28-hour shifts

[J ROD]

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@J ROD How did your program guarantee two hours of sleep? Are they continuous? I know it might not sound like much but just getting a little bit makes such a difference for me.

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They are supposed to continuous.....I got it once. One time I got none and the rest 1 to 2 hrs. The senior holds the pager while the intern sleeps. The senior does not get any guaranteed sleep.

 

[PTPoeny]

They are supposed to continuous.....I got it once. One time I got none and the rest 1 to 2 hrs. The senior holds the pager while the intern sleeps. The senior does not get any guaranteed sleep.

Oh, that is much less exciting...

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[J ROD]

I've heard this a lot, but do you have an example? Is it more of a, "We don't care that you haven't slept in 24 hours, do it," and "I'm your superior bow down" or what?

Not questioning your experience at all, just curious as to what exactly you're talking about.

The 28 hr call thing is a different reference to the other part. Call is call. You are busy.....you are not gonna be able to take a nap.

I have been told by one attending "We own you!" I feel like I am not free to voice an opinion or defend my point with a patient. That makes you argumentative. Get asked an opinion, and if it is different that what they are thinking then I just have to sit there and say okay. It is a false what do you think. Just do what I say

 

[Light at end of tunnel]

Naw. The program would always position itself as open and available to address resident fatigue. But if you just follow some of the older cronies and their position on this topic, you get a better sense of what reality is.

Lets be honest, nobody teaches you that not sleeping for 28 hours is healthy. You wouldn't sell that to your patient and it definitely doesnt inspire confidence if you shared that right before doing a procedure on them.

And no, Olympic athletes actually have real physicians that ensure they get adequate rest as part of their training. If you know of an olympic athlete who goes 28 hours without sleep every 3 days please let us know.

Not to mention that silly thing we like to call memory consolidation, which science tells us requires sleep to become permanent and therefore actually "learned."

No matter how many clever ways we find to sell the bottom line inhumane treatment of residents (including the tried and true "that's how I did it," the "it'l make you stronger," and of course the "why did you go into medicine then?") nonsense, the simlple fact is you need sleep to effectively learn anything. This isn't up for debate - it's fact.

So unfortuntaely, longer hours won't make you better, it will however make you more dangerous, also a fact.

 

[Light at end of tunnel]

I don't have a randomized controlled trial to prove my assertion. It's my opinion. You can evaluate it, and decide for yourself.


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Your honesty is refreshing. There really is no science to longer hours doing any good for you, whereas there is tons of data that shows longer hours are dangerous to patient care.

I do think there is something to be said for working hard and having the desire to go above and beyond in becoming the best doctor you can be, but it is important for all the future potential doctors to realize that this hand-me-down is all anectodal and inconsistent with published data.

 

[begoood95]

I think the problem is multifaceted and complex, muddied with the fact that, indeed, we have done this for a long time, and more importantly it has worked—how could we pre-meds, MS1-4s, residents and fellows convince superiors who hold power to change things? To an extent, we could use their own standard, one with which all physicians ought to comply: evidence. Yet, even then, in the face of clear evidence that 28 hour shifts are detrimental to both the patient and the physician, things don't really change.

Then, what do we do? Stage sit-ins and protests? But then our patients suffer. Lobby? But who has the time to do that? The truth is that we don't have many options. Unfortunately, this could be a case of maintaining the status-quo until something dramatic and devastating happens (which, probably happens anyways, though unreported).

I'd be interested to see the effects of changing these standards on burn-out, on efficiency and efficacy, and on physician well-being. What we need is a conclusive, longitudinal study. That study needs to then be covered and disseminated widely—in both our medical circles and in the public sphere. Only then, probably, will we see much change. Otherwise, the status-quo will continue.

 

[Light at end of tunnel]

Cite said data please.

The only data I'm familiar with regarding patient care demonstrates no differences in outcomes

You mean the data that shows that staying up beyond 24 hours is equivalent to functioning with a BAC of 0.08? With the "BAC" getting only higher into 28 hours and beyond. You can find that in any police manual. We don't let drivers operate cars at that level, you think doctors should?

