An ideal schedule : does one exist?

[Habeed]

---

Members do not see this ad.

All the research clearly shows that working shifts for longer than 12 hours sharply increases errors.

In addition, I suspect that most of you on the forums know from personal experiences that once you exceed your 'battery life' of a human being of about 16 hours since you last slept, you subjectively start to feel terrible. None of your thoughts flow like they do when you are fresh, and you start to make all kind of errors. I, personally, start to feel like a *******.

Adrenaline can temporarily make it better, but you still make more errors than if you were 'pumped' and well rested.

So why oh why do hospitals force their physicians to work longer than this?
A busy hospital will always be a perpetual emergency. Patients will still be sick whether you hand off after 12 hours or after 30.

"Continuity of care" and "sacrifice" are the reasons given. First, continuity. I agree that with surgeries, you can't easily swap surgeons in the middle of a procedure unless there were arrangements made in advance. Nevertheless, most procedures aren't more than a few hours at most.

Second, "sacrifice" : attendings and residents should have to sacrifice their health and lives to be surgeons. That's just a stupid idea : if more surgeons were trained, the current ones wouldn't be so overwhelmed, and the real sacrifices being made are the patients that suffer the complications of errors.

Anyways, it took me all of 5 minutes to think of an ideal schedule. First, a hard limit : 12 hours on duty for a surgeon or any other physician. Similar rules as airline pilots. Only in actual emergencies should doctors work more than that.

Every patient would have a pair of doctors : meaning, exactly 2. They should know each other well, and there should be an efficient method of handoffs. Essentially, you need to be able to trust your counterpart to keep your patients alive while you sleep.

Timing? Well, since large institutions like hospitals have all their office staff working 9-5, the big shift hand off has to be at a time where each "half" of the medical staff gets equal access to administrative resources. So, I suggest a handoff time of around noon to 2pm. There would be an hour of overlap between the shifts, where the 2 crews could communicate and conduct meetings and rounds on the interesting cases.

So, the actual time on the clock would be roughly 13-14 hours per day. Each "crew" would be a full selection of physicians with equal numbers of attendings and residents between the shifts. Not the current system of "night float" that leaves residents in charge and interrupts the sleep of attendings.

That leaves 10 hours per day of sleeping, eating, exercising. The bare minimum to completely recharge a human. Residents would work all 7 days of the week, 14 hours per day, for a maximum of 98 hours 'booked'.

Attendings about 5 days per week.

The solution to emergencies and other things messing up this carefully crafted schedule would be that 'overcoverage' of 98 booked hours. To stay under 80, residents would be allowed days off whenever the day/night before ran significantly overtime.

Anyways, I know🙄 you surgical residents and attendings have constructive things to say about my dreamed up schedule.

And, no, I have NO EXPERIENCE working as a physician. That doesn't make me automatically wrong, I could be dead on. But I have probably overlooked things.

Here are the "set in stone" criteria I used to dream it up
1. Physicians who work more than 12 hours straight start to kill people, with increases in errors of at least +40%
2. "continuity of care" is stupid : better to have 2 physicians who share the load than one physician made to stay on the job for 30 hours straight
3. Day and night, patients should be watched by experienced physicians, i.e. attendings
4. Hospitals are a business and have to have their main office employees work from 9-5, or they would have to pay the staff much higher wages
5. Sleep schedules should be consistent, with changes only made once a month
6. I know from personal experience that it is a lot easier to work 98 hours per week if you get enough sleep per night. In fact, if the job is enjoyable, it isn't even that big of a hardship. It's the sleep deprivation and irregular schedules that kill you.

 

[Winged Scapula]

I must have long life batteries because I can go much longer than 16 hours between rest periods without feeling "terrible". There are many of us here, I can name at least 4 off the top of my head, who do not need 8 hrs of sleep a night; we simply cannot sleep longer than 4-6 hrs.

Besides, don't you think "start to kill people" is a bit strong a statement when referring to someone who has been up for 16 hrs?

