Viewing a single comment thread. View all comments

bananaforsteve t1_j1ymy49 wrote

Reply to comment by swollennode in How do shifts work on really long medical operations? by TerjiD

But... what about sleep?

214

Satire-V t1_j1ysg7z wrote

I don't know much about the reality of medical professionals, but from what I understand sleep seems to be one of those "do as I say, not as the structure of my employment has me do" for them.

486

LonelyGnomes t1_j1zkse9 wrote

Especially in surgical specialties (and especially as a trainee) sleep deprivation is a constant. It’s kind of hazing

213

sky_blu t1_j1zs6ka wrote

"if you see a transplant surgeon, give them a coffee and point them in the right direction"

181

Acrobatic_Safety2930 t1_j2123vp wrote

You people seriously think that our bodies don't get used to caffeine?

​

you get almost 0 effect from it at some point

6

MagicTheDudeChef t1_j21h14m wrote

As an aside, I think there was a study on caffeine where they put people with varying levels of caffeine tolerance through a series of performance tests with and without caffeine, and it showed that even people who had built up a high tolerance and didn't consciously "feel" the effects of caffeine still experienced the same performance benefits of the caffeine. Sorry I don't have the details or the reference (so I can't speak to the robustness of the study), but it's out there somewhere.

16

deldr3 t1_j2224hq wrote

and even if you feel less of the stimulant effect, it still messes with your adenosine neurotransmitters impacting your ability to sleep.

4

WookieeSteakIsChewie t1_j1zqi0u wrote

Wonder how much the surgery death rate and success rate would change if they didn't do this.

103

Cyclops_is_Right t1_j1zr1bt wrote

Unfortunately, we’ve learned that continuity of care is better for patient outcomes in practically all scenarios compared to physician rest. Handovers may occasionally result in loss of information leading to poor outcomes which is just the nature of switching hands.

196

thegypsyqueen t1_j20dllp wrote

There is no true comparison study of these strategies and for every study looking and finding handoff errors there is another showing long shift lengths also increase errors. We very much do not know which one is “better” but physicians would argue that it’s not humane to accept a system that forces them to work 24, 36, or more hours in a row. We are already working an incredible amount of hours in a week. My point is, this is not a forgone conclusion and the biggest study looking at your argument of increased hours being superior for reduction of errors was a biased study conducted by a group of resident directors.

55

LonelyGnomes t1_j21i7uh wrote

Pretty sure a study was recently published that physicians on average thought fewer handoffs were better for patient care, but would not want to be seen by a doc at the end of a 24 hour shift. So basically we’re hypocrites.

6

TheRomanRuler t1_j20mkgd wrote

But why can't you do them in such a way that you got 2 surgeons working at the same time, each with 8 hour shifts but which start 4 hours apart. So you got 4 hours working at the same time, but after 4 hours one of them is changed. After another for hours one who has not yet changed is changed. Every time one who has been working longer is the primary surgeon at the moment, other assists.

That way you got 4 hours of time to get in touch with current state of the operation.

27

Kael_Doreibo t1_j216kom wrote

Your biggest problem with this, particularly in the emergency departments, is the sudden onset of emergencies, their scale, and the time needed for certain surgeries/procedures. There are times when you, as a medical practitioner, need to be on for the entire period that it takes to resolve the onset of cases before you because any switch-over will result in loss of information and potentially death. With so many emergencies happening all the time in a larger population/operational radius of the hospital it become untenable to keep to that kind of schedule consistently and any inconsistencies results in a cascade effect across rosters/schedules.

It's good to at least attempt to keep to that kind of schedule and it makes sense to try it at least but ultimately it is impossible to just say "this is the solution" for every scenario.

15

ninecat t1_j21qd73 wrote

There is already an international shortage in all of the medical professions. Emergencies don’t work to rosters and medical culture trains doctors and especially surgeons that they are super human and can carry on robotically despite fatigue.

2

Boring_Vanilla4024 t1_j203ty7 wrote

Yep, and as much as residents love to complain about how much they work, there really is no other way to pack all of the training a physician needs in a few years. There is still a ton to learn and master as an attending.

