I am about to enter internal medicine rotation/ residency with 28 hours shift with no or minimal sleep. How can I maintain my concentration and performance in such sleep-deprived and heavy workload environment?
I am about to enter internal medicine rotation/ residency with 28 hours shift with no or minimal sleep. How can I maintain my concentration and performance in such sleep-deprived and heavy workload environment?
Call is how often? 1:4? For a one month rotation that’s 7 calls? Get sleep before and after...and rarely , unless you aren’t efficient, will you be busy the whole 28 hours...go take a nap during your down time.Coffee PRN. Nap whenever possible. While possible, it is unlikely that your IM 28hr call will have no opportunity for you to catch a couple hours of sleep.
EitherPart of the struggle is that my support system does not include a physician to coach me through clinical reasoning. I do have advisors who I plan on using to help support my transition elsewhere, but they're definitely not going to have the time to coach me just to help. Does anyone know of any physician coaching services to improve in areas such as clinical reasoning?
I think he posted in the wrong threadEither
A: You're responding to someone I have ignored so I don't have context
B: I'm completely missing where this comment came from
C: You are also the op but forgot to switch accounts before responding.
Edit: just realized that you have been posting extensively in a related but separate thread. I'm assuming that you responded here by accident as your comment here is otherwise something of a non sequitur.
As a matter of fact, yes there is.Is there any data to show that 24 hour shifts in residency actually do anything to improve (1) the quality of physician it produces at time of graduation, and (2) the quality of care a patient receives. Seems like at this point it's being done for the sake of tradition and at the potential peril of patients and physicians alike.
As a matter of fact, yes there is.
"...One secondary analysis revealed that when adjusted for workload, the relative risk of a serious error during the intervention schedule was half as high as the risk when resident physicians worked 24-hour shifts. This finding further suggests that extended-duration work shifts are hazardous. The increased workload of resident physicians appeared to be the most likely explanation for the lack of success of our intervention in the primary analysis.
Beucler et al. discuss the challenges of reducing work hours when the workforce is inadequate. We agree that too few personnel can preclude safe reductions in work hours, but we think that the health care system must invest funding to address this challenge, as recommended by the National Academy of Medicine.5 Mueller et al. also raised concerns related to the structure and financing of the health system, specifically the manner in which the operational dependence of academic medicine on trainees’ labor may create a conflict of interest that makes it difficult for institutions to address resident physicians’ long work hours. Although these are major pragmatic challenges, we strongly agree with Mueller et al. that it is past time that academic medicine shed its denial of the science regarding the adverse health and safety effects of sleep deprivation and start investing in sustainable change."
"It is troubling that the medical profession continues to collectively tolerate the well-established problem of systematic sleep deprivation and fatigue that affects employee health and patient safety. Indeed, the authors state that a “robust literature” already documents an adverse effect of sleep deprivation on the performance of resident physicians. The Joint Commission documented this problem in a 2011 Sentinel Event Alert.2
A 24-hour period of hospital call means that resident physicians frequently work excessive hours without sleep or rest and then may have a dangerous drive home.3 Whereas long hours of continuous duty were long ago eliminated in other high-risk professions because of the danger that they pose to members of the profession and the public they serve,4,5 physicians persist in challenging the settled science on the necessity of sleep. We must ask ourselves whether this denial of science is driven by a heavy dependence on resident labor in academic medicine. Regardless, it is time for physicians to stop studying an answered question and start changing practice."
Is there any data to show that 24 hour shifts in residency actually do anything to improve (1) the quality of physician it produces at time of graduation, and (2) the quality of care a patient receives. Seems like at this point it's being done for the sake of tradition and at the potential peril of patients and physicians alike.
Is there any data to show that 24 hour shifts in residency actually do anything to improve (1) the quality of physician it produces at time of graduation, and (2) the quality of care a patient receives. Seems like at this point it's being done for the sake of tradition and at the potential peril of patients and physicians alike.
As a matter of fact, yes there is.
There are actually a few studies looking at work hour variations, and generally they show that shorter shifts are either neutral or lead to more errors due to handoffs. The PICU one is the most recent one
On one hand I would love not to have shifts extend beyond 12 hours, on the other hand, I don't want residency programs to grow and pump out more residents and saturate the market.
Honestly I could be way off, but I'm conflicted over the issue of resident hours. On one hand I would love not to have shifts extend beyond 12 hours, on the other hand, I don't want residency programs to grow and pump out more residents and saturate the market.
Honestly I could be way off, but I'm conflicted over the issue of resident hours. On one hand I would love not to have shifts extend beyond 12 hours, on the other hand, I don't want residency programs to grow and pump out more residents and saturate the market.
This exactly.As a devil's advocate - my program did night float which was awesome - nights were fun and you were free from the tedium of rounding and meetings, but we also didn't get the experience of doing a 30 hour call and learning how to function in that mindset/sleeplessness. Thankfully we did q4 30's (28's, whatever is allowed now) in the ICU. Why am I saying thankfully?
