Sleep deprivation on NPR

[OldPsychDoc]

Tomorrow (12/13) on "Talk of the nation" (Usually airs at 2 pm EST)

"Dec. 13 · Three years after hospitals were told to limit the hours of young doctors, a new study says they're still exhausted, and this lack of sleep is bad for patient care."

 

[LovelyRita]

Tomorrow (12/13) on "Talk of the nation" (Usually airs at 2 pm EST)

"Dec. 13 · Three years after hospitals were told to limit the hours of young doctors, a new study says they're still exhausted, and this lack of sleep is bad for patient care."

Thanks! Unfortunately I'll be on call and unable to listen to the radio. 🙂

 

[phllystyl]

Thanks! Unfortunately I'll be on call and unable to listen to the radio. 🙂

And im so tired postcall that i cant tune in either

 

[deleted87716]

When I listen to NPR, sleep deprivation usually isn't a problem...where do they find those announcers, anyway? 😴

😉

 

[OldPsychDoc]

When I listen to NPR, sleep deprivation usually isn't a problem...where do they find those announcers, anyway? 😴

😉

Alright, alright...I get the message, guys...just trying to help! 🙄

 

[deleted87716]

Alright, alright...I get the message, guys...just trying to help! 🙄

Just kidding. If you fall asleep during the live broadcast, you can read a transcript or listen to the audio after 6:00pm EST on their Web site: http://www.npr.org/templates/story/story.php?storyId=6619687 😉

 

[Faebinder]

You know there is a minor advantage of being sleep deprived.... You can take your SO to a boring chick-flick movie and just sit back and ZZZzzz.... This wont work if you snore loud.. she will get mad.

Speaking from experience here...

 

[lumanyika]

Heard the broadcast. A little bit trite IMO....as long as the individual States mandate the hours there will always be discrepancies in any National studies conducted in the investigation of sleep deprivation. furthermore, some residencies invariably require more (unofficial) work-hours than others (I'm not sure if they brought up surgery and its sub-specs. as a comparison). The solution is simple. We need more doctors, but that's not going to happen because we would need more medical schools and historically, that has been a point of contention within the American medical establishment.

 

[treesap]

Trite, maybe. But that doesn't solve the actual problem. No one can argue that the risk of medical mistakes go up with doctor fatigue. Study after study has been published that residents make silly mistakes, don't think as clearly, and have an increased risk of endangering others lives on the road when overtired. I know I've certainly been victim.

The ACGME rules are a good start, but if programs really want to tout that they follow evidence based medicine they're going to have to start being more proactive. (BTW, the NPR talk focused on 24+6 shifts).

Maybe the more they discuss the issue on NPR, the more it will outrage the public. I'm not keen on having patients ask me how long I've been at work, but it is their health and they have a right to good care. I know I've done stupid stuff and hope I never have to explain a bigger error to a medical board (or coroner's inquest, for that matter).

 

[mlw03]

Maybe the more they discuss the issue on NPR, the more it will outrage the public. I'm not keen on having patients ask me how long I've been at work, but it is their health and they have a right to good care. I know I've done stupid stuff and hope I never have to explain a bigger error to a medical board (or coroner's inquest, for that matter).

I think this poster makes an important point that we resident can whine and studies can come out all the time, but until the public gets pissed enough to get politicians more involved things probably won't change. Maybe the sister of an important senator will have to be killed by a resident on their 73rd hour of a week and 23rd hour of a day before things change. I've seen residents and med students drug themselves with caffeine to try and fight off the natural desire to sleep and the data doesn't lie - tired docs screw up more often than rested ones.

I agree the issue is that we need more doc work hours, not necessarily more docs. After residency docs work way less hours and still get paid more. I don't know what the solution is, but there has to be a better compromise between 80 hours a week and $40K/yr in residency versus 50 hours a week and $180K/yr post-residency. I would finish by noting that to my knowledge emergency medicine residents NEVER work 24 hour shifts, let alone 36 hour ones. The docs we have on the front line for the most emergent problems are given adequate rest - don't we want the surgical resident performing a laparotomy to have that adequate rest also?

 

[beetlerum]

I think this poster makes an important point that we resident can whine and studies can come out all the time, but until the public gets pissed enough to get politicians more involved things probably won't change. Maybe the sister of an important senator will have to be killed by a resident on their 73rd hour of a week and 23rd hour of a day before things change. I've seen residents and med students drug themselves with caffeine to try and fight off the natural desire to sleep and the data doesn't lie - tired docs screw up more often than rested ones.

I agree the issue is that we need more doc work hours, not necessarily more docs. After residency docs work way less hours and still get paid more. I don't know what the solution is, but there has to be a better compromise between 80 hours a week and $40K/yr in residency versus 50 hours a week and $180K/yr post-residency. I would finish by noting that to my knowledge emergency medicine residents NEVER work 24 hour shifts, let alone 36 hour ones. The docs we have on the front line for the most emergent problems are given adequate rest - don't we want the surgical resident performing a laparotomy to have that adequate rest also?

I would think the solution is clearly more docs, not working attendings harder. Right now there is an artificial control on the supply of docs. We need to increase the number, which should be continually increasing anyway to keep up with the growth of the population.

