Work Hour Studies

mvenus929

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        Kind of dumb time for that article, the study ends in june 2016. Although there is the fact that study programs are allowed to continue to break the rules for 2 years after june 2016. Personally at least as a Sub-I I liked the rule breaking hours, more time off during day hours and you actually get to nap a bit during overnights vs night float which is non stop busy.
         
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        NotAProgDirector

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          Coming from AMSA, I think this is ridiculous. As mentioned, if they really had a problem with this they should have stopped it before it started, at this point you might as well let it run its course.

          That said, one of the reasons (of many) that I didn't join the study was the lack of consent from residents. If we were going to join, I was going to ask all of the residents to consent in a private/anonymous fashion. If anyone refused to consent, we wouldn't participate. But there were other reasons we ultimately declined.
           
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          NotAProgDirector

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            Part of the issue was how iCompare and FIRST were initially set up.

            FIRST is designed to be really easy to implement, and is designed to show no difference. Programs that participate can put as much, or as little, overnight call in as they want. Plus the 2 year waiver after the study is completed. Ultimately, no matter what the study shows, programs are likely to argue that they are already back to 24 hour call. Lots of programs placed 24 hour call over the weekends, and that's unlikely to show any difference. But unclear what the trial will really be able to conclude. In any case, the FIRST trial is over -- data collection ended 6/30/2015. Results coming Feb 3.

            The iCompare trial was designed by internists, and was designed to really answer the question. Initially, the trial was a randomized cross over trial. Each program had to do 24 hour call for 1 year, and then regular schedule for 1 year, randomly assigned. And when you're in the 24 hour arm, you needed to be "all in" (or as much in as possible). Although a better scientific design, it was a nightmare to consider. Who in their right mind would be willing to rebuild your entire schedule, then rebuild it again the next year? Great idea, but unrealistic IMHO. Plus, you then had to go back to no-24-hour-call after the trial ended until the results were published and the ACGME decided what to do with it. And, iCompare initially called for "strategic napping" where on call residents needed 4 hours of uninterruped sleep -- this required some sort of a night float anyway (one NF person covering 2 residents doing a 24 hour call for 4 hours each) or having a resident cover two services for 4 hours. Ultimately, iCompare was changed to be similar to FIRST and was more flexible, but I think the damage was already done.
             
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            Crayola227

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              Kind of dumb time for that article, the study ends in june 2016. Although there is the fact that study programs are allowed to continue to break the rules for 2 years after june 2016. Personally at least as a Sub-I I liked the rule breaking hours, more time off during day hours and you actually get to nap a bit during overnights vs night float which is non stop busy.

              I could be wrong, but I'm wondering if that has been prompted by what, as I understand it, have been results that have not supported that work hour restrictions improve patient safety (I'm not sure I buy that but I haven't personally dug into it, I'm all for work hour restrictions regardless).

              Groups that support work hour restrictions may have initially been on board with such research if they thought it was going to support their position, however, it's not uncommon when people start getting answers they don't like to start calling for a halt to research, however late in the game.

              Dunno. What do you guys think?
               
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              dozitgetchahi

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                I could be wrong, but I'm wondering if that has been prompted by what, as I understand it, have been results that have not supported that work hour restrictions improve patient safety (I'm not sure I buy that but I haven't personally dug into it, I'm all for work hour restrictions regardless).

                Groups that support work hour restrictions may have initially been on board with such research if they thought it was going to support their position, however, it's not uncommon when people start getting answers they don't like to start calling for a halt to research, however late in the game.

                Dunno. What do you guys think?

                Ding ding ding, we have an answer.

                If these studies were really so offensive to everyone's sensibilities, there would have been a massive outcry to stop them before they started.

                That said...as stated above, what is 'the question' that these studies are trying to answer? '24hr call vs night float' is a very different question as opposed to '80 hr week vs 100 hr week' or whatever.
                 
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                Law2Doc

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                  (a) 30 hour shifts aren't as oppressive as they seem to those who haven't done them.
                  (B) more errors/dropping the ball occurs at each additional sign out than occurs due to tired residents.
                  (C ) people are still tired and equally error prone toward the end of a night float week.
                  (D) AMSA doesn't actually have a dog in this race. Med students aren't in a good position to evaluate which call system is "better" and many are being duped if they think a 30 hour call now and then is worse than never ending weeks of night float.
                  (E) while nobody likes to work crazy hours, you will find your training suffers at times if there are hard and fast rules that say you must leave the building even when once in a lifetime educational opportunities present themselves.
                   
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                  Crayola227

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                    Ding ding ding, we have an answer.

                    If these studies were really so offensive to everyone's sensibilities, there would have been a massive outcry to stop them before they started.

