mom?

You sound pretty frustrated about the whole situation, and I totally get it. I've been there and it sucks. I'd recommend getting involved with the politics of this issue so that you can help make a change. Are you involved with the ACGME? Does your residency / fellowship have a union? If not, consider making contact with the the Committee of Interns and Residents (CIR)--I met with them when I was a resident and learned a lot more about what I could do to help make things better for myself and my colleagues.

The argument I've heard is also in the article, "the change will enhance patient safety because there will be fewer handoffs from doctor to doctor." I've been told studies have shown this--of course there's a limit. I thought that limit was 16 hours (the previous max listed in the article). I'm sure handoff procedures also affect this. When our first son was born the nurses would come in and verbally handoff in front of my wife so she could clarify and confirm things (unless something critical was happening). You could see the nurses scribbled notes before handoff and they were diligent in recording things in their computer system.

On the business side, are doctor's paid hourly? I imagine having fewer doctors paid overtime would be cheaper overall. At least in other professions after 12 hours they get paid double-time.

Lots of doctors who are attendings get paid for what they bill. But this change is for doctors who are 1st year residents/ interns. They haven't graduated to being an attending yet. Residents do not have a medical license yet and must operate under the supervision of an attending. In theory, they are getting paid a salary to learn / sharpen their skills in their chosen specialty (ie family medicine, internal medicine, etc.). But in reality, they are more like low wage labor as 1 attending can supervise many residents.

Yeah, this is a stupid excuse. If handoffs are a problem don't make doctors work more, figure out a better handoff system.

The handoff stuff is at least fixable in principle, whereas sleep deprivation is...not (at least not sustainably).

We don't especially know what purpose sleep serves. It's possible someone will figure it out and how to work around the need for it.