 

[KidDr]

I think this poster makes an important point that we resident can whine and studies can come out all the time, but until the public gets pissed enough to get politicians more involved things probably won't change. Maybe the sister of an important senator will have to be killed by a resident on their 73rd hour of a week and 23rd hour of a day before things change. I've seen residents and med students drug themselves with caffeine to try and fight off the natural desire to sleep and the data doesn't lie - tired docs screw up more often than rested ones.

better yet, Oprah needs to hear about this & do a show on it...THEN things will change!!! can you imagine? when Oprah speaks, everyone listens.

 

[AF_PedsBoy]

Traditionally, too, the concern has been less hours=less learning. Attendings then ask, "Would you rather work 64 hours a week for 5 years, rather than 80 hours a week for 4 years?" (in essence - this discussion took place when the *80* hour rule came into play; giving rise to the documented 80 hours and countless undocumented hours which you WILL do or get canned for "inefficiency" and "poor commitment to patient care") to which I reply, "**** yeah!" Same amount of experience, more study time and living time from day to day, less sleep-deprived errors, safer patient care. Now why would I want that? Of course it'll ever happen in our lifetimes...

 

[deleted109597]

I think this poster makes an important point that we resident can whine and studies can come out all the time, but until the public gets pissed enough to get politicians more involved things probably won't change. Maybe the sister of an important senator will have to be killed by a resident on their 73rd hour of a week and 23rd hour of a day before things change. I've seen residents and med students drug themselves with caffeine to try and fight off the natural desire to sleep and the data doesn't lie - tired docs screw up more often than rested ones.

Yes, but at the same time, it took public opinion to make us take Step II CS. It may work in our favor, or it may end up adding a year to everyone's residency.

I agree the issue is that we need more doc work hours, not necessarily more docs. After residency docs work way less hours and still get paid more.

Depends on the field. Most surgeons and OBs work more than 80, and don't get post-call days.

I would finish by noting that to my knowledge emergency medicine residents NEVER work 24 hour shifts, let alone 36 hour ones. The docs we have on the front line for the most emergent problems are given adequate rest - don't we want the surgical resident performing a laparotomy to have that adequate rest also?

Not true. EM residents work 24 hour shifts all the time. Off service. The RRC for EM states that we cannot work more than 12 hours, and must be gone by "well under 13 hours". This is due to the fact that when other people are on call, they may get to sleep (even though most don't), whereas in the ED, you don't get to sleep (although sometimes people have if it is Thursday night at 3am and nobody is there, etc).

 

[nobrainer]

Not true. EM residents work 24 hour shifts all the time. Off service. The RRC for EM states that we cannot work more than 12 hours, and must be gone by "well under 13 hours". This is due to the fact that when other people are on call, they may get to sleep (even though most don't), whereas in the ED, you don't get to sleep (although sometimes people have if it is Thursday night at 3am and nobody is there, etc).

mlw03 obviously meant on service in the ED

 

[8744]

I would think the solution is clearly more docs, not working attendings harder. Right now there is an artificial control on the supply of docs. We need to increase the number, which should be continually increasing anyway to keep up with the growth of the population.

Many, mant hours of your training time are going to be absolutely wasted.

A good chunk of my time is spent on absolutely mind-numbing paperwork, most of it redundant. Let me give you an example:

For every ICU patient, I have to write a long not every morning on which I have to copy, by hand, the lab values, imaging study results, and vital signs all of which information can be found on the nurses notes or on the computer. It would be a lot simpler and take a lot less time (a lot less) if I could occasionally just write, that patient was "AVSS" (Afrebrile, Vital Signs Stable) and only comment on pertinent lab values. It's the assessement and plan that's the important part of the note. Why recopy the same infomation about things that don't change much from day to day?

The attendings don't write long notes on patients they follow. Sometimes they only scrawl a few lines of boilerplate before getting into their assessment and plan, the only part of the note that most people read.

If you need to document for billing purposes then everybody needs to go to the "T-sheet" system of at least an EMR note that defualts to normal ROS and PE items which you can modify as required.

Most of every note you will write is boilerplate. I hear all of the complaints about 80 hours per week not being enough time to train a resident but you could save twenty hours a week just by cutting out half of the paperwork.

The only thing I really hate about call now that I have gotten the hang of things (well, except being tired) is having to write detailed, extensive histories and physicals that nobody is ever going to read. It is just hard to concentrate on this task at 3AM, especially when you have a backlog of notes to write because this is the first breather you've had since the afternoon.

It's not the long hours, it's all the notes. I could work for three days straight if I didn't have to wear out a pen every week or two.

 

[Colinator]

KidDr.

Word on Oprah. But I get no love from Oprah when it comes to medicine relevent topics. I actually wrote her a letter about the woes of students loans and medical student indebtedness impacting career choices . . . but hey, a quarter mil of debt is really no big deal, right? In reality, we all have roofs over our heads, food on the table, etc, so can't complain too much . . . but she could certainly feature a doc story than another episode of Tom Cruise jumping on furniture like a toddler or some other over-hyped fool.

 

[Igor]

Acutally attednings do write "long notes" on patients we follow. We're only allowed to write short notes if we can link to house officer's note from the same day.

Most of the time outside large academic medical centers we write our own notes. ICU note exist for a reason - ICU care is complicated and "Afebrile, stable off pressors" doesn't mean much if the patient is critically ill.

I can try an convice everyone about the need to work long hours but I doubt I will succeed. Let me tell you about my day today. Schedule had me on call from 7 AM to 7 PM.