                    That said...as stated above, what is 'the question' that these studies are trying to answer? '24hr call vs night float' is a very different question as opposed to '80 hr week vs 100 hr week' or whatever.

                    good point

                    there WAS some outcry at outset, plus maybe tempered by hope results would support the restrictions and help that cause
                    there was some concern this study would show limited benefit and lead to return to prior schedules which there was obvs people who didnt want that

                    as far as Law2Doc's points, yeah patients die from med errors, question is what is trade off
                    Don't want deaths from resident car accidents either (I know not common but ya know)
                    Depression, burnout, etc has health affects resident & patient alike, plus resident families
                    I'd like to see that as part of the study

                    PIPE DREAM: we clean up healthcare costs in this society, and train more doctors for longer with more Medicare etc funding, so they can have smaller patient loads, reduce paperwork, spend more face time with patients teaching helping health literacy, better outcomes, less doc visits, docs get more sleep & time with family, we all hold hands and sing kum-by-yah

                    there's nothing instrinsically magical about our current schedules, other countries do it different, it is theorectically possible to right our ship and improve overall health
                     
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                    Crayola227

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                      (a) 30 hour shifts aren't as oppressive as they seem to those who haven't done them.
                      (B) more errors/dropping the ball occurs at each additional sign out than occurs due to tired residents.
                      (C ) people are still tired and equally error prone toward the end of a night float week.
                      (D) AMSA doesn't actually have a dog in this race. Med students aren't in a good position to evaluate which call system is "better" and many are being duped if they think a 30 hour call now and then is worse than never ending weeks of night float.
                      (E) while nobody likes to work crazy hours, you will find your training suffers at times if there are hard and fast rules that say you must leave the building even when once in a lifetime educational opportunities present themselves.

                      I agree mostly.

                      30 hr shifts are plenty oppressive to some people, some students have exposure to night call (I did) as well as working nights (ED rotation, ob, and surg overnight call)
                      Students DID have dog in the fight as they are looking to future and the training they know they are headed for
                      And E) is totally true
                       

                      Law2Doc

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                        ...
                        Students DID have dog in the fight as they are looking to future and the training they know they are headed for
                        ...

                        Well my point was mostly that AMSA represents med students, not residents, and looking to the future means you are really just guessing which is "better" as opposed to having any real or useful frame of reference. As a med student, I would have thought thirty hours would be worse but experienced both and it's so much better to do that a few times than enduring long stretches of night float. So I'm not sure AMSA is representing a majority of its members on this in terms of what they'd ultimately prefer, and for obvious reasons this really is and needs to be a post med school issue.
                         
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                        WinslowPringle

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                          good point
                          PIPE DREAM: we clean up healthcare costs in this society, and train more doctors for longer with more Medicare etc funding, so they can have smaller patient loads, reduce paperwork, spend more face time with patients teaching helping health literacy, better outcomes, less doc visits, docs get more sleep & time with family, we all hold hands and sing kum-by-yah

                          there's nothing instrinsically magical about our current schedules, other countries do it different, it is theorectically possible to right our ship and improve overall health

                          Train for longer? Nine to twelve years is enough for me, thank you very much.
                          Smaller patient loads? Sounds like less operating. No thanks.
                          Less paperwork? YES. Find a way to do this!
                          Spend more time teaching health literacy? Meh. If you mean, spend more time discussing risks, benefits and options of surgery then, yes. If you mean I need to spend more time counseling patients about the importance of analyzing sodium content on Campbell's soups, then nope.
                          Fewer doctors visits? For some patients, sure. For lots of other patients - if only I could get some of the farmers in the area to come in once every few years I'd be happy.
                          Holding hands spreads infection.
                          Kum-by-yah is a terrible song.
                          ;-)

                          Night float stinks because less operating. 30 hour call stinks, but means more operating. I know which one wins for me...
                           
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                          Law2Doc

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                            Train for longer? Nine to twelve years is enough for me, thank you very much.
                            Smaller patient loads? Sounds like less operating. No thanks.
                            Less paperwork? YES. Find a way to do this!
                            Spend more time teaching health literacy? Meh. If you mean, spend more time discussing risks, benefits and options of surgery then, yes. If you mean I need to spend more time counseling patients about the importance of analyzing sodium content on Campbell's soups, then nope.
                            Fewer doctors visits? For some patients, sure. For lots of other patients - if only I could get some of the farmers in the area to come in once every few years I'd be happy.
                            Holding hands spreads infection.
                            Kum-by-yah is a terrible song.
                            ;-)

                            Night float stinks because less operating. 30 hour call stinks, but means more operating. I know which one wins for me...