They sucked. But now as an attending I have an incredibly lucrative moonlighting gig where I cover a small hospital from Friday at 7am thru Monday at 7am. That's right party people - 72h strait as solo physician coverage. I get paid absolute bank, and honestly it's still better than the shifts in the ICU which prepared me to be able to handle it and learn how to sleep when on call - as well as what's important enough to go in for at 2am and what can wait until the morning.
So do they suck? Absolutely. Are they a valuable learning experience that will better prepare you for your future career? Absolutely. And feel free to disagree with that, but you'll never convince me that learning how to competently manage patients at hour 24 of sleep deprivation is going to do you a disservice long term.
I have an incredibly lucrative moonlighting gig where I cover a small hospital from Friday at 7am thru Monday at 7am. That's right party people - 72h strait as solo physician coverage.
....you'll never convince me that learning how to competently manage patients at hour 24 of sleep deprivation is going to do you a disservice long term.
In theory that sounds good, but what happens if for any number of reasons you cannot get much, if any, sleep working that many hours. As a patient I don't want that doctor coming anywhere near me if he/she walks in to my room looking like death. I don't want them making medical decisions for me or having anything to do with my care if they aren't well rested and in their best and sharpest frame of mind. Patients are owed that. You (and every physician) are prone to the same fatigue and poor clinical reasoning as anyone else would be with sleep deprivation. This notion in medicine that dismissing the need for sleep as we render complex medical care is both absurd and incongruous with our understanding of how the brain and sleep work, and in 25 years I'm sure this will be viewed as barbaric as it should be. Pt safety should always be first (and docs too for that matter), and lack of sleep is a pretty darn good way to increase risk of errors being made regardless if you're a resident or an attending. There are dozens of occupations out there where work hours are restricted due to the inherent risk to the public that comes with sleep deprivation. Having a medical license doesn't exclude us from those same vulnerabilities.
Edit: stepping off my soapbox now.
In theory that sounds good, but what happens if for any number of reasons you cannot get much, if any, sleep working that many hours. As a patient I don't want that doctor coming anywhere near me if he/she walks in to my room looking like death. I don't want them making medical decisions for me or having anything to do with my care if they aren't well rested and in their best and sharpest frame of mind. Patients are owed that. You (and every physician) are prone to the same fatigue and poor clinical reasoning as anyone else would be with sleep deprivation. This notion in medicine that dismissing the need for sleep as we render complex medical care is both absurd and incongruous with our understanding of how the brain and sleep work, and in 25 years I'm sure this will be viewed as barbaric as it should be. Pt safety should always be first (and docs too for that matter), and lack of sleep is a pretty darn good way to increase risk of errors being made regardless if you're a resident or an attending. There are dozens of occupations out there where work hours are restricted due to the inherent risk to the public that comes with sleep deprivation. Having a medical license doesn't exclude us from those same vulnerabilities.
Edit: stepping off my soapbox now.
Exactly. Would anyone want to fly in an airplane with a pilot who was working a 72 hour straight shift where they got an hour or two of sleep between flights? or even a 24 hour one?
Look, and I get it, but where I live there legitimately is often not an alternative. So you can either get a sleep deprived me or you can get nothing. That pneumonia you have? Yep, you'll need to get life flighted down to the closest center, enjoy the $25,000 bill for the flight. Cellulitis? Airplanes on the way. Oh, you'd prefer ground transport? Sorry, we don't have a crew that can make the 12 hour round trip.
I also realize I'm never going to convince someone who doesn't think there is value to learning how to work sleep deprived that there is a benefit in doing so. It's like anti-vaxxers (or now anti-maskers) - the opinion is set and often fixed.
Think of it this way. You get married. You have a kid. That kid doesn't sleep through the night, so you don't sleep through the night. There will be nights you'll spend up in an ER or up with a vomiting baby. Do you call in for those shifts because you've been awake for 24h and can't work the next day? And where do you draw the "sleep deprived" line? Lord knows I would argue I want someone who has had a full 8 hours over someone with a broken 6 because they're up with a baby.
What happens if at some point insomnia comes for you - do you go on disability because you physically can't fall asleep until 3 o'clock in the morning?
These examples seem ridiculous, I get it. But this is what you're arguing for.
Those studies are inadequate because they don't measure mental health outcomes, morbidity, and even mortality among the providers in each group.
I said nothing about the impact on residents. The question was about patient safety. These studies all looked at patient safety and there aren't differences. I agree that they aren't looking at the right outcomes, but what works for me individually may not work well for someone else.
And, as others have mentioned, there are other factors as well. I know some of my classmates got better sleep in the hospital on call than they did at home with a new(ish) baby. YMMV.
As a devil's advocate - my program did night float which was awesome - nights were fun and you were free from the tedium of rounding and meetings, but we also didn't get the experience of doing a 30 hour call and learning how to function in that mindset/sleeplessness. Thankfully we did q4 30's (28's, whatever is allowed now) in the ICU. Why am I saying thankfully?