7 AM - start work, see patients
11:30 - lunch
3:00 incredibly boring adminsitrative meeting about effects on contruction on parking, patient room and pt flow
5:00 type up sign out because I'm bored
5:15 admit patient critically ill, start insulin drip, call multiple consultants, reformulate plan.
5:30 forrage for food, find none. curse collegue who ate the last piece of cake before I got to the office fridge
6:45 consider paging night coverage for sign out but realize it's too early
6:50 code called on one of my partner's patients - emergently transfered to ICU, family called, consultants called
7:45 literally at the door of the ICU when my new admit has seizure (in front of family who call me by name to help)
8:30 family of other pt catches me in the hallway and has "just one more question, doc"

Patients always need care when you're tired, worn out, stressed out and on your way out the door. The purpose of residency is to learn how to consistently provide standard of care when nothing is going your way. If we as a society can't teach this to people who graduate med school but haven't yet started their career, this country will not be able to produce doctors who can care for its citizens once the "old guard" of folks like me are too old to work (or dead).

No one wants residents (or attendings) to crash their cars, have miserable lives, or be made to feel lousy. But we have to face reality, which means that everyone who finishes residency and goes on to practice is going to be in situations where they are forced to provide care when they're exhausted, stressed, hungry, and worried about something besides work.

I'd just as soon have a system where my doctors did that before, as residents, instead of learning how to do it as attendings.

Igor

 

[Faebinder]

Many, mant hours of your training time are going to be absolutely wasted.

A good chunk of my time is spent on absolutely mind-numbing paperwork, most of it redundant. Let me give you an example:

For every ICU patient, I have to write a long not every morning on which I have to copy, by hand, the lab values, imaging study results, and vital signs all of which information can be found on the nurses notes or on the computer. It would be a lot simpler and take a lot less time (a lot less) if I could occasionally just write, that patient was "AVSS" (Afrebrile, Vital Signs Stable) and only comment on pertinent lab values. It's the assessement and plan that's the important part of the note. Why recopy the same infomation about things that don't change much from day to day?

The attendings don't write long notes on patients they follow. Sometimes they only scrawl a few lines of boilerplate before getting into their assessment and plan, the only part of the note that most people read.

If you need to document for billing purposes then everybody needs to go to the "T-sheet" system of at least an EMR note that defualts to normal ROS and PE items which you can modify as required.

Most of every note you will write is boilerplate. I hear all of the complaints about 80 hours per week not being enough time to train a resident but you could save twenty hours a week just by cutting out half of the paperwork.

The only thing I really hate about call now that I have gotten the hang of things (well, except being tired) is having to write detailed, extensive histories and physicals that nobody is ever going to read. It is just hard to concentrate on this task at 3AM, especially when you have a backlog of notes to write because this is the first breather you've had since the afternoon.

It's not the long hours, it's all the notes. I could work for three days straight if I didn't have to wear out a pen every week or two.

Yup you are right...but the notes are necessary Panda.... believe it or not, a lot of people can need to go through those notes sometimes years later.

E.G. The other day i dug up 50+ charts from 1994 so i can look at their stay in the hospital for complications for a study... The progress notes of the surgeons (the nearly unreadable notes) were pretty much my only information source.

 

[dry dre]

Just kidding. If you fall asleep during the live broadcast, you can read a transcript or listen to the audio after 6:00pm EST on their Web site: http://www.npr.org/templates/story/story.php?storyId=6619687 😉

It was interesting to hear a pediatric resident in a fairytale hospital in the state of New York describe how sleep deprevation was not much an issue in the medical education community.



How about bringing in a resident outside of New York who incorporates some amount of physical activity in their 30++ hour shifts? When I fall asleep during a case, I often find myself dreaming/having a nightmare about being a pediatric resident in a fairytale hospital...

 

[dutchman]

For as long as medical education is run by sadistic pricks with high intelligence but no common sense, this will always be a problem. Who the hell needs scientific research to prove that lack of sleep increases the probability of making mistakes. And you wonder why the public is loosing respect for physicians.

 

[3dtp]

Many, mant hours of your training time are going to be absolutely wasted.

A good chunk of my time is spent on absolutely mind-numbing paperwork, most of it redundant.

. . .and only comment on pertinent lab values. It's the assessement and plan that's the important part of the note. Why recopy the same infomation about things that don't change much from day to day?

. . .I hear all of the complaints about 80 hours per week not being enough time to train a resident but you could save twenty hours a week just by cutting out half of the paperwork.

Agree 100% You forgot "and introduce errors after recopy."

. . . is having to write detailed, extensive histories and physicals that nobody is ever going to read. It is just hard to concentrate on this task at 3AM, especially when you have a backlog of notes to write because this is the first breather you've had since the afternoon.

I think that some do read those notes, and in detail. Consulting services always (or should, I think) read those notes. They contain important information on formulating a plan of care/treatment for consulting services. I agree that noting lab studies on an exception basis would be much more efficient and probably more accurate than hand copying everything from the lab database. I would have no problem with all labs WNL (within normal limits, not 'we never looked'), except glucose 806 and ANC 400, platelets 50 would be quite adequate.

Patients always need care when you're tired, worn out, stressed out and on your way out the door. The purpose of residency is to learn how to consistently provide standard of care when nothing is going your way. If we as a society can't teach this to people who graduate med school but haven't yet started their career, this country will not be able to produce doctors who can care for its citizens once the "old guard" of folks like me are too old to work (or dead).