                            I think at the heart of it is the change of focus between med school and residency. Med school is foundation -- it's lots of stuff you'll never use but you still have to have learned it once to be a doctor. Residency is training to do that which you want to do for the rest of your life. So suddenly the goal isn't solely to get past it so you can do something else. You are already doing that something else and this is now your chance to do and see enough as you can on someone else's liability and watch. So the goal in residency isn't to minimize hours, maximize sleep and avoid being hassled (like it is to some in med school). The goal is to do more cases, see more of those rare zebras, get facile at doing the basic and not so basic procedures you might be asked to do down the road, by doing a lot of them. Much of learning is about repetition, and so you want to come out of residency having done a lot of everything, seen a lot of everything. So someone telling you you should see less and sleep more isn't always good or helpful advice, even if it is meant to protect some people from malignant overlords. And it particularly doesn't sit well when coming from Med student organizations, who haven't walked the walk, and it doesn't sit well when studies show it doesn't improve patient safety a lick.

                            Lots of us emerge from residency to jobs with even longer hours, more call. A fair number of fields have their newbies pay their dues the first few years. So basically residency duty hours Protect people from learning skills that would be really helpful when they emerge and suddenly don't have those protections or supervisors to teach them.

                            So in short your focus in residency, particularly later residency, will be different. The goal is no longer just to get through it, it's to fill your bag of skills and experience with things you need. Someone says, come help me with this cool once in a lifetime case, or do you want to drive the scope on this GI bleed, or can you help me cath this guy, or are you going to see the grand rounds by the top guy in your field, or whatever, you never want to be in a position where you have to say, "wish I could but I've got to be out of the building in 5 minutes". And yet that's precisely the position residents find themselves each week now. And for what-- a few extra hours of sleep a week (if you even believe the night float people are using more of their down time to sleep). That's why med student organizations don't get it -- the focus in med school is to pass your courses and get through, while in residency you are trying to amass as much experience as you can in a relatively short time.

                            It's just bad policy that sounds good to people outside the system, who have been led to believe a tired doctor is more dangerous than a less trained doctor, despite any real data.
                            And it's not like you aren't chronically tired while on night float besides, even if in theory you have all day to sleep.
                             
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                            KnuxNole

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                              While I do feel like working long hours straight is brutal(I have made LOTS and LOTS of mistakes after midnight!), I do agree with the notion of missing out on certain opportunities due to restrictions.
                               

                              Law2Doc

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                                While I do feel like working long hours straight is brutal(I have made LOTS and LOTS of mistakes after midnight!), I do agree with the notion of missing out on certain opportunities due to restrictions.
                                The point isn't that no mistakes are made overnight. The point is that studies have NOT shown that schedules where you sign people off more frequently and get more sleep reduce errors at all, and in most cases the error rates actually go up. So when you combine thst fact with the point about also impacting training, it becomes a no brainier.
                                 
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                                KnuxNole

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                                  I agree, shoddy handoffs can screw things up. I am getting better at it, and after residency, will have a career where I will have to focus on handing off patients daily, so it is a critical skill!
                                   

                                  Law2Doc

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                                    I agree, shoddy handoffs can screw things up. I am getting better at it, and after residency, will have a career where I will have to focus on handing off patients daily, so it is a critical skill!
                                    Yes and no. While you can certainly always do better, You will NEVER be able to bring someone up to speed on everything that happened with every patient during your shift and still get out of there in a timely manner. something always falls through the cracks even with the best of handoffs. And when you double the handoffs you double the error rates. So shoddy or not, having more handoffs ends up being a bigger source of errors than being tired. People have been working to improve handoffs and documentation for years but this source of errors persists, forcing people to realize that maximizing continuity of care to as few shifts a week as possible is probably the best way to address errors. Not more sleep and shorter shifts.

                                    And part of the problem is also that you don't control people outside of the hospital. Just because you make someone's shift eg 14-16 hours instead of 30 doesn't mean s/he's going to sleep 8 hours. A lot of people trying to sleep in the day may be happy if they manage 3-4. So you may have a fairly tired person working AND more shift changes under some of these rules. So I posit that we may be going in the totally wrong direction.
                                     

                                    calvnandhobbs68

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                                      Yes and no. While you can certainly always do better, You will NEVER be able to bring someone up to speed on everything that happened with every patient during your shift and still get out of there in a timely manner. something always falls through the cracks even with the best of handoffs. And when you double the handoffs you double the error rates. So shoddy or not, having more handoffs ends up being a bigger source of errors than being tired. People have been working to improve handoffs and documentation for years but this source of errors persists, forcing people to realize that maximizing continuity of care to as few shifts a week as possible is probably the best way to address errors. Not more sleep and shorter shifts.

                                      And part of the problem is also that you don't control people outside of the hospital. Just because you make someone's shift eg 14-16 hours instead of 30 doesn't mean s/he's going to sleep 8 hours. A lot of people trying to sleep in the day may be happy if they manage 3-4. So you may have a fairly tired person working AND more shift changes under some of these rules. So I posit that we may be going in the totally wrong direction.