The fact that the 80 hour rule was put in place precisely because New York found that overworked and chronically sleep deprived residents do in fact accidentally kill their patients at an unacceptable rate? I'll go ahead and cite the ACGME with the 80 hour rule for that one.

This isn't even up for debate. I get you are a surgeon, and that sometimes misery loves company, but at some point common sense prevails.

 

[begoood95]

Cite said data please.

The only data I'm familiar with regarding patient care demonstrates no differences in outcomes

My quick look agrees with you:

A Systematic Review of the Effects of Resident Duty Hour Restrictions in Surgery

The Effect of Restricting Residents' Duty Hours on Patient Safety, Resident Well-Being, and Resident Education: An Updated Systematic Review.

What effects have resident work-hour changes had on education, quality of life, and safety? A systematic review.

Interestingly though, all of these only look at surgery. Do we have a selection bias in researchers looking into this subject? It's much harder to find papers that look at other residencies. It doesn't make sense at all to only look at surgery. Maybe in your field, there are negative outcomes, but your field is a minority of medicine, and I'd bet there are different effects of decreases in residency hours in IM specialities, and others.

 

[Matthew9Thirtyfive]

You mean the data that shows that staying up beyond 24 hours is equivalent to functioning with a BAC of 0.08? With the "BAC" getting only higher into 28 hours and beyond. You can find that in any police manual. We don't let drivers operate cars at that level, you think doctors should?

The fact that the 80 hour rule was put in place precisely because New York found that overworked and chronically sleep deprived residents do in fact accidentally kill their patients at an unacceptable rate? I'll go ahead and cite the ACGME with the 80 hour rule for that one.

This isn't even up for debate. I get you are a surgeon, and that sometimes misery loves company, but at some point common sense prevails.

He is asking for the data that shows that longer shifts adversely affects patient outcomes. Because as has been said, it's about the patient.

Hint: the data shows longer shifts don't adversely affect patient outcomes.

 

[Light at end of tunnel]

He is asking for the data that shows that longer shifts adversely affects patient outcomes. Because as has been said, it's about the patient.

Hint: the data shows longer shifts don't adversely affect patient outcomes.

Yea, but the point of residency is to also LEARN how to be a doctor, not just "avoid killing your patients" - a pretty pathetic standard by the way.

Learning requires sleep. Period. 8 hours per night, not a 30 minute nap in the call room. 6 billion years of evolution is data enough for me.

 

[URHere]

28 hour call is incredibly polarizing for residents. I did 3-4 months of 28 hour call as an MS4 and could not have been happier to get back to it as a PGY-2.

Personally, I HATE working night shift. I don't think there are many things worse than spending one out of every 4 weeks on night float (which is how most of my intern year was structured) and as a result spending a full half the month desperately trying to regulate your sleep cycle. At least 28 hour call means that my days still seem like days, and if a night happens to be slow and I manage to get some sleep, the post-call day is like an extra day off. Mentally, I think it also helps to know that I'm going to be there until 10am the next day. I always hated going into a long call that "ended" at 8, only to watch it become 9, 10, or 11PM while I was still trying to stabilize admissions and finish notes. And (most importantly for patient care), if I'm by myself at night with minimal back-up, it really helps to have been present for rounds and all the crazy things that happened with patients during the day. Sign out is never perfect, and you never know patients as well when you only cover them at night.

That being said, some of my co-residents have a lot more trouble with staying awake for 28 hours straight. They can be a huge trigger for migraines, anxiety/depression, seizures, etc. I wish you could, but you're never going to make everyone happy.

 

[begoood95]

@Light at end of tunnel @Matthew9Thirtyfive @SouthernSurgeon this is a shot in the dark, because I'm just a pre-med student and have no real idea what surgery entails, but here's a hypothesis:

Maybe, surgeons in-training don't need as much sleep because, while you're right @Light at end of tunnel sleep is important in memory consolidation and etc., perhaps it's not as important in things such as the motor-coordination skills honed and required in surgical specialties? I'm not saying surgeons don't require critical thinking and so-on, but, from what I can tell, after years of practice they're usually in a state of flow during their surgeries—and at some point their mastery comes from muscle memory and etc, especially for the more routine procedures.