3

El-Diable t1_j207eo8 wrote

Then why not pack it in a few more years?

17

Boring_Vanilla4024 t1_j208dob wrote

That would be one option. But physicians already aren't making real money and starting their lives until early to mid 30s as it is. I think most residents today wouldn't want that option though. They essentially want more money for less work hours/less training. They have high confidence and really don't understand what it is like to be out on your own, making most of the decisions on your own without being able to ask your attending what to do.

I personally was happy to get done in a shorter time even if that meant several years of 80-100hr work weeks.

−4

Purecasher t1_j20ib8n wrote

Do you really believe this, or have you gotten used to hearing and/or making up these excuses. If you looked at how other countries train their physicians, you would know this is not true. I mean, just by reading this, I know what country you work in, doesn't that mean something to you?

Residents are needed to keep continuity of care, and they are cheap and profitable. There's also no good reason they can't be paid more... You act as if wanting more money and less work/hours is in any way a bad thing. But clearly, because of people and a mindset like you, this is neigh unchangeable.

Just stop pretending it's a good thing that people are getting used like this.

More rest and free time add to better learning.

12

Boring_Vanilla4024 t1_j20k581 wrote

Less work hours means less exposure to learning cases. End of story.

Also, residents certainly do a lot of work. But every decision they make needs to be supervised by an attending. A private practice attending often can do the work a team of residents does at a training facility. I really don't think they're grossly underpaid. Maybe somewhat, but it isn't like they're working in sweatshops. And, at the end of the day, they are being paid to be trained. It costs serious money to train a resident.

I'm all for more rest and free time if the number of years of training is increased to compensate the loss of experience.

1

Purecasher t1_j20m8md wrote

That's the only reasonable alternative in your mind, which does not surprise me. Except, it is possible to train physicians without significant quality difference, with less exploitative working conditions in the same amount of time. AND there are fewer medical errors.

To me, it is truly laughable that you consider it a privilege that residents are paid to be trained when you calculate how much they bring in as revenue and quality of life for the graduated physicians. Admittedly, I don't know much about the numbers in your country, to that regard.

3

Boring_Vanilla4024 t1_j20pn99 wrote

It can cost upwards of $180k per year to train a resident in the US. Stop with the BS about how much revenue they bring in... they don't, and they're a liability.

When I worked at an academic center my residents were often out the door on non-call days hours before I finished. And you spend a ton of time teaching, looking for and catching errors, and explaining to angry family members why what the PGY1 said on pre-rounds was incorrect. Residents don't bring more quality of life to attending, but quite the opposite. Academic attendings are rewarded by being paid less than their private practice colleagues.

4

jbeansyboy t1_j21b0ez wrote

I tend to agree with most of what Vanilla says. I’m a relatively new private practice general surgeon and I’ll tell ya, I wish I had more time in residency, or at least more time for what I do.

I trained in the days of the “80 hr work week”. All the older folks say they are much better than us because they worked 120 hrs, etc. I think they may have graduated slightly better at overall surgery because they didn’t have to deal with as much administration as we do and most things were operative back then, AKA trauma solid organ injuries, AAAs, or intraabdominal abscesses are a few quick things that come to mind vs now we nonop most of those things.

Additionally I think they had the confidence to think they were good to go after residency because they had more autonomy back then. Most hospitals require attendings in the room now vs back in the older days, residents could operate alone. The ACGME leaves it up to the attendings to allow residents to operate alone but the hospitals have rules that supercede that if more conservative.

This all being said my 80hr work week was never such. Always in the high 90s and on transplant in the low 100s. But we log it as 80. Because we don’t want to get in trouble or losing credentialing.

I would be in favor of lengthening residency with the last year kind of a…. Pseudo attending year where you can operate alone with someone in the hospital in case you need it. You run your own clinic, take your own call, etc. and then having less hrs per week.

But I don’t think I would be in favor of tacking on more years for that. I’d like to get rid of some of the basic science in medical school. I spent a year relearning basically everything I learned in undergraduate courses. That I never use now. I’d just put those things as prerequisites to medical school.