They sucked. But now as an attending I have an incredibly lucrative moonlighting gig where I cover a small hospital from Friday at 7am thru Monday at 7am. That's right party people - 72h strait as solo physician coverage. I get paid absolute bank, and honestly it's still better than the shifts in the ICU which prepared me to be able to handle it and learn how to sleep when on call - as well as what's important enough to go in for at 2am and what can wait until the morning.
So do they suck? Absolutely. Are they a valuable learning experience that will better prepare you for your future career? Absolutely. And feel free to disagree with that, but you'll never convince me that learning how to competently manage patients at hour 24 of sleep deprivation is going to do you a disservice long term.
I also realize I'm never going to convince someone who doesn't think there is value to learning how to work sleep deprived that there is a benefit in doing so. It's like anti-vaxxers (or now anti-maskers) - the opinion is set and often fixed.
I never understand residents who don’t like the night float systemThe creation of a night-float service solves a lot of this. As it stands right now at our institution multiple services have either 24-28 hr shifts or they have 12-16 hr shifts, depending on the program. The only reason some have the longer shifts is because the residents have basically decided that they'd prefer not to have more call when not on the inpatient service or they'd prefer shorter nightfloat (e.g. 4-5 days a week rather than 6), so they are doing the 28s. Personally, I think its sadistic. Sleep is an essential and directly impacts your quality of life.
Right now psychiatry has a solid night-float system, but it means residents are doing 4-6 weeks of continuous night float (6 days a week, 11-12 hr shifts), which sucks, but at least you're sleeping (albeit on a different more lonely schedule). They are debating changing it to be more like IM night float. They want to have 2 residents on doing 16s and once weekly 24s, alternating every other day for 8 weeks, and the goal was stated as decreasing call when on other rotations. Personally that sounds so much worse that I don't even understand how they're considering it.
I've done enough 24/28s to know that they suck, and I never want to experience them again. 12-16s, yeah I can do those any day of the week.
Really? Weeks on end without seeing my spouse or interacting with anybody outside of the hospital? And never having more than a single day off during the entire time to fully recharge and decompress.I never understand residents who don’t like the night float system
The only reasoning I can come up with is that.... they’ve never experienced the night float system....
It’s eons better
That can be said about literally everything and should not be the basis of policy. If you have a baby and can't sleep at home, go sleep somewhere else. No one's stopping you from sleeping in the call room. But what we know - as doctors - is that sleep deprivation is real. We tell our patients to protect their sleep. We even prescribe sleep aids to help them do that. Then we turn around and make policies that are inconsistent with normal sleep. We're hypocrites.
After all, it's not 'normal' to sleep during the day.
Alertness and performance remain most impaired during night shifts given the lack of circadian adaptation to night work. Although healthcare workers perceive themselves to be less alert on the first night shift compared to subsequent night shifts, objective performance is equally impaired on subsequent nights.
By that argument, we shouldn't have night float at all. After all, it's not 'normal' to sleep during the day
But medicine during the night looks different than medicine during the day. Decisions are made based on available resources, for better or worse. That experience is important. Doesn't make it normal to work nights
You seem to think we're on different sides, and I don't think we are. Sleep deprivation is an issue, and we certainly shouldn't force people to work in unsafe situations. But if Resident A functions better on a 28 hour call every 4 (or whatever days) and Resident B functions better working a week of nights every month, whose 'truth' should we follow?
Which policy is 'right'? Neither lead to great sleep outcomes, but, again, doing medicine at night is an important learning experience
You're trying to balance two competing interests. Not to mention the competing interest of 'days off'... when you can get a true day off working 24s vs a 24 hour period off by working a night float system
This all isn't to say that we shouldn't try to make things better, but often people are working within the confines of the resources available to them.
This is an important point. The idea that night floats are a panacea begs the question "Are night shifts healthy?" There's data to suggest they aren't. So which one is "least bad"?
The Impact of Shift Work on Sleep, Alertness and Performance in Healthcare Workers
What are you talking about? That giant block from right when you wake up in the early afternoon to 6-8 at night you couldn’t see anyone? Couldn’t have dinner then? Seriously?Really? Weeks on end without seeing my spouse or interacting with anybody outside of the hospital? And never having more than a single day off during the entire time to fully recharge and decompress.
You can't see why some people would prefer being able to have dinner and see my spouse 5-6 days a week and having golden weekends to visit the rest of my family and take hiking trips with my dogs?
Nope. I much preferred the rotations with call over the rotations with night float in residency. I understand that some people hate the call nights and don't have family around. However, I am surprised that you cannot understand that some residents are much happier under each system and night float isn't a perfect panacea.
Our night float started at 5pm and my husband (and friends) didn't get home from work until after then. So no, we didn't ever have dinner together when I was on night float. Did your night float really not start until 8pm at night? Yes, I often got some sleep on night float, didn't make me hate it any less!What are you talking about? That giant block from right when you wake up in the early afternoon to 6-8 at night you couldn’t see anyone? Couldn’t have dinner then? Seriously?
Literally can have dinner every single night..
Also, youre peds trained: you weren’t sleeping a few hours for a good bunch of those nights in residency, allowing for an even larger chuck mentioned above? I find that hard to believe