If that's true, then longer hours may be better than night floats, for they allow more practice of the fine-tuned motor skills required of surgeons. As for other specialties that require more diagnostic work, solving the riddles of pathology and etc, higher brain functions would be much more important, and therefore sleep as well.

Again, I could be totally wrong in my characterization of a surgeon's work, but it's just a thought.

 

[Light at end of tunnel]

I woulnd't want to be a passenger on an airplane with a pilot who had been awake for 24 hours. I wouldn't want my family or friends to be on that flight either.

Data won't substitute for common sense and simple human nature - we are talking hunter-gatherer level of obvious logic here.

 

[Light at end of tunnel]

@Light at end of tunnel @Matthew9Thirtyfive @SouthernSurgeon this is a shot in the dark, because I'm just a pre-med student and have no real idea what surgery entails, but here's a hypothesis:

Maybe, surgeons in-training don't need as much sleep because, while you're right @Light at end of tunnel sleep is important in memory consolidation and etc., perhaps it's not as important in things such as the motor-coordination skills honed and required in surgical specialties? I'm not saying surgeons don't require critical thinking and so-on, but, from what I can tell, after years of practice they're usually in a state of flow during their surgeries—and at some point their mastery comes from muscle memory and etc, especially for the more routine procedures.

If that's true, then longer hours may be better than night floats, for they allow more practice of the fine-tuned motor skills required of surgeons. As for other specialties that require more diagnostic work, solving the riddles of pathology and etc, higher brain functions would be much more important, and therefore sleep as well.

Again, I could be totally wrong in my characterization of a surgeon's work, but it's just a thought.

Very good points. I don't know the answer to that either. What I can tell you is that surgery residency has an attrition rate close to 30 percent for a reason...

 

[Matthew9Thirtyfive]

Yea, but the point of residency is to also LEARN how to be a doctor, not just "avoid killing your patients" - a pretty pathetic standard by the way.

Learning requires sleep. Period. 8 hours per night, not a 30 minute nap in the call room. 6 billion years of evolution is data enough for me.

I don't disagree. I'm just saying that there are no data to support that it hurts patients, and seeing your patients through the most of their care as possible versus just parts of it because you have to leave every day is probably better for learning.

I'd also rather have a day off and a post call day. Working 16 hour days 6 days a week sucks.

 

[Matthew9Thirtyfive]

@Light at end of tunnel @Matthew9Thirtyfive @SouthernSurgeon this is a shot in the dark, because I'm just a pre-med student and have no real idea what surgery entails, but here's a hypothesis:

Maybe, surgeons in-training don't need as much sleep because, while you're right @Light at end of tunnel sleep is important in memory consolidation and etc., perhaps it's not as important in things such as the motor-coordination skills honed and required in surgical specialties? I'm not saying surgeons don't require critical thinking and so-on, but, from what I can tell, after years of practice they're usually in a state of flow during their surgeries—and at some point their mastery comes from muscle memory and etc, especially for the more routine procedures.

If that's true, then longer hours may be better than night floats, for they allow more practice of the fine-tuned motor skills required of surgeons. As for other specialties that require more diagnostic work, solving the riddles of pathology and etc, higher brain functions would be much more important, and therefore sleep as well.

Again, I could be totally wrong in my characterization of a surgeon's work, but it's just a thought.

Interesting thoughts. I will say that while I'm not a surgeon, I was an OR tech for many years. I've also responded to casualties (medical or otherwise) at my last two commands. Being up all night in the OR or responding to an emergency sucks, but it's not as bad as it seems like it would be.

I've also been working 30-36 hour shifts every 3-6 days for the last 5 years. Granted, many of those shifts I got sleep, but there were many where I maybe got an hour or two tops, and sometimes none at all. It blows. I'm always wrecked by the time I get home, and I'm usually struggling to stay awake by lunch time. But it's definitely doable, and I know I'm able to function.

I woulnd't want to be a passenger on an airplane with a pilot who had been awake for 24 hours. I wouldn't want my family or friends to be on that flight either.

Data won't substitute for common sense and simple human nature - we are talking hunter-gatherer level of obvious logic here.