                                      Plus it's not even everything that's happened to them during that shift...you have a background of everything that's happened to someone for the last several days, if not longer while you've been there. Like you said, some piece of information gets lost almost every handoff with every patient just because you can't possibly convey everything that's happened since you've been there. You've internalized that information and can use it if a situation comes up but it's not feasible to recall everything during your minute long signout per patient. This is why I really do think it's tough when comparing the call vs night shift system. Personally, I feel like the continuity in a call system is probably actually safer overall. Like everyone else said, your sleep schedule gets so screwed up on nights that it probably cancels out any supposed benefit you get from that system.

                                      I do think that the old school q3 call is too inhumane to do for any extended time while you're on floors/service but the way our system is set up it could be a q4 call system that's turned into a 3 person day + 1 person night team where the night people rotate through a new team every week. Continuity was probably better with someone from the team who's been there the entire month.
                                       
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                                      Law2Doc

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                                        Plus it's not even everything that's happened to them during that shift...you have a background of everything that's happened to someone for the last several days, if not longer while you've been there. Like you said, some piece of information gets lost almost every handoff with every patient just because you can't possibly convey everything that's happened since you've been there. You've internalized that information and can use it if a situation comes up but it's not feasible to recall everything during your minute long signout per patient. This is why I really do think it's tough when comparing the call vs night shift system. Personally, I feel like the continuity in a call system is probably actually safer overall. Like everyone else said, your sleep schedule gets so screwed up on nights that it probably cancels out any supposed benefit you get from that system.

                                        I do think that the old school q3 call is too inhumane to do for any extended time while you're on floors/service but the way our system is set up it could be a q4 call system that's turned into a 3 person day + 1 person night team where the night people rotate through a new team every week. Continuity was probably better with someone from the team who's been there the entire month.
                                        I don't think there's a single way to do it that works flawlessly, but I do think in virtually all cases patients are actually a lot better off in hour 25-30 with a doctor who has been up all night with them and knows exactly what's been done/tried over the past day, than hours 1-5 of a well rested doctor who heard the quick blurb about them from the previous guy anxious to get home. Most who have been in both situations would agree that there's nothing more frustratingly terrifying than to try to figure out what's going on on some crashing patient you barely know, who wasn't highlighted in sign out. That's the weak link in the healthcare chain right there --at some point your doctor needs to go home. But that's the kind of insight the public, AMSA, etc don't seem to understand when people raise the specter of a "tired doctor" botching care. And data doesn't bear out that shorter shifts are safer anyhow.
                                         

                                        NotAProgDirector

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                                          I don't think there's a single way to do it that works flawlessly, but I do think in virtually all cases patients are actually a lot better off in hour 25-30 with a doctor who has been up all night with them and knows exactly what's been done/tried over the past day, than hours 1-5 of a well rested doctor who heard the quick blurb about them from the previous guy anxious to get home. Most who have been in both situations would agree that there's nothing more frustratingly terrifying than to try to figure out what's going on on some crashing patient you barely know, who wasn't highlighted in sign out. That's the weak link in the healthcare chain right there --at some point your doctor needs to go home. But that's the kind of insight the public, AMSA, etc don't seem to understand when people raise the specter of a "tired doctor" botching care. And data doesn't bear out that shorter shifts are safer anyhow.

                                          I agree there's no perfect system. However, remember that in an overnight call schedule, the on call team is "there" for the patient overnight, but then leaves the next AM. So when something happens the next day, there's usually very poor coverage -- at best a day float, at worst the next day's call team who needs to cover. So, in a world where you know that all the "action" is going to happen on the first night of an admission, an overnight call system might be better. But when something can happen night #2 or #3, an on call person covering another team is equivalent to a night float. And we have certainly seen patients who tend to regularly get into trouble at night and have the night float sign out to us "Mr. Smith did his usual thing at 2AM, and I took care of it".
                                           
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                                          LucidSplash

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                                            I agree there's no perfect system. However, remember that in an overnight call schedule, the on call team is "there" for the patient overnight, but then leaves the next AM. So when something happens the next day, there's usually very poor coverage -- at best a day float, at worst the next day's call team who needs to cover. So, in a world where you know that all the "action" is going to happen on the first night of an admission, an overnight call system might be better. But when something can happen night #2 or #3, an on call person covering another team is equivalent to a night float. And we have certainly seen patients who tend to regularly get into trouble at night and have the night float sign out to us "Mr. Smith did his usual thing at 2AM, and I took care of it".

