Upcoming interns can now do 24 hour shifts?

[heysexylady]

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I can't imagine doing 24 hour shift as an intern and glad that when I started I wasn't allowed to do it. I feel sorry the the next batch coming in 2017 if this does get voted in this upcoming February.

https://www.washingtonpost.com/national/health-science/first-year-doctors-would-be-allowed-to-work-24-hour-shifts-under-new-rules/2016/11/04/c1b928c2-a282-11e6-8832-23a007c77bb4_story.html?hpid=hp_hp-more-top-stories-2_doctors-11am:homepage/story#comments

 

[wolfvgang22]

Psshhh... in my intern days we felt good if we left the hospital by 28 hours. (I still haven't caught up on sleep. And pretty sure that is when my hair started turning gray. ) Out with the old new rules, in with the new old rules. I feel for program directors that will have to shake up their programs all over again for this.

Those who advocate for longer intern hours claim it is all about patient safety and reducing hand off errors. Yet they haven't been able to show more hand off errors consistently with longer or shorter hours. I suspect it is more about getting cheap resident labor for the hospital overnight and the patient safety claim is a fig leaf argument. The American Hospital Association is a big lobbyist for lessened resident work hour restrictions, I suspect because residents are cheaper than attending physicians or mid level providers, or even nurses.

 

[nitemagi]

Psshhh... in my intern days we felt good if we left the hospital by 28 hours. (I still haven't caught up on sleep. And pretty sure that is when my hair started turning gray. ) Out with the old new rules, in with the new old rules. I feel for program directors that will have to shake up their programs all over again for this.

Those who advocate for longer intern hours claim it is all about patient safety and reducing hand off errors. Yet they haven't been able to show more hand off errors consistently with longer or shorter hours. I suspect it is more about getting cheap resident labor for the hospital overnight and the patient safety claim is a fig leaf argument. The American Hospital Association is a big lobbyist for lessened resident work hour restrictions, I suspect because residents are cheaper than attending physicians or mid level providers, or even nurses.

I most definitely have "wings" that came on during my 30 hour shifts.

 

[sazerac]

Hmm, now I have a new question for all those "do you have any questions for me" interview moments.

 

[birchswing]

Does that mean you're literally working 24 hours or that you're available to be called for 24 hours? That doesn't make sense if it's the former. Who could be coherent after 24 hours of being awake doing anything let alone practicing medicine? People have marathons watching movies to see who can stay up the longest . . . and they're watching movies, which requires an order of magnitude less brain activity than practicing medicine. And I don't even think they last 24 hours.

After I had surgery earlier in the year, I called the after hours number with a question and I said I didn't want to wake anyone but was told that there was a doctor on call for after hours question. It was very obvious that I had woken up the doctor, though. It made me wonder if that doctor was working at that point or not, and if that would be considered part of a 24 hour shift?

 

[wolfvgang22]

It means you are there available in the hospital for 24 hours. Generally, you are working the whole time. The first two years of my residency, I was on call every 3 days and was lucky to get a 20 minute nap while on call and actually worked in the hospital for 30 hours straight. 28 hours was supposed to be the limit, but the program expected me to attend the morning meeting. I'm sure a few other residency programs are a little less rigorous, but many I know were like mine

 

[birchswing]

It means you are there available in the hospital for 24 hours. Generally, you are working the whole time. The first two years of my residency, I was on call every 3 days and was lucky to get a 20 minute nap while on call and actually worked in the hospital for 30 hours straight. 28 hours was supposed to be the limit, but the program expected me to attend the morning meeting. I'm sure a few other residency programs are a little less rigorous, but many I know were like mine

Really hammering in that lesson about stress affecting health through real world experience.

 

[hamstergang]

Does that mean you're literally working 24 hours or that you're available to be called for 24 hours? That doesn't make sense if it's the former.

It makes perfect sense since that's the way it was prior to 2011, and that's the way it is already for non-first year residents. At some point before that, this 24 hour cap didn't even exist. If you'd read the article in the OP, you'd know that they didn't make this decision for no reason -- they did a study and found no differences in patient care outcomes with the shorter vs longer shifts (or so they claim).

 

[deleted736562]

It's ridiculous. It's really nothing but a blatant abuse of residents in an abusive system.

 

[birchswing]

It makes perfect sense since that's the way it was prior to 2011, and that's the way it is already for non-first year residents. At some point before that, this 24 hour cap didn't even exist. If you'd read the article in the OP, you'd know that they didn't make this decision for no reason -- they did a study and found no differences in patient care outcomes with the shorter vs longer shifts (or so they claim).