Thus before assuming all surgeons need 8+ hrs and feel "terrible" after working 16 hrs, it might behoove the sleep researchers to factor in that some people have different needs and they may be attracted to a field which prizes those.

 

[Habeed]

I'm basing this on actual, objective studies. You may feel fine and think you have greater capacity. But the average doctor does not, and I suspect that if someone were to track your error rate, they would find you make many, many more mistakes later in a shift. Just because you think you're squared away doesn't change reality.

Read Atul Gawande's Complications, or the recent article in the New Yorker on checklists. Surgeons and doctors of all types kill people all the time through preventable errors.

The best way to show these mistakes is what happens when you improve the algorithm. While on a case by case basis, it is tough to 'blame' anyone for a death, if you change the way things are done, and death rates drop, then you know mistakes were being made.

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all

Note how the central line infection rate plummeted once basic procedures were followed.

 

[Winged Scapula]

I never denied that medical mistakes weren't made nor that excessive sleep dep wasn't at the root of some of them. Nor do I assume that I am immune from such mistakes. It is a simple fact that I have never, and probably never will, required a lot of sleep. It would be ridiculous to assume that all human beings need 8 hours of sleep per night, as this is simply the average. I have found a lot of people with similar needs for less sleep tend to gravitate toward surgery. I am capable of admitting that I do make more mistakes when I am tired, but to claim that happens after 16 hours of wakefulness is a bit presumptuous.

You are also not strengthening your argument by quoting the lay press or a physician whom many in the medical field do not agree with. Gawande tells a good story which I also enjoy reading, but his beliefs are not shared by everyone in the field.

Having algorithms and checklists is good in theory, but doesn't always work in the real world. The data on decreased central line infections when using such standards is based on 1 ICU in one hospital. The reality is that so many factors changed from standard practice, its hard to know what the reason for the decrease was (was it using chlorhexidine prep instead of standard Betadine, was it actually having an assistant [as most of us have done or do lines without any sort of assistant], was it the full body drapes as opposed to the smaller ones usually used, was it taking the lines out earlier than usual, or were the physicians placing the lines more careful because they knew they were involved in a study AND that nursing was watching them and reporting on their practice?).

With regard to your schedule above:

- have you thought about the detriment to health and working ability to the person who is always working the 12a-12p shift? There is plenty of data that suggests that night shift workers are less healthy, die earlier and make more mistakes. Your schedule would appear to have the same person on every night.

- you have not allowed for "office staff" outside of the hours of 9-5. That means that the administrative work will fall to the physician, since he/she appears to be the only one in house around the clock. Add several more hours per day to your schedule to get things done that the clerk, techs, etc. would only be doing during the day, but which cannot wait.

- again, your schedule presumes that everyone needs 8 hours of sleep per night

- what are your plans for vacation? Do the residents get any time off or is it 7 days per week, 12-14 hours per day until vacation? That schedule, even if it allows for 10 hours off per day can get pretty tiring, not to mention psychologically exhausting/depressing. While some residents will claim they love their job, many do not and its not necessarily the hours that are the reason. See threads about "Would you do it over again?"

- the resident who is working overnight - how is he/she going to get surgical cases done? If he/she is off every day at noon, there will have to be an extension of the length of residency as he/she will not get enough cases to fulfill ABS requirements or to be skilled enough. This is the problem with night float - at least NF only happens for a rotation here and there.

Clearly you feel strongly about your position and I am unsure as to the point of your post here in the Surgery forum. I am all for reducing mistakes and will happily fill out more and more paperwork and change my practice everytime some pencil pusher comes up with a new and improved technique to make my patients and the hospital run better, but I would suggest that you might want to actually work as a physician, taking call, etc. before pronouncing yourself an expert on such things or presuming to know what is best for me, my colleagues and patients.

FWIW, you might contact some of my colleagues and ask them my thoughts about sleep deprivation and reduction of infections and I'm sure you will get answers about how I am, more than most, willing to reduce hours and change practice for the safety of my patients.