                                            But this only describes one way of doing overnight call. My experience is such that the person on call overnight is missing the next day (after rounds) but the rest of the day team is there so there is more consistency. It isn't a new call team for us, it is the regular day team. The missing person is back the next day, someone else may be missing, but there is more overlap day-to-day than with a nightfloat system. I did overnight call as an intern and then did nightfloat as a PGY2 and 3 after the rules changed. Nightfloat is far inferior to call in my program in terms of continuity of care, sleep hygiene, and lifestyle. I doubt there is a single resident in my program who doesn't wish we could go back to the pre-2011 rules. We have maintained overnight call for senior residents, but as there are fewer people available for weekend call (the nightfloaters are exempt), coverage on the weekends tends to be a bit worse, frequently with more crosscover than we used to have pre2011. The juniors are less well-versed in the services they are covering on the weekends (as they only take crosscover call on weekends instead of at least 1-2x/week) and we try to give 50% weekends off. I have multiple juniors when I'm on as senior, and they change in the middle of the day since they can't take more than 16-hours, instead all of us being a team for 24 hours. Its a mess and none of us like it.
                                             
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                                            22031 Alum

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                                              I think a night float system works well for OB. We have a patient population that is largely uncomplicated, with high turnover, so the effect of multiple sign outs is limited. I'm also only familiar with systems where night float is a separate team, so there are handoffs between two consistent teams every morning/night - the "call team" doesn't have to start from scratch learning about a patient because they were there the night before. Weekends are slightly different, but you almost always have someone from the day team covering so again, nobody is being handed a patient they've never heard of before.
                                               
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                                              ThoracicGuy

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                                                Is there really that much of an advantage to 30 hour shifts versus 24 hour shifts that this would be an issue?

                                                Honestly I'm kind of worried about 30 hour shifts in residency- I can do 24 hours, but 30 hours is about where I hit my seizure threshold :(

                                                When I did those calls, I typically got at least an hour of sleep in there, sometimes more. 30 hour shifts allow you the chance to tidy stuff up before you leave for the day so you don't just dump everything on the rest of your team or another team.

                                                It's a far far better system than the current 16 hour intern limits. I saw how my interns had to deal with this and not only were their weekends significantly affected, but I felt that their overall quality of life was affected by this.
                                                 
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                                                Raryn

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                                                  Is there really that much of an advantage to 30 hour shifts versus 24 hour shifts that this would be an issue?

                                                  Honestly I'm kind of worried about 30 hour shifts in residency- I can do 24 hours, but 30 hours is about where I hit my seizure threshold :(

                                                  It is a 24 hour shift... with 4 hours allowed for overlap for things like signout and wrapping up the care of your patients. 28 total. 30 hasn't been allowed for years.
                                                   

                                                  Law2Doc

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                                                    Is there really that much of an advantage to 30 hour shifts versus 24 hour shifts that this would be an issue?

                                                    Honestly I'm kind of worried about 30 hour shifts in residency- I can do 24 hours, but 30 hours is about where I hit my seizure threshold :(

                                                    When they used to allow 30 hours, it really wasn't any worse than 24. It only sounds worse to those who've never done it. And the best part is, when you are working toward an 80 hour work week, you get there real fast in 30 hour chunks.
                                                     
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                                                    Mad Jack

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                                                      When they used to allow 30 hours, it really wasn't any worse than 24. It only sounds worse to those who've never done it. And the best part is, when you are working toward an 80 hour work week, you get there real fast in 30 hour chunks.
                                                      It's less an issue for me of how arduous it is- I don't have any problem staying up for 24 or 30 hours. Except when I have a seizure. I'd prefer to run through it straight myself if my brain would cooperate, but I'm just more concerned about my health. Unfortunately lack of sleep is my biggest trigger- hopefully I can find a way to deal.
                                                       
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                                                      NotAProgDirector

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                                                        It's less an issue for me of how arduous it is- I don't have any problem staying up for 24 or 30 hours. Except when I have a seizure. I'd prefer to run through it straight myself if my brain would cooperate, but I'm just more concerned about my health. Unfortunately lack of sleep is my biggest trigger- hopefully I can find a way to deal.

                                                        If you have seizures from sleep deprivation, that's an ADA qualifying diagnosis. Should you request reasonable accommodations under the ADA, programs will be required to address it. A request for a maximum of 24 hours is likely to be considered completely reasonable by the courts -- in fact, a 16 hour limit is likely completely reasonable.

                                                        Any accommodation request will need to pass a few tests. It can't change the essential functions of the job -- i.e. you can't make someone else do something that is core to your job. You need to be "otherwise qualified" for the position -- i.e. with the exception of the accommodation, you need to be able to do the job adequately. And it can't cause "undue hardship" for the employer. This is the most complicated part, since exactly how do you determine "undue". The court assesses each case on it's own merits. The larger the employer is, the less effect a financial impact will have. The more residents in the program, the more the program will be required to accommodate your needs with schedule changes (since the change would be less impactful for the other residents)

                                                        You do not need to disclose this at all during the application process, nor can programs ask you. All they can ask is "Can you meet the minimum standards of this position with or without reasonable accommodations?". If you answer no, then they can refuse to hire you. If you answer yes, they are not allowed to ask what those accommodations are.