The pilot analogy falls flat though, especially in non-surgical fields. In an airplane, the plane is being piloted by two people. A resident has many levels between him and the patient to prevent errors. I would still fly if I knew the co-pilot had been up all night. As long as the captain was fresh and wouldn't be leaving the flight deck.

 

[begoood95]

I think the answer to all this ends up being more or less - "it's complicated".

I don't think surgeons are magic beings by any means. We need sleep just as much as the next guy.

But surgical training I would argue is a little bit different. I just spent an ungodly amount of time as chief of our trauma service. Trauma and emergency general surgery are a fundamentally different experience at night than it is during the day. So you have to be in the hospital at night in order to get that exposure. How you split up the nights is a difficult question. As alluded to above, both systems (night float and 24 hr call) suck. It's a question of which suck is better or worse. As trauma chief, we (meaning my co-chief residents and I) all agreed that night float was a better option. This was primarily a patient care driven decision as it meant that there would be a consistent daytime chief who rounded on everyone every day and knew the longitudinal plans, and a consistent nighttime chief (We rotated on trauma as pairs). I hated it so much more than the old 24 hr calls I did as an intern. But (a) gotta be there at night and (b) we chose a system that we thought made sense from a continuity of care perspective.

As to why there is no difference in outcomes? That's a really hard question to answer. For trials like the FIRST trial and iCompare, they aren't perfect by any means. Many would argue they are, despite giant sample sizes, underpowered to detect small changes in the quality of patient care - stuff that will never make it into a major database of outcomes. My criticism of the trials is that, concurrent to the duty hour changes, a different and more important shift has happened in our training: the level of direct supervision has increased astronomically. Pre-2003, it was very common for patients to be admitted, operated on, and provided with 12ish hours of care before an attending every got involved. Posters here used to brag about this and see it as a strength of a training program. But the level of oversight and redundancy has changed. I think that is a significant confounded in any of these studies of outcomes - the bottom line is that residents probably just aren't as important as we like to think we are in the patients' care.

I think you're spot-on with the, "it's complicated," surgery being no exception. And while not explicitly stated, I think you touched on something important: there isn't going to be a one-size-fits-all solution to this issue, even within specialties. For instance, maybe neurosurgeon residents (and patients) benefit from 24+ hour schedule, while cardiothoracic residents don't; maybe hem/onc residents are terribly effected, while rad/oncs couldn't care less. Complicating all this even more, is the pace at which technologies evolve in certain specialties (i.e., if an algorithm is used to supplement resident decisions, maybe hours won't matter at all).

These institutional oversights must change with changing circumstances and small nuances within and without disciplines in order to comprehensively and effectively implement training protocol. Yet, such attention to detail is often much too difficult, such that we're left with incomplete policies at best, harmful ones at worst.

I agree with your last statement too, that residents may not be that important after all—at least in this current day and age of medicine—in delivering patient care!

 

[KnuxNole]

I was able to sleep soundly for half of my call nights.

The ones where I up 24+ hours straight, I think I did harm patients. I'm sure I missed some diagnoses(at that point, since I was so tired, I didn't give a **** about being detailed), ordered a wrong med or dose(thank god for pharmacy), and probably made some people cry. I remember telling a nurse, clearly she is a big person with those rolls. But, I went through it, and somehow survived, haha. I had to get someone to drive me home once since I fell into a ditch one time.

 

[ServiceFirst]

Would somebody be able to point me towards the studies that concern this topic?

I find interesting (from "Agency for Healthcare Research and Quality-US Department of HHS) that they mentioned in an article in a randomized EXPERIMENT that there was no attributable decrease in quality of care between the 16 and 28-hour residency work day limit. However, if this is no attributable difference, why would the governing agency opt to retain the 16-hour limit in regards and concerning the health and wellbeing of the resident?

 

[Matthew9Thirtyfive]

Would somebody be able to point me towards the studies that concern this topic?

