One group runs a gauntlet of fire by sleep deprivation during pre-med training: with on-call work hours up to 120 hours a week. And the other group are typically on shift rotas so their sleep patterns are permanently disrupted.
I'm going to call it for them being oblivious to the sleep requirements of ordinary human beings, because these professions are self-selecting for sleep-dep survival traits; only people who can work insane hours make it through hospital medical training, and only people who can take shift work in their stride make it as hospital nurses.
(Also, my observation of hospital doctors is that anyone you see on a ward outside core office hours is relatively junior, i.e. aged about 22-35. Senior consultants and professors work normal hours like everybody else. As for the nurses ... my understanding is that ICU nursing burns them up.)
(Source of observations: former hospital pharmacist here, who just got a refresher course c/o a relative who spent three months on an acute stroke ward this fall.)
I would argue this is the source of injury and death to the patients that needs to be addressed rather than powered through in some sort of macho hazing ritual. Anecdotally a very tired doctor is allegedly how my wife lost her mother.
* Through roughly 9 hours, the error rate was about the same. Say, x%
* In the 10th hour, the error rate increased. Say x + y%.
* In hours 11 and 12, the amount the error rate increase doubled the 10th hour's increase. So x + 2y%.
* In hours 13 and 14, the amount the error rate increase quadrupled the 10th hour's increase. So x + 4y%.
* In every subsequent hour studied, the error rate increase doubled again. x + 8y% in hour 15, x + 16y% in hour 16.
I want to say the study went to 18 hours, but I don't recall if it was 16 or 18 at this point. The paper made the recommendation that shift lengths should be limited to 10 hours maximum.
Every health care professional I spoke to about the article (resident doctors and nurses, maybe 10 overall, mostly in the ER) said the same three things:
1. They had personally witnessed someone make an error they could attribute to tiredness.
2. They themselves had never made a mistake due to tiredness.
3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.
3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.
I think those two items and the tribal knowledge that handoffs are more dangerous to the patient helps the overwork model persist. Sounds like it's past time the medical industry prove that handoffs are more dangerous to patient outcomes. Doctors are trained to be problem owners and problem solvers, but that doesn't make them good team players. And lowering handoffs also limits oversight and prevents second guessing which is great if you're convinced you're always right, but clearly doctors are not always right and patients often pay the price.
And the sleep deprivation and hazing "I did it so everbody else must too!" is definitely a cultic thing.
I use cult very deliberately to point at the reasoning being entirely irrational and social as opposed to underlying value. And also because actual cults use slerp deprivation.
Also explained that the guy who created the residency program was a cocaine addict who rarely slept, and since then all doctors have to try to follow his crazy schedule for no good reason..
So she's only "scheduled" for ~67 hours a week averaged throughout the month, but realistically it is in the 85-90 range.
It's easy to see how a more demanding or emergent field could seriously select for folks who are more able or willing to work on less sleep.
The original rationale was that the "on call" hours were not supposed to be busy and the duty doctors could spend most of them sleeping in a bunk or studying: but by the late 1980s (when I heard about things) they were working more or less constantly through their shifts.
The EU Working Hours Directive was supposed to fix this by banning workers from putting in more than about 50 hours a week without very specific protections being enforced, but one of the first things the UK's Conservative government did in 2010 was to stop enforcing this.
I know labor unions (sometimes rightfully) get a bad rap, but it seems this is exactly the type of abuse they were designed to stop. There are some [0] but the rate is low, less than 15%, and there's a sort of self-censorship style of pressure against pushing harder for them.
[0] https://www.theatlantic.com/business/archive/2017/02/doctors...
It controls a great deal about doctor's education and working conditions. It does not collectively bargain, so it's not strictly a union. But it's more powerful than most unions at this point. So a glib, "maybe doctors should get a union to represent them" answer to poor working conditions for residents doesn't really make sense. They already have a powerful organization that should represent them.
I think that there is at least some group of physicians who really think that poor working conditions for residents improves patient outcomes and doctor training.
As for patient outcomes, I'd love to see a study of them for the roughly 15% of residents that have a union and very modest work place improvements, compared to outcomes for the rest of residents. You're right, many doctors do seem to "feel" the traditional method is superior, but I'd like to see hard data.
I found this paper: http://www.acgme.org/Portals/0/PDFs/Position%20Papers/Commit...
It's citations have some hard data. Maybe the most interesting part for me was this:
"There exists instead a widespread belief that physicians can be trained to defy the biology of sleep and that safeguards are in place so that patients and residents are not harmed by work schedules that are unheard of in any other workplace, let alone a hospital. That belief is most evident today in the FIRST and iCOMPARE studies that set out to prove that there is no difference in patient outcomes from residents who work 16 or 30 hour shifts. The principal investigators were so convinced that no harm would come of these experiments that they determined it wasn’t necessary to obtain informed consent from either patients or residents in the hospitals where the studies were conducted. This determination has been widely disputed and is now under investigation by the Office of Human Research Protections."