You're right that I didn't and haven't read the artilce. I was surprised by the general length that doctors can work, whether it's 20 or 24 hours. I didn't really assume before hearing this that there was a legal limit, but I assumed there was a de facto limit, like I don't know, 8-10 hours per day. Unless, as I said, their definition of working is different and means you're working seeing patients 8 hours and on call 16 (and by on call I mean could potentially be called in). Could a person actually be doing labor, as in seeing patients or doing paperwork etc, for 24 hours in a row? That's almost as long as some work weeks.

 

[chicagochildpsych]

In 2009 (my intern year) I did 24 hour call covering 48 inpatients and upwards of 15 admits...alone with no supervision. Then the next year we had to supervise the interns after being expected to do it alone the previous year. The interns who suffered through unsupervised 24 hour call had more clinical acumen.


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[Psychotic]

Glad I am past all of that...never again.

 

[Rogue Penguin]

I think most people aren't directly answering your question. When we're "on call" we are in the hospital and covering any medical or psych issues that arise on the inpatient psych unit, any psych issues that arise involving patients on any of the other units in the hospital, and covering the ED and new admits via transfer. Between those things we are generally quite busy throughout the period of time we're "on call". We're not at home or sleeping. We're indeed actively working as a physician for the entire time. There are nights where it slows down and you can nap but you can't count on getting any sleep. And, yes, you can have a 14 hour call shift after you've already worked a 10-12 hour day and have to be "on" the whole time. We work 24-30 hours straight without resting at all as residents. I'm an intern so I haven't had to, but I've watched the upper levels do it. I will have to do it next year. I find 16 hours pretty brutal so I don't know how I'll make it through 24+. When I'm on nights I feel tired even if I've slept all day to prepare, my circadian rhythm doesn't want to shift. Regardless, you keep working because you have to. No one is going to get hurt if you fall asleep during a movie marathon but when you have demanding responsibilities staying awake is doable even if it is incredibly unpleasant and unhealthy. I know I'm not at 100% at 4:00 AM but I do my best and hope it's good enough to get the job done right.

There is also "home call" where you stay at home and can sleep unless/until you're called but we only have one off-service rotation that works that way and it's considered super cush.

Residents are clearly almost universally exploited as cheap labor.

You're right that I didn't and haven't read the artilce. I was surprised by the general length that doctors can work, whether it's 20 or 24 hours. I didn't really assume before hearing this that there was a legal limit, but I assumed there was a de facto limit, like I don't know, 8-10 hours per day. Unless, as I said, their definition of working is different and means you're working seeing patients 8 hours and on call 16 (and by on call I mean could potentially be called in). Could a person actually be doing labor, as in seeing patients or doing paperwork etc, for 24 hours in a row? That's almost as long as some work weeks.

o o

 

[NickNaylor]

Eh, maybe we've just been lucky but out "24-hour calls" haven't been too terrible. We have two forms of 24-hour calls: on two of our inpatient units, we do roughly q4 overnight cross-cover home call, and then on the other inpatient unit we do a 24-hour in-house call over the weekend twice per month. Both are essentially cross-cover calls, though with the latter experience we're expected to see all newly admitted patients, do initial documentation, and initiate an initial plan until the primary teams return on Monday.

The home call is somewhat tiring but not bad. The in-house call isn't terrible, but it's also only twice in a month.

Personally I like call for the reasons mentions above: I find that I'm more cautious and thoughtful when I don't have anyone "backing me up" (which isn't strictly true, but for minor issues I'm not going to call the on-call attending at 3am). I find it easier to learn, am more motivated to learn, and am much more cautious because I don't want to be the one that screwed everything up when the teams come back in the morning. I'd like to think that I'm always cautious and thoughtful, but the truth is that I think that I'm even more so when acting autonomously. I think it's somewhat easy to slide into the fact that "oh, the attending is behind me, they'll catch any errors that I might make."

At least at my program, the 24-hour calls aren't horrible. I can imagine why some of you are reluctant about this change based on how you're describing your experiences with 24-hour calls.

 

[wolfvgang22]

It makes perfect sense since that's the way it was prior to 2011, and that's the way it is already for non-first year residents. At some point before that, this 24 hour cap didn't even exist. If you'd read the article in the OP, you'd know that they didn't make this decision for no reason -- they did a study and found no differences in patient care outcomes with the shorter vs longer shifts (or so they claim).

Credible research hasn't shown ANY difference between an exploiting, inhumane call system that worsens intern and resident health and shorter shifts with more break time in between. Doctors are motivated, hard working people who rise to the occasion when the going gets tough. That shouldn't give institutions license to exploit us.