 

[medfriend]

Just out of curiosity, what views of Gawande are considered controversial? I know that he has written in support of "focused" hospitals that do nothing but hernias, spine work, etc. Is this something that has made enemies for him?

 

[Winged Scapula]

Just out of curiosity, what views of Gawande are considered controversial? I know that he has written in support of "focused" hospitals that do nothing but hernias, spine work, etc. Is this something that has made enemies for him?

Its not that Gawande is controversial; far from it...the criticisms aimed at him are more that he hasn't told us anything new, spouts a lot of cliches and simplistic viewpoints that frankly, can come off as condescending.

Is any one suprised that some doctors are better than others (ie, its a bell curve)? That medical mistakes happen? That the malpractice system is broken?

And it would be fine if he posited himself as just pointing out these things to the ignorant around the world that didn't realize these existed, but to many he comes off as arrogant in assuming that he others living on the right side of the Bell Curve know things that others don't and simplistic with his solutions. He doesn't seem to realize that medical students have been told for generations to listen to their patients, that patients have been told (at least for decades) to ask their health care providers for more information, or to put on a pair of gloves, or that some patients actually die in spite of medical care - sometimes because we don't have the ability to save them, sometimes because perhaps (and just perhaps because this is a judgment call) they were "meant" to die. He seems to think he is the first one to come up with these ideas.

Thanks for the advice to listen to my patients, to ask them open ended questions. I hadn't thought about that before.

At any rate, I don't know that he has any enemies but many find his work as pablum for the masses without any real insight or answers to the problems.

 

[Habeed]

There are some useful things Gawande points out. His article on "the bell curve" implies that there must be doctors out there who think they are great, and have a smoothly running clinic, but are actually terrible.

Essentially, my proposal splits the night/day load up equally. Half the doctors spend the afternoon in the hospital and half the night at work. The other half start in the early morning, and spend half the day in the hospital.

So, neither doctor is "the night shift" : that is one of the reasons why I think my proposal is a good one.

When I said clerks from 9-5, I did not mean they were the only ones on duty. I was trying to point out the reality that the majority of the employees of a hospital work in the daytime, so the "shift change" needs to be in the middle of the working day, so that each set of doctors have equal support.

I considered that about operative load : that is why neither shift has all the attendings. It is split evenly. Basically, in the morning the O.R.s would be busy with the "morning" surgeons, and in the afternoon, the O.R.s would be busy with cases for the other set of surgeons. Whether you are a "morning" or an afternoon resident or attending, you more or less have the same access.

Yes, when I am a doctor, I'll have a chance to see why it is done the way it is done. I hope I can find a hospital that has a good solution to this problem, however.

 

[medfriend]

Would you say that Donald Berwick has any good ideas about reforms? I am under the impression that a lot of people think he does, but has met with opposition from many hospital admins because it would be very costly and chaotic (at least in the short run).

 

[maxheadroom]

Thanks be to God! Some undergrad has SOLVED OUR PROBLEMS! I guess all of those guys over at the Institute of Medicine can quit their jobs and go lounge on the beach.

If you want to do shift work, be a nurse. If you want to take care of patients, be a doctor.

 

[Winged Scapula]

If I was restricted to morning or afternoon for my cases, it would be months instead of weeks before I could get all of my patients into the OR. And I do shorter cases; what about the big surg onc cases that run from morning into the afternoon?

I'm not a big fan of restraint of trade anyway but it is not feasible to schedule surgeons into OR shifts...especially when operative schedules also depend on radiology schedules, nuc medicine schedules, vascular lab schedules, etc.

 

[ACSurgeon]

How often do attendings work more than 16 hours a day? I know it can be highly variable based on the type of practice, but I would guess most attendings are not on call more than a couple of times a week, right?

 

[drtx]

Shift work maybe works but it is hardly ideal. Things just get lost. After a 30 hour call. I am at home and just got off the phone with the PACU to make sure that someone who I saw last night indeed could be trusted to go home, call the OR for his add on time today and actually show up to have his surgery.