. . .But we have to face reality, which means that everyone who finishes residency and goes on to practice is going to be in situations where they are forced to provide care when they're exhausted, stressed, hungry, and worried about something besides work.

Igor, I agree with some of what you said. Our patients do need us when we are exhausted, worn out, and ready to leave for the day. But, they also need us clear headed.

And, I think that our GME system does teach us how to provide good care when nothing is going right.

It does not and, in my opinion, cannot and should not teach us to provide consistently good care when we are sleep deprived, whether that is acute or chronic or acute on chronic. This is not healthy. We know this. We have known this for more than 100 years.

I have no objection to an occasional 16, 18, 24 or even 36 hour day, when the situation demands it. These circumstances should be very rare, if they happen at all. These situations happen in every industry and task at which humans endeavor and are not unique to medicine. The difference is, that most industries manage these situations better. Medicine chooses not to because of economics. Or perhaps ego?

If there is a compelling reason that offsets the clear and convincing evidence that this is a very bad situation to justify doing this for 3-6 years of residency, willfully, deliberately and routinely, other than the economic advancement of hospitals, I have yet to hear it. If there is such evidence, I assure you I will listen with open ears and mind.

After doing the 7th consult with 6 follow ups and 4 procedures in a day, do you really think it's fair at 7 PM when the 7th consult of the day is asking for your input on how to proceed with the next phase of their cancer treatment, as you, exhausted, quickly read the path report and miss the key phrase that will change the plan? Or miss the adrenal mass that changes the Stage from I to IV? Thus substantially altering what needs to be done?

This is why we do schedule appointments, why we do allocate blocks of time to our patients.

I accept that there will be an occasional, or perhaps even frequent urgency or emergency, depending on your practice and specialty where exceptions can arise requiring extra time and effort. This goes with the territory. The precise timing of a specific emergency cannot be predicted, but historical information can be used to predict the frequency and pattern of emergencies. That information can then be used to build more appropriate office schedules and practice patterns. This will allow us the physiologic rest our minds and bodies require daily and are designed for.

 

[Hurricane]

It was interesting to hear a pediatric resident in a fairytale hospital in the state of New York describe how sleep deprevation was not much an issue in the medical education community.

Yeah, and the bit about how the nurses see she's tired and let her go sleep and restrain themselves from paging her. That may work in a small hospital or ICU. But I have patients scattered across mutliple wings of multiple floors, and I can assure that the nurses never get together in a central location to discuss how I look tired so perhaps they shouldn't page me at 4AM to renew a medication that the patient isn't even asking for. And the bit about how every single order from an intern is reviewed by the senior resident before it's written... in what world?

Instead of spending so much time on the resident from Fairyland Hospital, I wish they had spent more time on the fact that the "regulations" are not laws except in New York and why they're not laws, and gone more in depth about the "disincentives" to reporting that they touched on a little bit.

Anyway, I think its ridiculous that we like to talk about how "evidence based" we are yet continue to ignore study after study about the effects of sleep deprivation because of some romanticized notion of tradition - a tradition which (as noted in the radio piece) is based on a substance induced mood disorder.

And I totally agree with Panda that hand copying numbers from a computer screen onto a piece of paper is inane. Seriously, we can build robot airplanes to kill people, but we can't implement a standardized EMR in this country? If I could have back all of the time I spend copying things from computer to paper, filling out forms, looking for forms, and waiting for the elevator, I think I'd have an extra day a week.

And for all my griping, I'm at a very non-malignant (but busy) program. I really feel for those at the truly malignant programs.

 

[Faebinder]

An all US EMR... what a dream.

Wont happen unless a) The government does it... or b) A major company does starts a service of transfering EMRs between hospitals of different corporations/owners, but for this one to work they need the permission of the government since it's illegal.....

Basically.. the government is the problem.

 

[gutonc]

An all US EMR... what a dream.

Wont happen unless a) The government does it... or b) A major company does starts a service of transfering EMRs between hospitals of different corporations/owners, but for this one to work they need the permission of the government since it's illegal.....

Basically.. the government is the problem.

Which is why I have never understood why the best EMR available (CPRS) was created by the gummint and is available for free to anyone who wants it and yet not mandated by the gummint. I think Medicare should demand a universal EMR for any hospital that wants to accept Medicare payments. It'll never happen but I can dream.

 

[8744]

Acutally attednings do write "long notes" on patients we follow. We're only allowed to write short notes if we can link to house officer's note from the same day.

Most of the time outside large academic medical centers we write our own notes. ICU note exist for a reason - ICU care is complicated and "Afebrile, stable off pressors" doesn't mean much if the patient is critically ill.

I can try an convice everyone about the need to work long hours but I doubt I will succeed. Let me tell you about my day today. Schedule had me on call from 7 AM to 7 PM.

7 AM - start work, see patients
11:30 - lunch
3:00 incredibly boring adminsitrative meeting about effects on contruction on parking, patient room and pt flow
5:00 type up sign out because I'm bored
5:15 admit patient critically ill, start insulin drip, call multiple consultants, reformulate plan.
5:30 forrage for food, find none. curse collegue who ate the last piece of cake before I got to the office fridge
6:45 consider paging night coverage for sign out but realize it's too early
6:50 code called on one of my partner's patients - emergently transfered to ICU, family called, consultants called
7:45 literally at the door of the ICU when my new admit has seizure (in front of family who call me by name to help)
8:30 family of other pt catches me in the hallway and has "just one more question, doc"

Patients always need care when you're tired, worn out, stressed out and on your way out the door. The purpose of residency is to learn how to consistently provide standard of care when nothing is going your way. If we as a society can't teach this to people who graduate med school but haven't yet started their career, this country will not be able to produce doctors who can care for its citizens once the "old guard" of folks like me are too old to work (or dead).

