24-hour in-house call

[Giic]

I want to know people's thoughts on this, especially faculty in NICU and PICU.
In my personal experience, especially if you work in a crazy busy unit, there is a higher tendency for medical errors after about 2 or 3am. If it has been terribly busy (you know, on your feet constantly, barely any bathroom breaks or food breaks), then I usually can NOT function by 3 or 4am.

I know this is an age-old debate, but should 24-hour inhouse call not be outlawed?
I mean, would you get on a plane knowing the pilot is as tired as you were on your last call?

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[oldbearprofessor]

I would prefer that the legal system not put itself in the position of regulating attending physician hours. I'm in academics. When I do overnight shifts, which I have done for over 20 years as an attending, I work my day academic job (not necessarily on the clinical service), then do night call, then work my next days academic job. I can't really see how that could be banned or enforced. Should all doctors (or nurses, or pharmacists, etc) who work at night have to prove that they slept the day before the night shift rather than working? It is not the same as a resident/fellow situation.

 

[Cuthbert]

If you cannot manage to work 30 hours straight and keep your focus, you are better off coming to that understanding as a resident than as a practicing physician. It will help to guide you in your job selection in the future. I think limiting the workhours is laughable. It does not represent the "real world" practice of medicine (like it or not). No one is there to step in for me at 16 or 24 hours so I can nap.

 

[Giic]

If you cannot manage to work 30 hours straight and keep your focus, you are better off coming to that understanding as a resident than as a practicing physician. It will help to guide you in your job selection in the future. I think limiting the workhours is laughable. It does not represent the "real world" practice of medicine (like it or not). No one is there to step in for me at 16 or 24 hours so I can nap.

Then you're missing the point I'm bringing up. The point is that someone SHOULD be there to step in for you. And there's nothing laughable about that!!! For years, we've been taught that doctors are 'supposed' to work long hours, unless they are not good enough or don't care as much about their patients. Now THAT is laughable. I trained at one of the 3 largest children's hospitals in the US - and even with the best possible experts, there were unthinkable errors in medical "judgment" that occurred in the middle of the night. Unexcusable errors. The patients deserve better. The physicians deserve better.

 

[Giic]

I would prefer that the legal system not put itself in the position of regulating attending physician hours. I'm in academics. When I do overnight shifts, which I have done for over 20 years as an attending, I work my day academic job (not necessarily on the clinical service), then do night call, then work my next days academic job. I can't really see how that could be banned or enforced. Should all doctors (or nurses, or pharmacists, etc) who work at night have to prove that they slept the day before the night shift rather than working? It is not the same as a resident/fellow situation.

I actually wasn't thinking about the legal system getting involved (even though I did use the word "outlawed"). I was just thinking of within the medical community.
Working your day academic job before call is probably more acceptable. But what I was really referring to is 24 hours straight of patient contact.
And as to whether doctors should have to prove that they slept the day before - of course not, that is not practical. But that is a matter of personal responsibility (ensuring that you're fit to work). Same thing as not showing up to work drunk. However, scheduling doctors for a 24-hr shift in which they will not sleep and are essentially "drunk" by the end of it seems like a systematic irresponsibility. Please look up the article from Brown University where residents were randomized to 3 groups - either post-call or drunk (vodka) or control group, and asked to do a cognitive test. The postcall residents were no different from the drunk residents.

 

[oldbearprofessor]

Well, there are many articles on this topic. It took me a few minutes but I think you're referring to this one:

http://jama.jamanetwork.com/article.aspx?articleid=201473

I'll leave it to members of SDN to look at this article and decide if they believe that the conclusion is that during a 24-hour shift attending physicians are essentially "drunk" by the end of it. Note that since this was published, numerous other articles and studies have been done with very mixed results. The answer is not clear at all nor are the tradeoffs in choosing shorter shifts with more handoffs in a critical care environment. A better solution is that those who do not wish to work 24-hour shifts as they do not feel they are acting in a safe manner during the night-time not do them. There are plenty of NICU etc jobs that don't require 24-hour shifts if you don't wish to do them. However, I do not believe that the available whole body of evidence is supportive of a ban, legal or hospital-based on 24 hour shifts. YMMV on that but note that the ACGME does not even think such a ban should be in place for non-first year residents given the whole body of evidence on this issue. Also, consider that if, as an attending, you are never having a break during a 24-hour shift in a NICU, you might evaluate why that is the case. Are there no residents, fellows or nurse practitioners to handle some tasks? Are you being called over issues that do not need a call at night, etc, etc? Many 24-hour attending jobs have a reasonable prospect of some sleep most nights.