I find interesting (from "Agency for Healthcare Research and Quality-US Department of HHS) that they mentioned in an article in a randomized EXPERIMENT that there was no attributable decrease in quality of care between the 16 and 28-hour residency work day limit. However, if this is no attributable difference, why would the governing agency opt to retain the 16-hour limit in regards and concerning the health and wellbeing of the resident?

You get to follow the patients longer and see more of their care on 28s. Additionally, the patient has fewer handoffs. Also, there are no work restrictions on attendings. Might as well jump into it when you have the most supervision.

 

[dadaddadaBATMAN]

You get to follow the patients longer and see more of their care on 28s. Additionally, the patient has fewer handoffs. Also, there are no work restrictions on attendings. Might as well jump into it when you have the most supervision.

"Also, there are no work restrictions on attendings. Might as well jump into it when you have the most supervision."

I see this line used a lot. There are a handful of specialties where it might be relevant, but for many the "work hour restrictions" aren't necessary when you have actual negotiating power.

 

[ShyGuy0082]

I think the bigger reason is that there is no evidence showing the 16 hour limit improves resident well-being, and a significant amount of concern that for some programs (particularly surgical residencies and smaller programs) it actually made well being worse.

The reasons for this I and others have gone through in depth before (thus the initial plea to use the search function) but a few of the big ones are:
-Fewer days off
-Fewer weekend days off
-Separation from rest of the team
-Sleep cycle disruption
-Work compression
-Missing out on education opportunities

I wonder if patients be ok with "There is no medical evidence of your well being showing anything negative if you work yourself to death. Why is it that doctors tell their patients (and I don't mean those who are critically or terminally ill) to get more rest and get enough sleep and in the same breath tell their own, there is no evidence of your "well being" if you don't sleep.

 

[Matthew9Thirtyfive]

I think the bigger reason is that there is no evidence showing the 16 hour limit improves resident well-being, and a significant amount of concern that for some programs (particularly surgical residencies and smaller programs) it actually made well being worse.

The reasons for this I and others have gone through in depth before (thus the initial plea to use the search function) but a few of the big ones are:
-Fewer days off
-Fewer weekend days off
-Separation from rest of the team
-Sleep cycle disruption
-Work compression
-Missing out on education opportunities

I know I'd much rather work a 28 than work 6 days a week in perpetuity.

 

[Matthew9Thirtyfive]

"Also, there are no work restrictions on attendings. Might as well jump into it when you have the most supervision."

I see this line used a lot. There are a handful of specialties where it might be relevant, but for many the "work hour restrictions" aren't necessary when you have actual negotiating power.

True, but the studies were with regards to surgery, which is probably why that keeps popping up.

 

[ShyGuy0082]

Boy someone didn't even make it the whole way through my post

I did, I shortened it to highlight the part of "Evidence" 🙂

 

[dadaddadaBATMAN]

True, but the studies were with regards to surgery, which is probably why that keeps popping up.

Fair enough

 

[Endoxifen]

And so has my hand when I put soap in your mouth. 😉

 

[Endoxifen]

I've probably worked a couple hundred 24 hour shifts - such is the life of a PICU fellow. Nights vary, sometimes you're running around and don't sit down once. Others you're not particularly busy but the timing of new admissions doesn't allow for any down time. Other times, the first or second half of the night is quiet only to have the other half be crazy. And sometimes, literally nothing happens.

From having LOTS of experience, it was the nights where there was downtime and my brain had a chance to 'switch off' for a stretch that were most problematic for me. Truthfully the busiest nights were the least worrisome in terms of my own judgement while I was the one responsible. In fellowship, we'd sign out but still have to stay while the teams were rounding to put out fires and take calls from the ED/Transport/Rapid Response, and those crazy busy nights were the ones where that last 4 hours would be rough. It was almost like parts of my brain would just go offline during that time like it knew "you have backup".

The other important part that could make for an easy or rough night was what had I done the night before...Was I on call Sunday but still had tried to have a social life Friday and Saturday? That would be a setup for a rough go.

Keep in mind, that through experience, what I would consider a rough night, vs some intern having a rough night, probably are two very different things. With sicker patients and more to balance, I still was undoubtedly safer than someone with little or no experience. That was one of the biggest issues I had with the old rules that singled out interns - you then placed 2nd years who had no experience with decision making while tired in a position of leadership and supervision while they were struggling to adapt to new physical demands. Just didn't seem the smartest.