I don't know if working a 24 to 30 hour shift during residency every third day made me a better clinician or not. Certainly I was practicing mostly independent at those times while my attendings were home asleep. I did gain a lot of confidence in myself by necessity, as waking up an attending a lot is an unspoken sign of less than ideal competence. I don't really feel it was worth the impact it had on my physical health. But, residents have no choice but to serve or lose hundreds of thousands of dollars in medical school investment and years of effort.

If it is so very important to minimize patient hand offs for safety, why don't attendings volunteer for 24 hour shifts?

Like many attendings, I could shrug and say "Hey, I paid my dues, I made it, so residents today should quit whining", but that doesn't seem right to me. Ethical attendings need to advocate for residents, who are essentially indentured servants to training programs.

 

[deleted736562]

It's difficult to believe some residents are defending this. I don't know what "study" they made, but I believe there is a preponderance of evidence that overworked doctors tend to do a worse job. That's why the EU regulates the hours worked per week for junior doctors to 44, believe it or not. This is just shameless abuse of cheap labor that they shamelessly sell under "education" and, worse, "patient care".

 

[clausewitz2]

It's difficult to believe some residents are defending this. I don't know what "study" they made, but I believe there is a preponderance of evidence that overworked doctors tend to do a worse job. That's why the EU regulates the hours worked per week for junior doctors to 44, believe it or not. This is just shameless abuse of cheap labor that they shamelessly sell under "education" and, worse, "patient care".

Although also in fairness, much longer training times for the most part and it is not clear that everyone in all countries is necessarily working only reported hours.

Our shop doesn't have 24 hour call for anyone, though we definitely have plenty of overnight shifts and our share of 16 hour days. Our calls are generally spent covering the medical needs of 300 psych inpatients solo, which goes about as well as you might expect.

 

[FlowRate]

One of the more recent studies on longer call schedules decided to also survey the residents (surgical residents) on things like whether having to leave affected their learning. I felt like there had to be some additional biases introduced, but IIRC they concluded that longer hours --> better learning based on their survey data, with no change in adverse events... which you wouldn't noticed either way because they're so rare. Because they're so rare, any differences IMO could be entirely due to chance or individual residents.

We have 24 hour call in second year. I thought I was down with that, I had done 24 hour call as a med student a few times. But our 24 hour call has almost 0% chance of getting to sleep any (as a med student, those shifts were often with some chance of sleeping for both the student and resident), and I'm realizing now that it's a little different when you are actually responsible/making decisions, not just doing the med student gather data / observe stuff.

 

[wolfvgang22]

One of the more recent studies on longer call schedules decided to also survey the residents (surgical residents) on things like whether having to leave affected their learning. I felt like there had to be some additional biases introduced, but IIRC they concluded that longer hours --> better learning based on their survey data, with no change in adverse events... which you wouldn't noticed either way because they're so rare. Because they're so rare, any differences IMO could be entirely due to chance or individual residents.

We have 24 hour call in second year. I thought I was down with that, I had done 24 hour call as a med student a few times. But our 24 hour call has almost 0% chance of getting to sleep any (as a med student, those shifts were often with some chance of sleeping for both the student and resident), and I'm realizing now that it's a little different when you are actually responsible/making decisions, not just doing the med student gather data / observe stuff.

Yeah, call in med school can vary. I did Q3 call both MS3 and MS4, and was on call every Thanksgiving and Christmas both years prior to residency. I had friends who went to a DO school that did no overnight call at all in medical school, and so PGY1 was more of an adjustment for them than it was for me. On the other hand, I think I was more tired after 4 years of Q3 call most of the time.

Since at least 2004, people who want residents to work longer hours always point to surgery residents who say they need longer hours for better learning.

Surgery residents are in a different position than most other residents in that they need to do at least 750 of a variety procedures in just a 5 year residency in order to get board certified. It is going up to 800 procedures next year. They either have to work overnight when there is a chance of seeing more urgently needed procedures, or face the threat of a 6th year added to their residency in order to get the necessary experience. This is how surgery programs get surgery residents to advocate for 24 hour shifts.

I don't think that you can generalize this kind if forced choice surgery residents must make to a psychiatry or internal medicine residency.

 

[J ROD]

We do a 28 hr shift on internal med. I don't care anymore.....I just show up and count down the rotations until I am done.

 

[keifernny2]

I did this as an intern. The last few hours are crappy but there are fresh eyes working with you once the day crew arrives. The worst part was staying awake on the drive home from the hospital after 28 hours. The nice thing was the postcall day (Which you don't get with 16 HR shifts)


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