 

[ruralsurg4now]

A better solution is that those who do not wish to work 24-hour shifts as they do not feel they are acting in a safe manner during the night-time not do them.

Theoretically, yes, but that may not end up being the case. There's a similar push on now for surgery where, if you were up the night before, people are saying you have to disclose that to your patients. Something like that. To be honest, I don't really give a s**t what they say, so I didn't totally pay attention. Point is, you may be fighting a losing battle here because that other guy is just a product of the new culture of medicine and society where people want something without considering any repercussions. For example, in residency people were wringing their hands over the work hours, so they limited them. Did that really change anything in terms of errors? Uh, no. So what was the point? Well, the point is that we now "feel" better about how humane we are. Meanwhile, no resident feels more humanely treated because all they're doing is the same amount of work in a compressed amount of time. But the people who aren't in residency just walk off, patting each other on the backs and congratulating themselves over what great humanitarians they are and how much they cared. That's medicine today.

 

[ruralsurg4now]

By the way, reading that JAMA article cracked me up. Did anyone look at who was excluded from the study? One who had a sleep disorder and two who were taking medications that altered sleep cycles or daytime alertness. So basically there were at least three people out there that JAMA knows about who are pediatric residents who are impaired all the time, lol. High five!

 

[mvenus929]

There's a similar push on now for surgery where, if you were up the night before, people are saying you have to disclose that to your patients.

Since you brought it up... http://jama.jamanetwork.com/article.aspx?articleid=1764029 🙂

 

[ruralsurg4now]

Since you brought it up... http://jama.jamanetwork.com/article.aspx?articleid=1764029 🙂

a) I'm well aware of the poor science behind the argument.
b) I'm not impressed.

 

[Cuthbert]

Then you're missing the point I'm bringing up. The point is that someone SHOULD be there to step in for you. And there's nothing laughable about that!!!

I still get a good chuckle out of the idea. It would not work in my practice. We simply don't have the numbers for it. It may be a reasonable idea for some academic centers or certain practices but not for most private practices working on production. If my own practice split our time up into 12 hour shifts, I would never see my family or have any kind of personal life. It's unrealistic.

For years, we've been taught that doctors are 'supposed' to work long hours, unless they are not good enough or don't care as much about their patients. Now THAT is laughable. I trained at one of the 3 largest children's hospitals in the US - and even with the best possible experts, there were unthinkable errors in medical "judgment" that occurred in the middle of the night. Unexcusable errors. The patients deserve better. The physicians deserve better.

I trained at one of the smaller children's hospitals. We may not have had "the best possible experts," but we had good physicians who were smart and worked hard. The medical errors that I saw were typically due to inexperienced residents rather than due to lack of sleep. Limiting hours limits experience and will likely lead to the same number of, if not more, medical errors.

Interesting read: http://mobile.reuters.com/article/idUSBRE92O0XN20130325?irpc=932

 

[Giic]

I still get a good chuckle out of the idea. It would not work in my practice. We simply don't have the numbers for it. It may be a reasonable idea for some academic centers or certain practices but not for most private practices working on production. If my own practice split our time up into 12 hour shifts, I would never see my family or have any kind of personal life. It's unrealistic.




I trained at one of the smaller children's hospitals. We may not have had "the best possible experts," but we had good physicians who were smart and worked hard. The medical errors that I saw were typically due to inexperienced residents rather than due to lack of sleep. Limiting hours limits experience and will likely lead to the same number of, if not more, medical errors.

Interesting read: http://mobile.reuters.com/article/idUSBRE92O0XN20130325?irpc=932

Do you mind if I ask what kind of practice you have? Is this general peds, picu, nicu, etc? Are you currently in-house throughout your call?

 

[Cuthbert]

Do you mind if I ask what kind of practice you have? Is this general peds, picu, nicu, etc? Are you currently in-house throughout your call?

General peds. We cover a level 2 NICU, general peds floor and an occasional child in the adult ICU (mainly DKAs, overdoses, etc. - things that would not require a specialist). NICU is down to 32 weeks and will include the occasional vented child but obviously not the acuity of a level 3 (although we are still required to stabilize those patients prior to transfer). Call can be from home for us, but you can find yourself in house all night pending the acuity level of your patients and the amount of stabilizing treatments needed.

I apologize, my first post was not meant as a dig on your suggestion. It would be great if hours could be limited, but in many cases I don't think it's possible. In the case of residents, I think it is to their detriment.