                                                        What could the program do to address your need? They could schedule you for rotations that don't involve 24 hour call, as long as the educational experience is the same. They could arrange that you split the shifts with someone else -- you each do twice as many / half as long shifts (if this burden can be spread among enough other residents). They could find a way to shorten your shifts, and then add some additional shifts to make up any missed work time -- that would be completely reasonable, even if it required more weekend shifts from you on other rotations.

                                                        What can't they do? They can't fire you over this, or not promote you because of it. To absolutely require 28 hour shifts, they would need to show that it was an "essential function" of the job, or that addressing it is an undue burden. It's clearly not essential -- especially if they have any shift based services (like the ED) or night floats they could always shorten the shift. Whether it's an undue burden is an open question. They can't ask you about it beforehand. They can't limit your career options. I don't believe they are required to write about it in any reference letter they write for you -- but I'm not certain whether they are prevented from doing so.

                                                        In any case, your best option is to not need any accommodations at all and you might want to pick a residency program whose schedule doesn't conflict with your illness. Suing your residency program in court isn't a great way to start your career. Ultimately you'll need to decide whether you volunteer to disclose this during your interviews (and risk getting dropped off rank lists, but being more certain that wherever you do match is more amenable to addressing the issue), bring it up after match but before you're hired to adjust your schedule before you run into a problem, or not bring it up at all, and only address it if a problem occurs. Choice will depend on your personal feelings on the situation, and the field you're going into.

                                                        Reading material, if you're interested:

                                                        Start with this article about the ADA and medical residency in general: http://www.jaapl.org/content/40/4/553.full The example contained in the article is terrible -- the resident is clearly awful and using the ADA to hide behind. But it's a good summary of the law.

                                                        This is a good list of "essential functions" for medical residents: https://med.ucf.edu/media/2013/09/A...lities-in-UCF-GME-programs-final-FEB-2015.pdf I think we can quibble about some of the bullet points, but overall it seems reasonable. Still, it would seem to exclude anyone who was deaf, which seems a problem to me (and probably to the courts).

                                                        Here is a nice legal summary of some case law with the ADA and medical providers: https://www.healthlawyers.org/Events/Programs/Materials/Documents/AMC12/papers/P_pitts.pdf It's written in lawyer-speak, so isn't for the faint of heart.

                                                        This is another summary of medical ADA cases: http://adagreatlakes.com/Publications/Legal_Briefs/BriefNo18_ADA_in_the_Healthcare_Setting.pdf It's not as complete as the above, but an easier read.

                                                        Disclaimer: Not a lawyer. L2D may disagree with some or all of this. If so, likely I am wrong.
                                                         
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                                                        Mad Jack

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                                                          If you have seizures from sleep deprivation, that's an ADA qualifying diagnosis. Should you request reasonable accommodations under the ADA, programs will be required to address it. A request for a maximum of 24 hours is likely to be considered completely reasonable by the courts -- in fact, a 16 hour limit is likely completely reasonable.

                                                          Any accommodation request will need to pass a few tests. It can't change the essential functions of the job -- i.e. you can't make someone else do something that is core to your job. You need to be "otherwise qualified" for the position -- i.e. with the exception of the accommodation, you need to be able to do the job adequately. And it can't cause "undue hardship" for the employer. This is the most complicated part, since exactly how do you determine "undue". The court assesses each case on it's own merits. The larger the employer is, the less effect a financial impact will have. The more residents in the program, the more the program will be required to accommodate your needs with schedule changes (since the change would be less impactful for the other residents)

                                                          You do not need to disclose this at all during the application process, nor can programs ask you. All they can ask is "Can you meet the minimum standards of this position with or without reasonable accommodations?". If you answer no, then they can refuse to hire you. If you answer yes, they are not allowed to ask what those accommodations are.

                                                          What could the program do to address your need? They could schedule you for rotations that don't involve 24 hour call, as long as the educational experience is the same. They could arrange that you split the shifts with someone else -- you each do twice as many / half as long shifts (if this burden can be spread among enough other residents). They could find a way to shorten your shifts, and then add some additional shifts to make up any missed work time -- that would be completely reasonable, even if it required more weekend shifts from you on other rotations.

                                                          What can't they do? They can't fire you over this, or not promote you because of it. To absolutely require 28 hour shifts, they would need to show that it was an "essential function" of the job, or that addressing it is an undue burden. It's clearly not essential -- especially if they have any shift based services (like the ED) or night floats they could always shorten the shift. Whether it's an undue burden is an open question. They can't ask you about it beforehand. They can't limit your career options. I don't believe they are required to write about it in any reference letter they write for you -- but I'm not certain whether they are prevented from doing so.