It is things like this that are subtle, get missed with lack of continuity. Should I have signed this out? Yes. Did I forget because there were 500 other things I was wrapping up knowing I had a time frame this morning and just couldn't hang out post call until all the dust fully settled ? Yes. Did the patient show? Surprisingly, yes! Thank god.

With your system and this new system, crap like this will happen because the person who only has X amount of hours to get things done will prioritize. And the small stuff that also ultimately makes a difference gets lost. That's why I see the problem with this work schedule you describe.

 

[Winged Scapula]

How often do attendings work more than 16 hours a day? I know it can be highly variable based on the type of practice, but I would guess most attendings are not on call more than a couple of times a week, right?

Obviously as you note, it depends on the practice environment, vacations, partner illness and other commitments. But yes, probably most are not on call more than twice a week unless they are in an situation where they take call every night for a week or entire weekends (then nothing for the rest of the month).

I not infrequently work more than 16 hrs per day although much of that is paperwork at home rather than in the office. This is the "hidden" fact of attendinghood that many residents do not see or understand.

 

[GettingSeptic]

I guess the long spine, ent, neuro, and other cases longer than 6 hours will just have to start their operations at 12-1 am to be done with their cases by 12 pm when they have to leave the hospital for fear of "feeling terrible." While I appreciate people trying to figure out how to make patients safer, and it is something I fully support, THIS is definitely not a viable idea. I understand you are in college or not in the field yet, but why don't you wait to pass your judgement on how good some physicians are at 16 hours until you have experienced it.

 

[DrDre311]

How often do attendings work more than 16 hours a day? I know it can be highly variable based on the type of practice, but I would guess most attendings are not on call more than a couple of times a week, right?

On their OR days all of my attendings are physically in house until maybe an hour or so before I get to leave--6a-930p or 10p, regardless of whether they're on call or not. If a case runs late they're here later (0030a last night, for example). They'll typically take call for 3-4 days in a row unless they've got travel plans and have to switch it up. I haven't tried to calculate their hours, but the whole department of plastics is in the hospital a lot--more than the GS guys, even.

On a related note, surgery has traditionally attracted people who don't require a lot of sleep. Maybe I've been operating at 60% capacity my whole adult life, but it's rare that my body will agree to stay asleep for longer than 5 hours.

Plus, no matter how tired I am, I get pretty jacked up for a replant (or other awesome case) even if it comes in late at night and I completely forget when I got to work or how long it's been since I've slept.

 

[Danbo1957]

How often do attendings work more than 16 hours a day?

Not often. But, at times it is necessary to work whatever hours are needed - and the attending should have the experience and where-with-all to handle 16+ hours when required.

 

[Miami_med]

Just to reiterate the point on this sleep thing. I generally sleep 5-6 hours a night, and I have done that since I was about 14, after which I successfully accomplished a number of things that "tired" people are supposed to not be able to do. When I get really run down (as in a string of nights where I sleep less than 4), I generally am able to sleep about 8 hours for a couple of nights before I automatically go back down to 6. If I start trying to sleep in, I will simply start getting tired later so that I go back to averaging around 6. I do not feel remotely impaired (and consistently perform at my usual level at work and on exams) until I go multiple nights in a row on less than 4.

Attempting to apply sleep average to everyone is insulting. It's sort of like saying that the average person has an IQ of 100, so being an astrophysicist should be illegal.

 

[michaelrack]

Attempting to apply sleep average to everyone is insulting. It's sort of like saying that the average person has an IQ of 100, so being an astrophysicist should be illegal.

Do you think it is insulting to "apply sleep average" to truck drivers/pilots and limit their duty hours? Or are surgeons the only ones who can get by on 5 hrs of sleep?

 

[Habeed]

I think those of you that criticize me (winged scapula and GettingSeptic) are not really reading my proposal. You keep saying stuff like "well, how would I get all my cases done...or I would have to start long surgeries early".

I mean, I'm fine with criticism. In fact, I fully realize I am probably totally wrong - I haven't been there.