No one wants residents (or attendings) to crash their cars, have miserable lives, or be made to feel lousy. But we have to face reality, which means that everyone who finishes residency and goes on to practice is going to be in situations where they are forced to provide care when they're exhausted, stressed, hungry, and worried about something besides work.

I'd just as soon have a system where my doctors did that before, as residents, instead of learning how to do it as attendings.

Igor

I have great deal of respect for my attendings but they don't pull call as often or anything like residents as it is mostly home call and they only come in under the direst circumstances. We admit all the patients, write all the orders, take care of the lines and airway and then call the attending at home with a brief report. If it's "garden variety" they say "Okay, I'll see him in the morning."

I don't begrudge them this at all but that's just the way it is.

And they don't write long notes. The attendings write long Admit H & Ps but their daily notes in the ICU are brief, to the point, and as detailed or not as required. They do not just write short notes to agree with ours. My attending this week actually rounded on some patients this week before I did and told me that I didn't need to follow up his (brief but succint note).

I havce certianly never seen an attending hand copy lab results onto his note unless they were pertinent. They are in the chart, believe it or not. I only start hunting for them if they aren't.

And you can't train to go without sleep. The brain is not like a muscle that can be exercised for endurance. Like I said, it's only the paperwork that makes call a chore.

 

[8744]

Besides, my objection is the redundancy or the notes. Why recopy the vitals onto the note when they are already in the front of the chart? Same with the labs that, hot off the presses, are both put in the chart and copied onto the nurse's daily sheet.

Why also copy the patients list of meds when they are neatly printed on the daily MAR? Nobody ever looks at the daily note for the meds anyways as things can change and the only true record is the MAR and the nurse.

The meat of the note should be a detailed assesment and plan either by problem or system and it is here where you should, in my opinion, relate any pertinent studies or labs, their significance, the plan to address them. I literally spend more time as a modern version of the Mesopotamian scribe than I do taking care of patients. If we're in a hurry with multiple admits we usually just write the orders and the assessment and plan and write the rest of the crap in later when we have time.

The way we produce notes is so antiquated and idiotic that the charts rapidly become unreadable rat's nests of unreadable and unnecessary notes. I understand that this is may be necessary for lawyer protection but don't try to make a virtue out of it.

 

[KidDr]

Yeah, and the bit about how the nurses see she's tired and let her go sleep and restrain themselves from paging her. That may work in a small hospital or ICU. But I have patients scattered across mutliple wings of multiple floors, and I can assure that the nurses never get together in a central location to discuss how I look tired so perhaps they shouldn't page me at 4AM to renew a medication that the patient isn't even asking for. And the bit about how every single order from an intern is reviewed by the senior resident before it's written... in what world?

yeah, I was wondering the same thing---I thought that was pretty deceptive of her to imply that all orders interns write are reviewed by a senior resident, when this clearly isn't typically the case. I've worked at >10 different hospitals during med school and residency, and I've never seen this done.

Instead of spending so much time on the resident from Fairyland Hospital, I wish they had spent more time on the fact that the "regulations" are not laws except in New York and why they're not laws, and gone more in depth about the "disincentives" to reporting that they touched on a little bit.

agreed--this is where a lot of the real problems are with the current regulations, and where the problems are going to lie when (not if) the hours are changed again. I know a lot of people will disagree with me on this, but I think we need federal laws regulating resident work hours, with regular enforcement by federal officials, in much the same manner that airline pilots' hours are regulated. The ACGME has proven to be somewhat incompetent at regulating work hours (despite their protests to the contrary), and we all know about the issue with disincetives for residents to report work hours violations when violations are linked to whether or not a program gets accredited. I realize that having federal laws and government regulation will probably have it's own set of issues, but I don't trust the ACGME (at all) to regulate work hours.

if you're curious, here's the FAA regulations for pilot work hours:
http://www.faa.gov/news/fact_sheets/news_story.cfm?print=go&newsId=6762

Anyway, I think its ridiculous that we like to talk about how "evidence based" we are yet continue to ignore study after study about the effects of sleep deprivation because of some romanticized notion of tradition - a tradition which (as noted in the radio piece) is based on a substance induced mood disorder.

yeah, I thought that was a really interesting point. for those who didn't listen to the broadcast, Dr. Czeisler talked about how the whole tradition of being "on call" started with this dude who was actually a cocaine addict (hence why he was able to stay up way longer than the average person).

 

[NinerNiner999]

That is a true fact - Dr. Halsted, from Johns Hopkins, who is credited with starting the first formal residency program (surgery) had a cocaine addiction that supplied him with the energy to stay up for days at a time. Unfortunately, one night while working late, he was injured and given opioids for pain control, which led to another addiction. Dr. William Osler, another Hopkins doctor is well known for concealing Dr. Halsted's addictions as he constructed other similar residency programs throughout the nation.

This was in the late 1800's and now, 200 plus years later, we continue to find ourselves maintaining the same tradition and ideals...

 

[dry dre]

This was in the late 1800's and now, 200 plus years later, we continue to find ourselves maintaining the same tradition and ideals...

You must be 18 hours into your shift. I suggest letting the nurses note that you look tired and have them suggest to you that you leave the ICU for a catnap to refresh...