I’d also like to see more direct pathways to specialities ~5 years if one chooses. I do private practice MIS/gen surg. I spent many many many hours and days helping with liver and pancreas transplants that I do not feel help me on a regular basis, or ever. Maybe see a few but not spent 20 weeks on the service. That time could have been seeing and doing more bread and butter surgical cases. Same with endovascular and etc. vascular and CTS are moving toward this.

For those that aren’t sure what they want to do they would have to finish formal residency and then do fellowship like we currently have.

For things like family medicine, emergency medicine, peds, and derm, it already seems very doable how it’s set up. They didn’t seem to work many hrs at all given how their speciality. Good for them!

1

Raddish_ t1_j20noxq wrote

Uh is training a resident really that expensive? At what point are they just getting money back from not having to hire mid levels.

2

Boring_Vanilla4024 t1_j20oy5g wrote

It can be upwards of $180k per year. This was in 2014.

The Costs of Training Internal Medicine Residents in the United ... https://www.amjmed.com/article/S0002-9343(14)00596-8/pdf

3

passwordisnotaco t1_j20qiok wrote

Good thing that, in 2015, over 25% of hospitals received more than $180k in government funding for each resident they trained. https://www.fiercehealthcare.com/practices/study-suggests-medicare-overpaying-1-28b-annually-to-support-residency-programs

3

Boring_Vanilla4024 t1_j20tbs6 wrote

Great. Pay them more, and be sure to pass along some to the attendings that have final say in all decisions and bear all the liability. Don't train them less.

3

YoureGrammarWronger t1_j20tadx wrote

Yes withy he exception of breaks. With breaks, even with the handovers, there is an increase in positivity of outcomes.

3

SleepyMonkey7 t1_j21qzpg wrote

I've often wondered about this. Are there any studies showing this? I've heard from a few doctors that's it's this way just because 'it's the way it's always been done.' Also wonder if there is truly nothing that can be done about information loss during a handover. We've become pretty good with information these days.

1

B1u3baw12 t1_j1zr3cw wrote

Main issue I see if you have someone step in they need to know exactly what has happened and what's next. Problem is making sure all the info would be passed. Which is easier to happen that most people think

10

Dorsai56 t1_j20y9b0 wrote

"Well, that's how I learned to do it, and I survived. These kids just need to learn to toughen up."

1

[deleted] t1_j1zupnw wrote

[removed]

33

wishingtoheal t1_j1zx4pg wrote

This reads like someone who isn’t familiar with how physicians are trained.
The number of residency slots is effectively stipulated by the Medicare budget. There are more and more medical school grads who go unmatched to postgraduate training because there simply aren’t enough spots.

The answer to our healthcare woes is not to relax medical school standards and physician licensing standards.

The increasing degree burden you’re speaking of has nothing to do with physicians. Non physician provider education has been increasingly bloated by degree inflation for the sake of monetary gain on the part of the educational system. An NP, for example, used to require many years of bedside nursing followed by a masters degree. Now, you have for profit universities churning out new grad nurses who have gone straight from undergrad into all online “doctoral” NP program that allows them to practice unsupervised in some states, while having fewer than 500 clinical hours.

50

jfichte t1_j20erri wrote

Exactly, medicare funding needs to increase and be updated accordingly to allow for more residents, which would on turn increase the number of medical students, and ultimately, trained doctors.

12

wishingtoheal t1_j20h6zj wrote

Perhaps in the long term, but not necessarily in the short term. The process of medical school accreditation is separate from the number of residency slots, increasing program sizes, or creating new residency programs.

There are still MDs who go unmatched into programs and the job market for general practice without being board certified is very limited. I think it’s pretty illogical that in many states midlevels (usually NPs) can gain fully independent practice (FPA) shortly after graduating while physicians cannot (licenses require 1-2 yrs of residency training before you qualify for licensure).
A lot of this comes down to lobbying, unfortunately.

