I don't know, but least doctors have a reason for 30 hour shifts: continuity of care improves patient outcome. If they are rested but keep switching doctors, every shift you get a new doctor who's got to read up on you from scratch.

> If they are rested but keep switching doctors, every shift you get a new doctor who's got to read up on you from scratch.

Every time my wife or I or my kid have been in the hospital, we've been there for more than 30 hours. So the problem still exists - someone still has to read up on our situation. I'd much rather those notes be written down by someone who isn't on their 26th hour awake.

> So the problem still exists

It's obviously statistical. It exists, yes, but to a lesser extent.

I understand the issue with continuity of care, but to be honest that sounds like a communication problem at its core rather something that absolutely can only be addressed with aggressive scheduling.

It is a communication problem, but it needs a good filter because you can generate so much information through the EMR and other systems feeding into it (even plain-text sentence generation which just string-interpolates data -- naturally this takes time to read and it builds up quickly). Plus, multiple people can contribute to the medical record simultaneously.

Unfortunately the definition of a good filter is going to vary as much as workflows from hospital to hospital.

Can you share your sources for that? I've heard from medical residents that longer shifts do not result in better patient outcomes. The first paper I Googled agrees - it shows longer shifts for surgeons are not safer (longer shifts had 9.1% rate of complications/death and shorter shifts had 9.0% rate): http://www.nejm.org/doi/full/10.1056/NEJMoa1515724

What the literature consensus largely shows is that there's a roughly equal swap between more sleep/shorter hours resulting in more mistakes due to hand-offs, and longer shifts resulting in more mistakes due to exhaustion.

People in favor of longer shifts (read: docs who are long out of training and hospital admins that rely on residents as some of their most cost-effective man-hours) argue this shows that shorter shifts do not provide patient benefit, so fuck it.

Those in favor of shorter shifts (read: pretty much everyone else) argue that if it's all equal for patients, we shouldn't be torturing residents (they're people, too), and that what this really shows is that the hand-off process is shit and needs to be improved upon.

More sleep and better hand-offs are the road to better patient outcomes and happier (or at least sane) residents.

And it's worth noting that the fight for sane hours has, thus far, only extended to first-year residents. Second+ are still dogmeat.

...and that's the literature position. From first-hand experience, though, I can tell you true horror stories. Mistakes due to hand-offs can be reduced; mistakes because one of my colleagues had a dissociative episode during a way-too-long period without sleep is harder to catch. But no one discloses lapses in sanity during these studies.

Thank you! I kept hearing this "doctors need to be on call 30+ ,40+, 50+ hours because of handoff issues." Rarely has anyone mentioned they need to fix the handoff issue instead they prefer to keep the status quo.

You also have to look at the baseline in these papers. Many of these studies do daft things like compare 24 and 28 hour shifts, neither of which is likely to be anywhere near optimal performance.

Hand-off also seems like a thing that could be improved in many different ways, while fatigue is driven by fundamental limits of human physiology.

Seems like a patient handoff/briefing is something technology could improve, with automatically generated digests, AI-flagged indications, and well-designed infographics, whereas no machine on Earth is currently capable of getting 8 hours of sleep for you.

Technology doesn't help because many of the issues that are "lost" in handoffs exist only in a physician's head. And since digital documentation is both (1) incredibly inconvenient and (2) a legal liability, it's likely to stay there.

The issue with hand-offs comes down to trying to transfer too much information, too quickly. Fixing this is primarily a funding issue - everything else is trying to make up a fundamental resource scarcity with operational improvements.

It's amazing what a human can do while effectively sleepwalking. Life tip: (politely) ask how long your doctor has been awake, perhaps disguising the question as how long the shift has been.

Yeah, we know this one. No, we will not tell you we've been up for 28 hours. It creates issues, both of the liability type and the shifting-work-unto-your-coworkers type.

If you don't want an exhausted doc, you have to tackle it at the policy level. There are advocacy groups working on this, and the proper targets are your legislators and state medical societies.

patients are similarly well aware that doctors will lie to us to cover their ass. possibly why so many of us resent paying you exorbitant sums to do poor work?

Leaving aside he topic of money, as I've no intention of going down that rabbit hole of bs:

People have no idea what the quality of our work is: bad, good, or in-between. You have neither the expertise nor the information by which to judge. The Chief Quality Officer (and former anesthesiologist) at (major academic medical center) once told me, "I have access to more quality data than absolutely anyone else in this hospital ... and I still have no idea who the good surgeons are and who the bad ones are. I haven't known that since I left working in the operating room every day, when I actually saw them all work day after day." What he doesn't know, you certainly do not.

You know all those posts here about how managers have unrealistic expectations, and constantly misunderstand what software devs actually do? It's like that, only moreso.

That’s an abysmal rate with either system - nearly 1 in 10. I assume that hospital does some fairly heroic things, but a quick google didn’t reveal anything special.

How about two or three doctors rotating in shifts? You get continuity of care, and more rested eyes looking at the same issues.

I'd like to see data on that. I highly doubt anyone who hasn't slept in 30 hours can think straight.

Yes, it is hard to believe - sort of like the "open offices improve collaboration, it's totally not about saving money" thing.

Here's are a couple of data points though:

http://www.npr.org/sections/health-shots/2016/02/02/46524860...

Here's the original source: http://www.nejm.org/doi/full/10.1056/NEJMoa1515724?query=fea...

I think they're on call for 30 hours. I don't think they literally stay up for 30 hours routinely. They have a mess where they can sleep.

Being on call for 30 hours might as well be the same. All it takes is one patient that has a few emergencies in a short time frame for the sleep to get messed up. We have better regulations for train engineers and conductors - all for safety. My uncles do it, and my brother did for a while. Always on call, but once their shift starts, there is a strict limit on how long their shift is and a strict limit to how long they have free to sleep.

there have definitely been cold, calculating, studies done on the cost/benefit of doctor sleep to shift changeover ratios, and I don't know if it's 30 hours, but i do recall that it does not comport to your 'feel good' notions of how much a doctor should sleep.

Yeah, and when we had a newborn, we could "sleep when she sleeps". Guess how well we felt, and how capable we were of anything but the most routine tasks?

I would certainly not want my doctor or surgeon to be as “alert” as a new parent..

Just about the time I graduated (BS, not MD), the hospitals in Dunedin NZ had junior doctors on shifts of that long as a bare minimum, and they were on call for 72 hours following their shifts. They were supposed to get a few days off after that.

The 30-hour on-call shifts did start out as just on-call. However, it has long since become the case that it was effectively 30-hour straight shifts, with maybe an opportunity to catch a 20min nap.

Source: Had friends in Med School some years ago.

I don't understand how that make sense. What if you have a patient who comes in at the end of a shift. Wouldn't it make more sense to have more overlap in order to transition patients? I think doctors egos wouldn't handle that well.

> continuity of care improves patient outcome.

This is brought up in every such discussion. Is it really true that US and UK hospitals have better outcomes than EU/Scandinavian ones where the EU working time directive is taken at least a bit more seriously?