 

[8744]

That is a true fact - Dr. Halsted, from Johns Hopkins, who is credited with starting the first formal residency program (surgery) had a cocaine addiction that supplied him with the energy to stay up for days at a time. Unfortunately, one night while working late, he was injured and given opioids for pain control, which led to another addiction. Dr. William Osler, another Hopkins doctor is well known for concealing Dr. Halsted's addictions as he constructed other similar residency programs throughout the nation.

This was in the late 1800's and now, 200 plus years later, we continue to find ourselves maintaining the same tradition and ideals...

One of my attendings told me that when he was a resident back in the early seventies at our hospital, the place was full to the gills with patients but since there were few interventions and technological medicine was still in it's infancy, it cost very little to keep someone in the hospital and most of the patients were essentially long-term boarders, even many from local nursing homes who were parked over the holidays.

They only had a handful of ventilators in the entire city of Lansing and one of the "scut" jobs for medical students back then was to bag the occasional patient until they could get a vent delivered. There were no CTs, no MRIs, no heart caths, very few labs that were regularly followed, and very few things that could be done for things that are routinely treated today.

He said that today, even the regular run-of-the-mill patients on the general floors back then would have been in the ICU and the ICU patients would be dead years before. A resident from the seventies who could travel in time would return to the seventies to report that the entire hospital was an ICU.

Additionally, very few admits came through the Emergency Department which was rudimentary and a pale shadow of the admission mill it has become today. Most of the admissions were during business hours, if you can believe it.

Today everybody in the place is sick or they wouldn't be here, especially in the ICU. We treat patients with multiple comorbidities that were probably unheard of forty years ago as most of these patients died of the first major condition that zapped them. And we have a steady stream of admissions which, if anything, picks up at night. Not to mention that many of them are also extremely sick and require a great deal of both attention and attention to detail.

I will grant you that the poor residents in the eighties and nineties when medicine started to become too complex for generalists were royally screwed in a system that was designed for the leisurely pace of turn of the century hospitals but it wasn't always as bad as that. That's why the residents of olden-days has so much time for Grand Rounds and other traditions that are going by the wayside. Not to mention that in the old, old days you did an intern year and went into practice, there being very few formal residency programs. It's a lot different suffering for one year than for three or more.

 

[8744]

And I must repeat, it's not "call" at all. It's just another work day where you work in one stretch what most other people do in a week. I have actually had a pretty good call schedule this month in the ICU (Q5 if you can believe it) but I have not been able to get so much as an hour of sleep. I'm afraid to. The minute I put my head down the pager goes off. Even on a slow night I get at least four pages an hour, maybe not all requiring intervention (which is why I can post on SDN when I am on call) but most call days start at 0730 and it is midnight before I get to really sit down for any long stretch, if I'm lucky.

And I like ICU call because it is "procedure heavy." When we do medicine call we are nothing but admit scut-oxen churning out mindless H & Ps all night which nobody reads and may as well be written in sanskrit for all their utility.

So stop calling it "call." Call schmall.

 

[toofache32]

...My attending this week actually rounded on some patients this week before I did and told me that I didn't need to follow up his (brief but succint note)....

I can see it now....

ICU R3

I have examined patient & agree with excellent Attending note....

Yeah, and the bit about how the nurses see she's tired and let her go sleep and restrain themselves from paging her. That may work in a small hospital or ICU. But I have patients scattered across mutliple wings of multiple floors, and I can assure that the nurses never get together in a central location to discuss how I look tired so perhaps they shouldn't page me at 4AM to renew a medication that the patient isn't even asking for. And the bit about how every single order from an intern is reviewed by the senior resident before it's written... in what world?

I was thinking exactly the same thing. Since when do nurses care or even know how many hours we've been working? Many of them think we work 12 hour shifts like they do.

 

[8744]

I can see it now....

ICU R3

I have examined patient & agree with excellent Attending note....



I was thinking exactly the same thing. Since when do nurses care or even know how many hours we've been working? Many of them think we work 12 hour shifts like they do.

One of the ICU nurses went off shift, came back twelve hours later, and then went off shift and was amazed that I was still there. And she was suprised when I said we generally pull thirty hour shifts on call without sleep or breaks.

That's one of the beauties of Emergency Medicine as a resident. Most of your rotations are shift work with no call. I think every EM resident likes it for varying reason but I think we all despise call, rounding, and masturbating over sodium levels.

 

[deleted109597]

I can see it now....

ICU R3

I have examined patient & agree with excellent Attending note....

I love it. I want to use that on a chart.

 

[MBK2003]

When I fall asleep during a case, I often find myself dreaming/having a nightmare about being a pediatric resident in a fairytale hospital...

Where I did medical school training, the interns on the peds surg team would only get to operate on their post-call (q3 of course) days. Over half of my scrub-ins with interns I watched as they fell asleep over the little kids with the bovie in their hand. The attendings would even comment on it, but never asked them to scrub out. I still feel kind of guilty about all those parents who never knew that a fairly impaired surgeon was going to be operating on their kid.

MBK2003

 

[The_Sensei]

...versus 50 hours a week and $180K/yr post-residency.

If I made that little working that long, I wouldn't even bother getting out of bed in the morning.
😱

--- Your friendly neighborhood anesthesiologist

 

[AF_PedsBoy]

If I made that little working that long, I wouldn't even bother getting out of bed in the morning.
😱

--- Your friendly neighborhood anesthesiologist

Great now all the general pediatricians are crying....