8

JewishSpaceTrooper t1_j218mko wrote

ABSOLUTELY 💯 agree!!! The for-profit institutions, specifically the Nurse Practitioner schools, that, for the sake of aforementioned profit, have dropped pre-requisite skills and experience, to virtually the bare minimum. And, let’s not mention the ONLINE education slide (of abomination) from BSN to NP…how the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN) signed off on this is beyond me. Soon enough, the poor people in this country, will only see a physician very rarely….while NPs already handle cases far too complicated for their expertise. What a time to be alive

3

HogSliceFurBottom t1_j20lzid wrote

Similar to the treatment of Ignaz Semmelweis when he discovered washing hands saved lives, today's medical world ignores the facts that sleep deprivation causes mistakes which results in patient deaths.

The profession prides itself on working long hours even though evidence shows sleep deprivation is equal to or worse than being drunk. Pilots, truck drivers, air traffic controllers all work under regulated hours, but the medical world's hubris blinds them into believing they are impervious and the exception.

Medical error is estimated to be the 3rd leading cause of death in the US leading to 250,000 deaths each year. It's unconscionable that the profession does not take proactive steps to minimize these errors by starting with the elimination of sleep deprivation.

The model of working longs hours in residency was promoted by Dr. William Halstead, a cocaine addict, who expected his residents to be on-call 362 days a year and handle a workload that was difficult to maintain without artificial stimulants. It's a deadly rite of passage that continues today.

I haven't even mentioned the effects on residents and doctors themselves. Many residents and doctors commit suicide because of sleep deprivation or in the very least, develop mental illness. And guess what? Seeking mental help in the medical world is frowned upon; especially for students. Mental illness among the ranks is a mark of disgrace. The medical profession disregarding the Hippocratic Oath for their own is one of the worst ironic hypocrisies in the modern world.

31

fastspinecho t1_j213rno wrote

> Medical error is estimated to be the 3rd leading cause of death in the US leading to 250,000 deaths each year.

This is a highly controversial article. Among other things, it considers any intervention that leads to patient death an "error".

In other words, suppose you have an advanced brain tumor. Without treatment, you will die in 6 months. Your surgeon offers an operation that can cure you, but has a 10% mortality risk. You accept the risk.

According to that paper, if you die on the operating table then your death will be counted among the 250000 "deaths by medical error". To avoid errors, surgeons should not operate at all on high risk patients.

I don't think most people would equate known risk with medical error. And that's the only way the authors end up with such a high figure.

12

shapesize t1_j20r2bk wrote

All of that is true, except they’re not enough of us. Most sub-subspecialists are the only ones at a given institution. The decades of training and dedication is not something that everyone can (or wants) to do. Laws aren’t really helpful here, as obviously you’re not going to let a patient suffer just because there is no one else to handoff too. Of course, that means in the end the physician and their family suffer, but unfortunately that comes with the territory. Mostly people need to understand and have respect and patience for their doctors.

7

YoureGrammarWronger t1_j20tv70 wrote

At one of the hospitals I cover, we’re down to one urologist who takes all the calls. Because the other two left and there aren’t any others to help.

5

Wireeeee t1_j1yw1qa wrote

This, I don't understand. Surely, anything above even 15+ hours of concentration is counterintuitive, right? Like, what about the loss of focus, accuracy, and drowsiness? Maybe 24 hours is doable since they've had a lot of practice, but 36 hours is insane.

Like, I start going delirious and dissociating from reality at 30 hours mark (without any stimulant drugs), can't imagine a surgeon not tripping balls from the sleeplessness haha.

86

przyssawka t1_j1z1sdu wrote

Head and neck surgeon here. 24h shifts are the norm, it’s something you just get used to. It sucks but that’s the reality of it. 36 hours of nonstop work does happen, especially in residency. It’s definitely taxing and impacts your productivity especially during low stake work like charting. I had instances of my prechart notes being absolute gibberish due to sleep deprivation. But when it comes to procedures your body runs on adrenaline, tired or not it feels like a reset button was pressed, even during longer procedures like laryngectomies. Getting distracted doesn’t really happen unless you are a med student holding the retractor then all you have left is praying for mercy and sweet release

221

Wireeeee t1_j1z2ub0 wrote

ah, that's amazing, some superheroic stuff. Crazy what the human body and brain can achieve with practice beyond limits. Do you have sugar/caffeine too intermittently during these work hours or is it just adrenaline/chronic stress

32

przyssawka t1_j1z3ra4 wrote

We eat and drink coffee during shifts, nothing different compared to an office job. Part of resilience is definitely adaptation though, residency is exploitative. My speciality doesn’t have those 20-ish hour procedures (at least none that would be all-HNS team) so no surgeon rotation, if it’s 4-5h in the OT you’re stuck there for 4-5h. Then again, hunger or sore legs is the last thing you’re concerned with assuming you’re actively participating, even more so if you’re the primary surgeon.