But please at least read what I have to say before you just say "not the way it is always been done, so won't work"

For instance, re-read what I said about "booked" hours. It is theoretically possible under my proposal for an attending to work a maximum of 98 hours per week. Sure, the O.R. time would be just half a day each day...or maybe not, I'm sure scrub techs and those circulator nurses and P.A.s could work shifts to support you so that you could operate more of each 12 hour shift.

Basically, with a little juggling of scheduling, what can't be done with 98 hours total per week. Attendings don't usually work near that many hours now, even including paperwork done at home.

It's just that every one of those 98 hours you are legally mandated to get 10 hours of rest. For those of you that don't need a full 8 hours of sleep to be at peak efficiency, maybe you could do other things while lying in that bed of yours. Like paperwork

And yes, under this system, if you want to do a super long case, you have to start early...or, you get the next day off because the previous day ran overtime.

And I agree entirely with michaelrack : a few genetic mutants like you doctors claim yourselves to be shouldn't be able to force all the other doctors to adhere to a schedule that research shows doesn't work. Assuming you are, in fact, genetic mutants : what sort of changes would have to be made to the proteins in the brain such that it doesn't need sleep for prolonged periods?

I personally think that those posters who claim they can do just fine well past 16 hours a day actually can't, they just have trained their brains to ignore the signals of exhaustion but are still subject to the physiology of mental exhaustion. Sort of like how you can trick your brain into believing you can fly...right until you smack into the ground.

Patients aren't always endangered : that is what all the checklists and safeties are there to prevent. But the risk is statistically higher.

 

[Miami_med]

Do you think it is insulting to "apply sleep average" to truck drivers/pilots and limit their duty hours? Or are surgeons the only ones who can get by on 5 hrs of sleep?

Most truck drivers "cook the books," and we really have no idea how much they're sleeping. I almost don't care how much pilots sleep, because they don't really fly the plane anymore. In the sort of situations in which the pilot actually flies, the difference between 5 and 8 hours of sleep will pale compared to the adrenaline of trying not to die. I have a major problem with blanket rules that are imposed for political purposes that don't account for individual variation. I'm not even arguing that I want to never have more than 5 hours to sleep, but arguing that I don't function on that, even for extended periods of time, would be incorrect.

Residency is an interesting system, because we don't have a lot of control as residents over our lives. A resident can't say that he's not functioning well and needs to stop. He can't choose to take a day off or schedule a needed vacation. Those things might be real problems, but the lack of control over one's life isn't the same problem as saying that I can't work a full day after "only" 5 hours of sleep.

 

[Amgen1]

several points

1. you can not minimize continuity of care. if i completed a big hepatobiliary reconstruction, and that patient needs to go back to the OR; then it is probably best that I take that patient back to the OR. It would be more dangerous for a physician who knew none of the details of my 6hr operation to reexplore the abd then for me to rexplore the abd on my 16th hr of work. you can't effectively communicate every detail of a complex patient and that is why it is best to have one primary provider for that patient who is in control of their care (the person who knows every detail of that patient's hospital course and operation).

2. you can not minimize the fact that hospitals are run on normal daily schedules . The majority of the OR staff are present during the 7am- 3pm time frame. That includes nurses, scrub techs, anesthesiologist. most hospitals start pairing down the OR crews to skeleton/emergency only crews after 6pm. You would have a major loss of revenue if told half the surgeons they could only operate with emergency cases. the cost of having full up and running ORs 24hrs a day would be huge

3. You can not run clinics at night. Most surgeons have 1.5 to 4 days of clinic per week. If you don't have clinic, then you don't have patients to operate on, and you can't pay the bills. Patients won't come to clinic at midnight and it is not fair to tell a patient with breast cancer that they will have to wait 6wks for their surgery because you are on nights this month

4. the majority of surgeons' lives are not like the ER. there is not a constant flow of things that need to be taken care of 24hrs a day. I don't need to sit a patient's bedside and watch the monitor waiting for something to happen. yes some emergencies happen after hours, but not that many

 

[jbean]

You have to realize that the real problem is not for the attendings... even those who work Trauma or Transplant or those other crazy specialites with no concept of regular working hours can control their lives to some extent. They can come in late the next day or reschedule their elective cases to allow for some sleep...