 

[mlw03]

If I made that little working that long, I wouldn't even bother getting out of bed in the morning.
😱

--- Your friendly neighborhood anesthesiologist

Great now all the general pediatricians are crying....

Yeah, I was mainly referring to the hospitalist or general internal med guy with those numbers. the pediatrician's reply shows why primary care fields struggle to fill while "lifestyle" specialities, including anesthesiology, are increasingly competitive. what worse in peds is that even the subspecialists don't make that much more money, so it's an even harder sell to say to a peds resident "take another 3 years to become a pediatric pulmonologist even though you'll barely make more than a general pediatrician and you'll have to defer 3 years of real salary for a fellowship salary." patients often tell me how hard it is to get into the pediatric specialists.

 

[EctopicFetus]

Tomorrow (12/13) on "Talk of the nation" (Usually airs at 2 pm EST)

"Dec. 13 · Three years after hospitals were told to limit the hours of young doctors, a new study says they're still exhausted, and this lack of sleep is bad for patient care."

LOL.. who is surprised... the only difference is that we are now doing 110 hours of work is 80 (wink wink) hours..

 

[EctopicFetus]

I think this poster makes an important point that we resident can whine and studies can come out all the time, but until the public gets pissed enough to get politicians more involved things probably won't change. Maybe the sister of an important senator will have to be killed by a resident on their 73rd hour of a week and 23rd hour of a day before things change. I've seen residents and med students drug themselves with caffeine to try and fight off the natural desire to sleep and the data doesn't lie - tired docs screw up more often than rested ones.

I agree the issue is that we need more doc work hours, not necessarily more docs. After residency docs work way less hours and still get paid more. I don't know what the solution is, but there has to be a better compromise between 80 hours a week and $40K/yr in residency versus 50 hours a week and $180K/yr post-residency. I would finish by noting that to my knowledge emergency medicine residents NEVER work 24 hour shifts, let alone 36 hour ones. The docs we have on the front line for the most emergent problems are given adequate rest - don't we want the surgical resident performing a laparotomy to have that adequate rest also?

Attendings at real small hospitals do though! However they may see 24 patients in their 24 hours on!

 

[8744]

Attendings at real small hospitals do though! However they may see 24 patients in their 24 hours on!

I saw a job posting for a BC/BE Emergency Medicine physician that was eight 24-hour shifts per month for $220,000. Now, 24 hour shifts are hard but maybe I'd work 8 days to get 22 days off. If you sleep eight hours after your shift you are good to go. If you think about it, that's the same hours as a forty-hour per week job.

That's the problem with residency, by the way. When you are on call you work in one 36-hour stretch almost what most people work in a week. And if you are Q4 and have seven or eight calls in a month you pretty much get a standard amount of work for a month just on your call days.

 

[toxic-megacolon]

Just saw this on the ACGME website.

http://www.acgme.org/acWebsite/newsReleases/newsRel_11_03_06.asp

97%+ of residents work less than 80 hours per week?
That is just insulting.
Obviously the ACGME is turning a blind eye to the problem.
I was never really expecting to work less than 80, but for the ACGME to put on this whole production about how their work efforts are suceeding is just insulting. 👎

 

[Winged Scapula]

Just saw this on the ACGME website.

http://www.acgme.org/acWebsite/newsReleases/newsRel_11_03_06.asp

97%+ of residents work less than 80 hours per week?
That is just insulting.
Obviously the ACGME is turning a blind eye to the problem.
I was never really expecting to work less than 80, but for the ACGME to put on this whole production about how their work efforts are suceeding is just insulting. 👎

Insulting is right. Who do they think they are fooling?

I just saw that myself but didn't have time to look at their methods, who they surveyed, etc. Obviously only residents who either lied or worked so few hours they had time to answer the damn surveys.

"Lies, damn lies and statistics"!🙄

 

[glorytaker]

Just saw this on the ACGME website.

http://www.acgme.org/acWebsite/newsReleases/newsRel_11_03_06.asp

97%+ of residents work less than 80 hours per week?
That is just insulting.
Obviously the ACGME is turning a blind eye to the problem.
I was never really expecting to work less than 80, but for the ACGME to put on this whole production about how their work efforts are suceeding is just insulting. 👎

I think that should be changed to 97%+ residents REPORTED working less than 80 hours per week

 

[NonTradMed]

This is really sad. Does it really take studies to show that sleep deprivation make it hard to treat patients?

Also, I have heard that part of the reason for the long residency hours is to keep residency short (80 hours over 3 years vs. 40 hours over 6 years). But I'm thinking, given that residents are perpetually sleep deprived, at some point, the human brain is unable to learn and process anymore new information. Doesn't that mean there's a point of diminishing and decreasing return?

I mean, is a well rested person who has worked for 60 hours really leaning less than a person who is working an exhuasting 80 hours and perpetually sleep deprived?

If sleep didn't affect our learning capacity, why bother asking residents to sleep at all? The whole thing sounds like a poor excuse to maintain the status quo. I guess nothing will truly change until someone well known gets killed. The system is set up that allows for this type of abuse. Residents have no power and attendings have no incentive to change the arrangement.

 

[dutchman]

This is really sad. Does it really take studies to show that sleep deprivation make it hard to treat patients?