I don't know at what point the errors from sleep deprivation exceed the errors from patient handoffs. People seem to take different views depending on what side of the work hours debate they fall on.
Not in the US. The doctor per pop count is very low.
https://www.nationmaster.com/country-info/stats/Health/Physi...
Given the choice, I'm not sure someone whose 4-year earning potential is capped at $60k with $200k in student loans would want to extend that to 5/6/7 years.
I would challenge that assumption because I don't believe there's any consistent number of hours worked by residents in rotation, is there? I mean there are published schedules and then there are actually the number of hours worked which at least according to the other posters is even more than scheduled. So if there's already an element of randomness here and different doctors are getting different numbers of in-rotation hours then it's plausible hours could be made consistent and reduced, isn't it?
I'm sorry about your mother in law regardless.
In a plane in level controlled flight, there is very little to hand off between two type-rated pilots. Both folks understand the machine, and the machine is working the way it is supposed to. Humans work the same way! Parents "hand off" their healthy kids to schools or babysitters or relatives every day.
But imagine a plane that is in the process of crashing; it's in a dive, controls are not responding as expected, one of the engines keeps turning off. A pilot is fighting to regain control... how comfy are you with THAT pilot handing off the aircraft to another pilot in the middle of that situation?
It's a little silly as an analogy, since plane crashes tend to be resolved pretty quickly one or the other. But conceptually, just imagine a plane that is in the process of maybe crashing for 12 hours. There's a good argument for a pilot to just see that through instead of "clocking out" at 8 hours.
Are you aware that on long haul international flights pilots do in fact rotate who is actively "flying" the plane? Flying is in quotes because most of the work is done by automation these days. I won't draw any analogies between the autopilot doing much of the work for pilots and nurses doing it for doctors because I can't actually support the statement with any data.
I should also point out that the vast majority of doctors don't work 120 hours a week continuously, rather, they experience higher-than-usual clusters of working time vs. not working time. That is, they might be on rotation for 36 hours straight but then off for 36 hours or more. And some of their shifts might only be 8 hours. Residents work longer hours, but are supervised by doctors.
I know several ER docs and they all cite the dangers of patient hand-off as the main reason they continue to support long shifts.
We know from lab experiments that performance craters way, way before that, which is why pilots, truck drivers, cops, and every other profession work shorter shifts.
Patient hand-offs between shifts tends to introduce errors. Instead of finding ways to improve hand-offs, the ACGME is simply trying to have fewer of them.
These are supposed to be some of the "top minds" in medicine and that's the best they can come up with.
https://www.cnbc.com/2018/02/22/medical-errors-third-leading...
It's a bit like bringing someone from south Florida to northern Michigan this winter for some ice fishing. I understand that it's cold here, I intellectually know about, have observed the effects of, and can treat frostbite and other problems resulting from this cold - but all that would make it hard for me to intuit the problems of a visitor who was unable to control their fingers when they removed their gloves and dipped their hands into a minnow bucket to bait a hook. My fingers work fine in that bucket, everyone else on the lake is doing it, you're just going to dry them off in a few seconds and put them back in warm gloves...what's the issue?
I've just witnessed this with my partner's recent bout with cancer. While her oncological surgeon completely understands, her reconstructive surgeon had no conception of what she was going through.
That alone is 16 straight years of normalizing sleep deprivation. Time spent studying and working is regularly 80+ hours per week, certainly from med school onward and certainly the year spent studying for the MCAT.
If they start at 16 and finish their residency at 30 or 32, that's the only life they've ever known for all of their formative years. They cannot relate to people with a normal schedule because they have not experienced it.
Let's not even get started on how many nurses smoke.
Similarly, doctors and nurses do not have significant experience in being a patient, especially one who isn't around hospitals all day.
She eventually had to switch to another position, because it became too much. She said she lost a lot of her empathy for the people who had spent 60-70 years abusing their bodies, and now were just here to slowly die under her care (regardless of how good that care was). She also hated that so many people were kept alive on machines long past the point of having any life left, just to keep the families happy. She said after a while, she could tell the difference... that whatever made a person a person (the soul or whatever you believe in) was gone, and all that was left was a pile of meat being kept "alive" by the machines.
I think (without much data here) that medical training pushes insufficient sleep on doctors due to on-call schedules. While hospitals have doctors, many of their specialists come from private practice or multi-specialty clinics, which rotate being on-call between then (often in 12 hour shifts). The other cause of insufficient sleep is that if a patient under care of doctor has complications, they will often be called, even if just for a consult.