Lastly, undoubtedly in my clinical practice, more things have been missed with frequent handoffs than because of being tired. ICU patients are complex and it's easy to get distracted during signout. And there were plenty of times where people would start off signout super thorough only to rush through the last few patients because they were tired, something happened, or even just that food got delivered.

Out of curiosity, how does this all affect the weight and overall health of residents? I imagine it could get pretty bad in the later years.

 

[ServiceFirst]

You get to follow the patients longer and see more of their care on 28s. Additionally, the patient has fewer handoffs. Also, there are no work restrictions on attendings. Might as well jump into it when you have the most supervision.

Thanks for sharing that! Those are definitely valid points. Now in contrast, why aren't there experimental studies investigating just how far you can push the limit on the resident work day if overall there seems to be only emperically supported benefits from longer work days? (30, perhaps 32 hours instead of 28?)?

 

[Mian97]

Weak imo here at mcdonalds we normally work 40-80hr shifts without breaks


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[BigRedBeta]

Out of curiosity, how does this all affect the weight and overall health of residents? I imagine it could get pretty bad in the later years.

It varies, like anything. I didn't have particularly healthy habits going into residency, nor coming out. Fellowship demands are different than residencies (fellows in all fields are much more prone to breaking work hour rules in my experience). Some people prioritize it more than others. Did I put on weight? Yeah, but it was more than just doing a lot of night calls, and truthfully, my research time was a lot more sedentary than my time on service.

For the record, my residency program had a nice hybrid setup, and we were heavy into night float before the 2011 rules - the wards teams had night float Sunday through Thursday nights, and if you were on call during those days, you stayed until 8p. But Friday and Saturday nights still were 30 hour shifts (as was allowed at the time). In the ICU's you simply split up the nights evenly, did your 7-10 days and were on days the rest of the month (which many people liked because it meant you got your 4 off days compressed into fewer work days, plus a post nights day). The 2011 rules however, with their limitation on only working 6 nights in a row, were disastrous for night float, as it now meant in the ICU's that you frequently had to flip on to nights, back to days, and then back to nights. The people who wrote the rules had zero experience actually putting a schedule together, let alone actually living one.

I think what is getting lost here by many is that the options here aren't overnight calls vs banker's hours. Whether it's sleep, patient care, education, or other generalized/nebulous "well being", the comparison is not to some sort of idealized work schedule...it's to a schedule that's typically 16 hours a day, 6 days a week, with frequent handoffs, itself a schedule with major, major flaws. At its absolute best the 2011 work hour represented a non-inferior option, but definitely was not an improvement.

 

[Matthew9Thirtyfive]

Thanks for sharing that! Those are definitely valid points. Now in contrast, why aren't there experimental studies investigating just how far you can push the limit on the resident work day if overall there seems to be only emperically supported benefits from longer work days? (30, perhaps 32 hours instead of 28?)?

Probably because at some point you see diminishing returns from exhaustion and residents simply not being able to stay awake. I worked a 30-36 hour day every 3-6 days for the last five years. It sucks. A lot. Most of those days I was able to get at least a couple hours of sleep, but the times where I didn't were horrendous. At 30+ hours of being awake, you just don't care about anything but making it to your bed.

Now doing that every 3-4 days getting zero sleep every time would just be exhausting to the point of ridiculousness. I think the learning becomes inefficient at that point.

 

[bannie22]

Did nobody learn critical thinking in medical school and realize how flawed all that Bilimoria data is. In the first place, which resident logs hours honestly anyway?

 

[PTPoeny]

Did nobody learn critical thinking in medical school and realize how flawed all that Bilimoria data is. In the first place, which resident logs hours honestly anyway?

Everyone in my residency logged honestly. My program worked to make sure our schedules would allow us to comply with work hours. I broke twice in three years and both were me intentionally staying late after the next resident came and I took care of one sick patient and got to do some procedures that I needed. And I logged those honestly with an explanation. Senior residents are allowed to make that choice in my field, not sure if that is universal.

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