Also, I have heard that part of the reason for the long residency hours is to keep residency short (80 hours over 3 years vs. 40 hours over 6 years). But I'm thinking, given that residents are perpetually sleep deprived, at some point, the human brain is unable to learn and process anymore new information. Doesn't that mean there's a point of diminishing and decreasing return?
I mean, is a well rested person who has worked for 60 hours really leaning less than a person who is working an exhuasting 80 hours and perpetually sleep deprived?

If sleep didn't affect our learning capacity, why bother asking residents to sleep at all? The whole thing sounds like a poor excuse to maintain the status quo. I guess nothing will truly change until someone well known gets killed. The system is set up that allows for this type of abuse. Residents have no power and attendings have no incentive to change the arrangement.

My theory is that at some point lawyers will get arround to this stuff and start sueing hospitals.

 

[lumanyika]

My theory is that at some point lawyers will get arround to this stuff and start sueing hospitals.

I never thought i'd hinge my redemption to lawyers, but hey....

 

[gutonc]

I probably work <80h 90% of the time. But that may be 78 or 75 hours. While that may be statistically significant, I'm not sure it's clinically significant. Pfizer (or ACGME) may be able to sell a crap-ton of product based on that number but it's largely meaningless on the ground.

 

[ledocdiable]

One of my attendings told me that when he was a resident back in the early seventies at our hospital, the place was full to the gills with patients but since there were few interventions and technological medicine was still in it's infancy, it cost very little to keep someone in the hospital and most of the patients were essentially long-term boarders, even many from local nursing homes who were parked over the holidays.

Exactly. That hits it right on the nose! What's so dysfunctional about the modern residency system and the crazy 30-hour shifts (and I'm speaking from the Medicine side of things, don't know enough about the Surgical specialties to comment) is that it was essentially built for a world that existed decades ago-- back when the acuity and sheer volume of patients was much, much less than it is today.

IOW, being "on call" on a 30-hour shift really meant what it sounded like-- you were on call for exceptional emergencies at night, and otherwise, you slept, at least 3-4 hours and often more. That's what made these shifts manageable within what we all know (and which abundant research also shows) to be the fundamental human limits of performance under extreme sleep deprivation. Yet today, the patients are much, much sicker, volume is far higher, and admitting and management occurs around the clock. We have an antiquated system that puts residents (literally) through torture and turns them into mush on post-call morning, even as they're still writing crucial, detailed orders and making life-and-death decisions! Things used to basically chill out o/n, now, we regularly have pre-ICU patients in their 80's with dozens of drugs on tap, often in Stage III or worse CHF, often with multiple CABG's, and they're admitted all throughout the night to a bare-bones team that has to do everything *and* cover all the pages on their dozens of other super-sick patients on the floor!

It is simply NOT POSSIBLE to work for 24-30 hours straight on repeated periodic shifts, and be remotely functional by hour 24, 25, or 26, let alone 30. It goes against brain physiology-- even though we don't understand the mechanisms of sleep yet, it's as important as food and maybe even more so, which is why the torturers in POW camps would often use sleep deprivation as their method of choice in breaking down the POW's psychologically, with these 30-hour awake periods as critical contributors. Yet this is what we're supposed to put in with every shift-- in the modern hospital, 30 hours on call doesn't mean "on call", but on your feet and running around for 30 hours straight, week after week after week. It's not possible to do that without powerful stimulant drugs-- which have their own horrible side effects-- period!

I found it fascinating from the posts above that the guy at Hopkins who invented the residency system was a cocaine addict, who used the sympathetic activation to pump himself up for 30-hours straight, at great detriment to both his own health and the safety of his patients. That so totally makes sense! IOW, our whole residency training system is based on this guy's severe cocaine addiction, which he hid from public knowledge! I can't even keep count anymore of the number of my friends in residency who are hooked on something or another-- straight amphetamines, Adderall, anti-narcolepsy drugs or something else to keep their eyes open and bleary. They're following more in Halsted's footsteps than they could've imagined.

Honestly, this has to change now. Residency as it is today is one of the most blatantly obvious, painfully dysfunctional cheap labor rackets in the country today. And patients notice it-- when we come stumbling into their rooms post-call after being up 27 hours straight, looking drunk and strung-out, writing orders in the wrong charts and messing up doses by orders of magnitude, they inevitably ask how many consecutive hours we've been up. This sort of thing increasingly makes it onto the "sting" stories on the local news, which is a tremendous embarrassment to us personally and to our profession.

Being on-call for 30 hours straight was never supposed to mean "being on" for 30 hours straight!

I don't think we need radical solutions necessarily-- it's still possible to do the 24-30 hour overnight shifts on call, so long as "on call" goes back to meaning "on call." With all the increased volume and acuity, the hospitals should just hire (and fairly compensate) more NP's and PA's to work the night shifts so as to e.g. take on the new admits while the on-call team takes care of the patients they've already admitted during the day, or to get sign-out with us and help cover some of the simple things (and write orders) for the patients already there. Or maybe have overlapping floats.

That's what they do throughout Europe in places like France or Austria for the overnight teams-- they overlap the shifts and have rough equivalents of NP's there to take on the extra volume and acuity, so that the overnight team almost always manages to get 3-4 and usually more hours of sleep, being woken up only for the true emergencies (and the shifts in general are shorter too). This simple step wouldn't cost much (in fact it would save money from all the malpractice that results from sleep-deprived post-call residents making errors) but it would greatly improve quality of care and overall health of both patients and the house officers!