                                                          In any case, your best option is to not need any accommodations at all and you might want to pick a residency program whose schedule doesn't conflict with your illness. Suing your residency program in court isn't a great way to start your career. Ultimately you'll need to decide whether you volunteer to disclose this during your interviews (and risk getting dropped off rank lists, but being more certain that wherever you do match is more amenable to addressing the issue), bring it up after match but before you're hired to adjust your schedule before you run into a problem, or not bring it up at all, and only address it if a problem occurs. Choice will depend on your personal feelings on the situation, and the field you're going into.

                                                          Reading material, if you're interested:

                                                          Start with this article about the ADA and medical residency in general: http://www.jaapl.org/content/40/4/553.full The example contained in the article is terrible -- the resident is clearly awful and using the ADA to hide behind. But it's a good summary of the law.

                                                          This is a good list of "essential functions" for medical residents: https://med.ucf.edu/media/2013/09/A...lities-in-UCF-GME-programs-final-FEB-2015.pdf I think we can quibble about some of the bullet points, but overall it seems reasonable. Still, it would seem to exclude anyone who was deaf, which seems a problem to me (and probably to the courts).

                                                          Here is a nice legal summary of some case law with the ADA and medical providers: https://www.healthlawyers.org/Events/Programs/Materials/Documents/AMC12/papers/P_pitts.pdf It's written in lawyer-speak, so isn't for the faint of heart.

                                                          This is another summary of medical ADA cases: http://adagreatlakes.com/Publications/Legal_Briefs/BriefNo18_ADA_in_the_Healthcare_Setting.pdf It's not as complete as the above, but an easier read.

                                                          Disclaimer: Not a lawyer. L2D may disagree with some or all of this. If so, likely I am wrong.
                                                          Thanks for the wonderful advice!

                                                          I think I'm just going to try and do whatever schedule they give me and hope nothing happens. I haven't had a seizure in seven years and am off meds, but I've also paid very close attention to my sleep hygiene and diet. If I have one, then I'll discuss things with them. I'll disclose my issue likely after I get brought on, and explain that there's a chance it won't be a problem, but we should be ready to cross that bridge when we get there. 24 hours isn't an issue- it's the 30 that is risky. I'm going to do my best to rank programs and specialties that already have schedules that are more conducive to my condition, and that have affordable housing nearby so that I can just walk to work rather than risk having a seizure while driving. I don't want to be a burden to a program or my fellow residents, so I'm trying to accommodate them as much as possible before asking for them to do anything for me.
                                                           

                                                          Law2Doc

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                                                          1. Attending Physician
                                                            It's less an issue for me of how arduous it is- I don't have any problem staying up for 24 or 30 hours. Except when I have a seizure. I'd prefer to run through it straight myself if my brain would cooperate, but I'm just more concerned about my health. Unfortunately lack of sleep is my biggest trigger- hopefully I can find a way to deal.
                                                            Well, if you have a seizure
                                                            If you have seizures from sleep deprivation, that's an ADA qualifying diagnosis. Should you request reasonable accommodations under the ADA, programs will be required to address it. A request for a maximum of 24 hours is likely to be considered completely reasonable by the courts -- in fact, a 16 hour limit is likely completely reasonable.

                                                            Any accommodation request will need to pass a few tests. It can't change the essential functions of the job -- i.e. you can't make someone else do something that is core to your job. You need to be "otherwise qualified" for the position -- i.e. with the exception of the accommodation, you need to be able to do the job adequately. And it can't cause "undue hardship" for the employer. This is the most complicated part, since exactly how do you determine "undue". The court assesses each case on it's own merits. The larger the employer is, the less effect a financial impact will have. The more residents in the program, the more the program will be required to accommodate your needs with schedule changes (since the change would be less impactful for the other residents)

                                                            You do not need to disclose this at all during the application process, nor can programs ask you. All they can ask is "Can you meet the minimum standards of this position with or without reasonable accommodations?". If you answer no, then they can refuse to hire you. If you answer yes, they are not allowed to ask what those accommodations are.

                                                            What could the program do to address your need? They could schedule you for rotations that don't involve 24 hour call, as long as the educational experience is the same. They could arrange that you split the shifts with someone else -- you each do twice as many / half as long shifts (if this burden can be spread among enough other residents). They could find a way to shorten your shifts, and then add some additional shifts to make up any missed work time -- that would be completely reasonable, even if it required more weekend shifts from you on other rotations.

                                                            What can't they do? They can't fire you over this, or not promote you because of it. To absolutely require 28 hour shifts, they would need to show that it was an "essential function" of the job, or that addressing it is an undue burden. It's clearly not essential -- especially if they have any shift based services (like the ED) or night floats they could always shorten the shift. Whether it's an undue burden is an open question. They can't ask you about it beforehand. They can't limit your career options. I don't believe they are required to write about it in any reference letter they write for you -- but I'm not certain whether they are prevented from doing so.