The problem lies in Residency. I do not believe the current system is a good way to live for five plus years. I just finished my third year of training and I can feel the strain it has taken on my body. I am just used to being chronically tired all the time. I think many programs are trying to have humane work hours... but they often fail for silly reasons.

You have to realize that the major problem is the days when we are required to stay late post call for no good reason. Its one thing when there is a complication or emergency or a rare but cool case going on... but many times we are forced to stay to do yet anther elective case or struggle to stay awake during conference. I am not arguing a 12 or 16 hour workday, but I know for a fact that my ability to learn drops off after about 20 hours. The last four or six hours I am just doing what needs to get done. I think the difference between leaving the hospital post-call at 9 or 9:30am (27 hours)versus waiting until 12 or 1pm (30 or 31 hours) is huge. You can actually get home, get a decent amount of sleep and then spend a few hours with your family or studying... this goes a long way to making happier, healthier residents!

Also, one month a year with no night call would also help us to feel more human and normal. My program requires 6-9 calls per month for the first four years.

 

[Winged Scapula]

You have to realize that the real problem is not for the attendings... even those who work Trauma or Transplant or those other crazy specialites with no concept of regular working hours can control their lives to some extent. They can come in late the next day or reschedule their elective cases to allow for some sleep...

While I agree that the major problem is residency I think you have to careful not to confuse what you see in academia with what happens in "real world" surgical practice.

General surgeons and surgical specialists who take ED call cannot routinely reschedule elective cases, come in late, cancel clinic patients, etc. - when you do so, you lose patients, referrals and money. Most general surgeons I know as well as the Plastic Surgeons I work with (who take trauma call) do NOT do the above because they feel a financial as well as ethical responsibility to complete work. Also rescheduling cases, even for later in the day is not always possible - when you have booked your assistant, the anesthesiologist, etc. you are rescheduling multiple people. In academics, while cancelling cases and clinic (or delaying them) is frowned upon, it happens a LOT more than in PP, for the reasons I outlined above.

At any rate, despite what the OP said earlier, I nor no one else here has ever said that we should maintain the status quo because that's the way its always been done. Nor do we think surgeons are superheroes possessing powers than mere mortals do not. But it is ridiculous to assume that we all have the same need for sleep (please see the DeBakey thread and tell me that you would tell him that he was "killing patients" because he only slept 4 hrs per night. He may have killed a few in the early days, but it wasn't because of his sleep deficit.).

We are all willing to entertain new systems but given that we understand the systems better, it may be that we are able to see where the changes are possible and where they are not.

 

[DrDre311]

I think I speak for many surgeons when I say this: I'm gonna operate when I need to operate, because I'm good at it and nobody does it like I can. If it means I'm tired the next day, I can deal with that. Comes with the job.

It would be pretty difficult to combat this mindset--it's pretty widespread and our system is not equipped to deal with the financial fallout (not to mention access-to-care issues).

 

[Celiac Plexus]

to the op:

I'm not aware of any published data that conclusively shows work hour restrictions in residency cut down on errors.

I'm also unaware of how work hour limitations translates into more sleep. Just because pilots, truckers, and residents have work hour restrictions, doesn't mean they will sleep more. There really is no proven correlation there.

I cannot speak for others, but my mind does slow down after being up for 24+ hours. That said, I have enough experience working long hours to recognize this. When I get to that point I slow down and focus harder on what I am doing. It's not a big deal.

Finally, what is the obsession with limiting work hours? Safety will always be a concern, but short of forcing people to sleep for some mandated period of time in a room with a spy camera, how can your system work? People do what they want to do, and if they choose to go out to the bar, or stay up all night reading, how can you or anyone control that? That said, all the creative work schedules in the world won't reduce medical errors.

I think the best way to reduce medical errors is to gain experience. I don't get experience if someone tells me I have to leave the hospital before I'm ready to.

Plus, it's just not American to limit work.

Thank you. Have a nice day.