58

skisushi t1_j1z6n2a wrote

Head and neck surgeons do orchestrate some of the most complex and difficult surgeries though. You may have several teams doing different parts of a surgery and take turns. I have seen as many as 4 or 5 teams work together. Neurosurgery, ophthalmology, plastics, OMFS and ENT/ HNS all can participate on some large tumor resections and reconstructions. When actively involved you can get so focused that food, pee breaks, etc don't cross your mind for 8 to 12 hours. Then you finish and it all catches up to you.

29

przyssawka t1_j1z731i wrote

Yes but as you mentioned for stuff like anterior or lateral approach skull base surgery or large tumor dissections we do take turns. it’s usually a combined effort by neuro, maxfac and ENT. Compare it to stuff like transplantology where one team usually handles the entirety of the procedure.

17

DukeSuperior_Truth t1_j21d1m5 wrote

Exactly. Just because people can’t imagine doing something extraordinary, doesn’t mean it’s crazy or dangerous. People do ultramarathons that run 36 hours with no sleep as well. Adaptation is the operative word here.

2

Parappappappa t1_j21pubh wrote

Running a marathon is not a daily occurence though. Pulling an all nighter once in a while is very different than constant sleep deprivation. Also if someone chooses to run an ultramarathon but they lose focus the only person whose wellbeing is at risk is themselves - however if a doctor (or other staff) loses focus and make a mistake it impacts the patient as well.

5

DukeSuperior_Truth t1_j23ls9o wrote

Good points! I really just mean the analogy to be about how people can do extraordinary things when they are trained over time to do them. Surgery very difficult to get into, training excruciating and those factors help weed out most. The few left in the subspecialty surgery groups really love it, really deserve to do what they do and are of a different breed. Even among doctors, who are all pretty good at working hard and focusing.

1

Larrygiggles t1_j20aw82 wrote

Does stuff like polyphasic sleep ever come up as a possibility?

0

przyssawka t1_j20bd9t wrote

Polyphasic as a necessity more like. Jokes aside not really, the work is structured in a way that wouldn’t allow for the polyphasic sleep cycle outside of on-calls (and even then ER can wake you up at any moment). Not to mention I have yet to see research that proves that it’s a valid and sustainable alternative to regular cycle.

5

drerw t1_j211f4m wrote

That’s why you’re not a surgeon, right? I’m imagining this whole thread being about Navy Seals. They’re just different. It makes sense that someone who started an operation finishes it. It’s like learning an entire machine no one has ever seen, working on it, and then handing it off halfway through to someone else who has never seen it. Except the machine dies if you take to long to figure it out again.

4

Iced____0ut t1_j214ix9 wrote

30 hours without sleep should not have you going delirious and disassociating.

−3

Wireeeee t1_j21kulk wrote

Thank you for knowing more than me about how I’ve felt when I’ve got 30 hours without sleep

2

Iced____0ut t1_j21tcqz wrote

Just have to make yourself a victim? I said you should not, as in that isn’t a typical symptom of 30 hours awake.

You might want to look into your health if you are having that response to 30 hours awake.

−2

Modernfallout20 t1_j1zm6jx wrote

They don't do that. Maybe catch a 15-30min nap at most but surgeons and surgical techs/nurses can work 24-36hrs consecutively without sleeping. They shouldn't, but they can and do.

18

DickButtDO t1_j21twpa wrote

Are nurses and techs doing 24 hour shifts? I've never seen that...

1

Modernfallout20 t1_j221zx8 wrote

The only hospital I ever worked at certainly did, but it was out of necessity due to staffing issues.

1

MurkDiesel t1_j206ztf wrote

that's what malpractice insurance is for

and it's not like malpractice lawsuits are easy or successful

so why would they sleep?

0