                                                            In any case, your best option is to not need any accommodations at all and you might want to pick a residency program whose schedule doesn't conflict with your illness. Suing your residency program in court isn't a great way to start your career. Ultimately you'll need to decide whether you volunteer to disclose this during your interviews (and risk getting dropped off rank lists, but being more certain that wherever you do match is more amenable to addressing the issue), bring it up after match but before you're hired to adjust your schedule before you run into a problem, or not bring it up at all, and only address it if a problem occurs. Choice will depend on your personal feelings on the situation, and the field you're going into.

                                                            Reading material, if you're interested:

                                                            Start with this article about the ADA and medical residency in general: http://www.jaapl.org/content/40/4/553.full The example contained in the article is terrible -- the resident is clearly awful and using the ADA to hide behind. But it's a good summary of the law.

                                                            This is a good list of "essential functions" for medical residents: https://med.ucf.edu/media/2013/09/A...lities-in-UCF-GME-programs-final-FEB-2015.pdf I think we can quibble about some of the bullet points, but overall it seems reasonable. Still, it would seem to exclude anyone who was deaf, which seems a problem to me (and probably to the courts).

                                                            Here is a nice legal summary of some case law with the ADA and medical providers: https://www.healthlawyers.org/Events/Programs/Materials/Documents/AMC12/papers/P_pitts.pdf It's written in lawyer-speak, so isn't for the faint of heart.

                                                            This is another summary of medical ADA cases: http://adagreatlakes.com/Publications/Legal_Briefs/BriefNo18_ADA_in_the_Healthcare_Setting.pdf It's not as complete as the above, but an easier read.

                                                            Disclaimer: Not a lawyer. L2D may disagree with some or all of this. If so, likely I am wrong.

                                                            While I mostly agree with what's written, I caution that what constitutes a reasonable accommodation isn't about what's "reasonable" in the view of the person seeking the accomodating. Meaning a place could probably "accommodate" you by, say, extending your training a year such that you logged the same number of overnight hours.

                                                            Also a program may not be able to accommodate you at the expense of others, and the duty hour rules have largely handcuffed smaller programs -- they may not be able to give you less than 24 hours without making someone else work over 24, which they aren't able to do.

                                                            Finally there's duty hours and real life hours. Just because you hit duty hours really doesn't mean you can up and leave mid - Code, or skimp on sign out etc. It also doesn't mean that your co-workers aren't going to feel you are screwing them over when they miss anniversaries and kids plays logging more overnight shifts because you aren't pulling your weight. I wouldn't underestimate how important teamwork and everyone being perceived as being a team player is in this setting. Your co-residents may not see eye to eye with the program as to what's reasonable when your accommodation impacts their schedule and training.

                                                            So be careful what you seek.
                                                             
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                                                            Mad Jack

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                                                              Well, if you have a seizure


                                                              While I mostly agree with what's written, I caution that what constitutes a reasonable accommodation isn't about what's "reasonable" in the view of the person seeking the accomodating. Meaning a place could probably "accommodate" you by, say, extending your training a year such that you logged the same number of overnight hours.

                                                              Also a program may not be able to accommodate you at the expense of others, and the duty hour rules have largely handcuffed smaller programs -- they may not be able to give you less than 24 hours without making someone else work over 24, which they aren't able to do.

                                                              Finally there's duty hours and real life hours. Just because you hit duty hours really doesn't mean you can up and leave mid - Code, or skimp on sign out etc. It also doesn't mean that your co-workers aren't going to feel you are screwing them over when they miss anniversaries and kids plays logging more overnight shifts because you aren't pulling your weight. I wouldn't underestimate how important teamwork and everyone being perceived as being a team player is in this setting. Your co-residents may not see eye to eye with the program as to what's reasonable when your accommodation impacts their schedule and training.

                                                              So be careful what you seek.
                                                              This is exactly why I'm not seeking any exceptions unless I have an issue, and I'm staying away from certain fields and programs that are known for fairly arduous hours. I'm hoping I figure out during third year whether this will be a problem or not, in which case I could simply try and gear my application toward less hour-heavy residencies (PM&R, psych, preventative med, some of the less intense FM programs, EM, etc). I'm a realist- I've got limitations that would make it both unwise and unsafe for me to enter fields like surgery and Ob/Gyn. But There's a few fields out there where I think I can make it work. I'm not looking for exceptions, because I know that, at the end of the day, a program can find a way to get rid of me if they find me too inconvenient to keep around. The law and reality are two very different things in regard to the ADA.
                                                               
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                                                              KnuxNole

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                                                                Thankfully I've never had a seizure during a straight 24 hour shift, I have fell asleep while putting in admit orders though, thankfully nothing bad came out of that, haha.
                                                                 
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