Economically, this is likely efficient compared to having hospital specialists (which may end up with nothing to do many nights), but causes docs to train for worst case scenarios sleep-wise.
I'd hope someone doing something as high risk and important as surgery would be getting as much as they need regardless of how much that is.
Exceptions are specializations that are essentially emergency/urgent but even most of them are on rotations like another poster mentioned where they've shifted their own sleep patterns to match their hours.
Since watching my friends become doctors (psychiatrists, uroligists, neurointerventional readiology) and my wife become a surgeon I have started telling friends and family "If your doctor looks under the age of 35 then you should ask them the last time they slept before they start treating you.
tl;dr : hospitals straight up own the futures of their med students/residents/fellows .. so they overwork them while paying them $40-55k year, and when they aren't working they have to study for their exams.
Can someone please tell me why they still put medical students through this institutional hazing?
The reason resident physicians work so much is because residents make $60k working 80+ hour weeks, and the PAs or NPs who would be willing to cover the floors at night would make $150k+ working 40hrs/wk. Residents also have no collective bargaining power because of the residency match system. You can't easily leave one program and go to another because you don't like the working conditions, for example. If you want to leave, you're more or less blackballed unless you're switching fields. And you don't want to speak up about the conditions because you've got $300k in debt and a degree that's useless until you finish residency.
The 3rd year of medical school is much tougher since we spend about 10 months of that year on rotations in the hospital. While some rotations are much lighter, others like surgery again get close to the hours limits. This is complicated by the shelf exams we take every 8–12 weeks. These require an additional ~2–3 hours/day of studying and most of a weekend day as well. Obviously, this study time is not counted towards the hours limits, but it definitely factors into fatigue and burn out.
Sounds like they should just legislate away the "Residency match system."
Pre-med = college, and aside from the highly scientific work load is no different than any other college experience.
Medical school (no longer called "pre-med" by anyone) is typically 2 years of classes and 2 years of clinical rotations. The rotations are not going to be 120 hours a week but may be 60-80. But unless you go to a teaching hospital and consent to student contact (which may or may not be a requirement of treatment) no med school student is touching you.
Residency is after med school (they're full doctors now) where you train your specialty, and at least in the 4 year program I'm familiar with, their title is intern, resident, resident, senior resident for each of the four years. They have increasingly high levels of responsibility as they progress and by the 4th year they are basically oversight/management of the other residents who assist on complex cases and bring in at attending physician(s) for big stuff. Hours are typically 80+ and I'm sure you could approach 100 for very demanding or emergent specialties but it's certainly not "pre-med training" and 120 is pushing it for sure.
After you graduate residency you move to an attending, fellowship, or research position and the hours drop back down to the 60-70 range and decrease as you gain seniority.
There are only two reasons for someone to be in an ICU: they require a therapy no other floor will administer, or their condition/therapy requires very frequent administration/titration/observation. These two reasons frequently overlap.
Sleep isn’t optional in general. It’s optional in the ICU, because the premise is “if you don’t need this level of attention to survive, you absolutely shouldn’t be on this unit.”
I also wonder if, like 'emergency room', 'ICU' has lost some of its meaning in some places.
For non-ICU stuff, yes there could be some better coordination around sleeping time, but again there's so much non-verbal stuff going on in just a physical assessment.
What would really be useful is having cleaning services and admin/billing services come at the same time (well, right after) a nurse comes, to take advantage of that interruption.
I don't want to make it sound like it's impossible. It's not. But it is incredibly inefficient - which is why it doesn't happen - and the answer to "How can we make it happen?" is "Pay for it."
That’s cost effective for the hospital but simply not viable longer term. To be clear waking someone up every 2.5 - 3 hours is very different from waking them up every 2.5 hours and another 2+ random times during the night.
As long as somone is only in the ICU for 72 hours it’s not a huge deal, but start talking a week and it’s a significant issue.
If the hospital staff had sent her home, she would not be woken every two hours. The medical staff were fine with that.
It would have been perfectly reasonable for them to let her sleep; it would have been no more risk than they were advocating for.
Clearly it was optional.
Unless there was some regulatory, legal, or hospital requirement that she receive a certain standard of care. They may have been fine with her sleeping through the night at home, but if she's in the hospital they need to take care of her.
It would not be an easy sell in a courtroom to explain that while you checked everyone except her every 3 hours, you let her sleep through the night and there was an issue that cost her life.
Not that the physicians and nurses should have been taking that into account but the folks crafting the regulations or hospital policy very well may have.
What you've just said supports the article's argument that hospitals are designed to prevent people from sleeping.
https://www.youtube.com/watch?v=pwaWilO_Pig
https://podtail.com/en/podcast/the-joe-rogan-experience/-110...