Transport does indeed run 24/7. You ever drive on a highway in the wee hours of the morning or work a gas station during third shift?
I am not talking common sense, I am talking common knowledge. There are institutions that study nothing but sleep. I myself have and continue to get too little sleep. I have been surrounded from time to time with those who are long on hours and short of sleep. It appears that the only field of the many we humans go into who do not understand the need to get a certain number of hours of sleep each and every 24 hour period is the medical field.
Handover errors are communication errors. What the Fauci you guys do at turn over, “I had it, you got it.”, and leave? If handovers are such a problem with you, adopt the Japanese way and do away with them all together and stay with your patient until they leave, either to the crematorium or to home.
Taxi vouchers? Are you Faucing kidding me? In my home town, there we do not have a taxi service in the entire country. Guess you could hitch hick back home. Ride a bicycle or just walk.
We, your customers, do not like being seen by people who are just as sleepy as we were when we got into the accident that brought us to your hospital at 3 am.
Interesting question (should residents take the day off when they are tired), but it's framed so as to invite a binary response and a dialectical discussion. The unsatisfying answer, considering all trainees, is "maybe." Should the resident who has a long commute and a chronic health condition take the day off when he or she is tired? Sure. Should a resident on the exact same team, who lives within walking distance of the hospital, and has no health conditions take the day off when he or she is tired? Maybe not. I worked a 30 hour shift as a resident and then drove to San Francisco a few hours later; to be honest, I wasn't particularly tired, but I'm a heavy coffee drinker. I still got pulled over for suspected drunk driving and had to do a sobriety test, suggesting that my driving stood out as impaired. Another resident I worked with worked 36 hours straight, drove home a short distance from the hospital, and fell asleep at the wheel- driving into a ditch in the process. Perhaps these were learning experiences, but they weren't safe, nor did they show commitment to helping save lives. Some people seem more impaired without 7-8 hours of sleep per night than others, and many of the rest of us are probably more impaired than we think we are when we try to get by with less. I used to brag that residency taught me how to be highly effective even when highly sleep deprived; but I suspect that it really taught me to THINK of myself as a "highly effective person" when highly sleep deprived. In other words, residency taught me, among other things, to be highly delusional. And I would argue that we are deluded when we think we know how tired another trainee is, and how that feels. They are more likely to work hard and be dedicated if we respect them and believe them when they say they need a break.
27 hours is definitely a long stretch, but it’s worth noting that many specialties, especially those with busy on-call shifts like anesthesia, have already eliminated shifts beyond 24 hours. Nowadays, many call shifts range between 12 and 18 hours.
It seems you might be skeptical of the research, likely because it contradicts what feels like "common sense." However, I think the truck driver analogy might not be the most appropriate comparison. Driving can be monotonous and hypnotic, while medicine tends to be highly stimulating.
So, why might the research be correct? Can the debate be reframed to make sense from a common-sense perspective?
Patients who come into the hospital or experience an issue at 3 a.m. still need treatment, and the doctor who attends to them has likely been awake since 6 a.m., regardless of when their shift starts. Here are some questions to consider:
1. Will a doctor who normally starts at 7:30 a.m. significantly adjust their sleep schedule on the day of their call shift, which begins at 6:00 p.m.? In other words, will they actually be more rested?
2. At 3 a.m., will the doctor who started their shift at 6:00 p.m. be in better condition than the one who has been at the hospital since 7:30 a.m., given that they likely woke up at roughly the same time?
3. If you’re already admitted to the hospital, will the doctor who knows you (the 7:30 a.m. doctor) perform better than the one who doesn’t know you as well (the doctor who received the "handover" and started at 6:00 p.m.)?
4. If the 6:00 p.m. doctor is more rested throughout the night, is that benefit enough to compensate for the potential errors that could occur during handover?
5. What shift duration is the right duration? Can shifts be too short? Too long? At what point?
6. Is the problem the long shift, or is it simply the overnight hours, regardless of when the shift starts?
I happen to believe the research because it makes sense to me, and there is a respectable amount of it. But I also understand why some might find it hard to accept, as it contradicts what seems like common sense—a little like mask mandates. ;-)
No doctor enjoys extended-hour shifts, nor do we particularly like regular-length shifts that go overnight. But medicine isn’t about what we like or don’t like.
As for the concern about car crashes after extended shifts, it’s a valid point, but I’m not aware of research showing an increase in actual crashes. There are ways to mitigate this risk; for example, many (if not all) residency programs have provided taxi vouchers to residents for over 15 years now.
People who consider taking a day off for being tired think the the valuable part of medical education is the didactic stuff and what the learner does with that in their own head.
Alternatively, the valuable part of medical education might be the experience that people get seeing patients, listening to their stories, seeing what happens when you do stuff to them. The classroom material can be taught differently, or more efficiently, or tomorrow if you’re tired today, but today’s experience is obtained only today. Experience is by definition working a bunch of hours and seeing a bunch of stuff.
In my opinion, the important part of learning is how you integrate what you saw today with the patient with what you knew previously–whether it was from the classroom or bedside. A real doctor is infinitely more valuable than Dr Google. Experience with patients is what separates us.
I'm an NYC RN who after 35 years can say from experience there is an unmentioned consequence or even an acknowledgement by these residents.
That is that by taking that day, your patients often express the disappointment or anxiety they feel when they look forward to, and expect to see you, and an unfamiliar face comes into their room. Hospitalization is stressful enough.
Ultimately, the work has to get done or the patient suffers. If there's a team behind you, great. The day MAY come where you're the only one around, no way out, you're the attending. No other resident, no PGY1, no med students to help out. What then? Training to occasional extremes lets you know you can do it. I'm certainly not comparing myself to a navy seal, etc, but they train them to extremes for a reason, so when the world gets real, you've been there before. I worry we're getting a whole new generation that has never really been stressed....
Partly not their fault. They were raised by a generation of helicopter parents.
However, this is, as a broad brush, a generation that is fragile, coddled, anxious, a little bit entitled at times, and lacking in some resiliency, as an effect of their general upbringing.
The helicoptering is outrageous. I've seen one of my sisters get involved in college roommate problems afflicting one of her daughters. I can't get my head around that.
It's one of those careers you are either built for or you are not. Intrinsically rough and seemingly unfair. The major issue with "Wellness" is that it allows a liberal and subjective definition of fatigue and burnout. One persons unrested sleep is another's "insomnia". A series of URI's is someone else's "long COVID". Being asked three questions in rounds is often "psychological trauma requiring a wellness day off". Systems that deal with human life have to be predictable and efficient, and cannot allow staffing absences from subjective self-defined stress, anxiety, fatigue, and insomnia. We are doctors. We are not doctors if we are not reliable.
I agree Srinath, but unfortunately we do not have ways yet to make these issues objective. Should a healthcare worker call out for a 102 fever? absolutely. should they call out after a string of days with only 1-2 hours of sleep where they are passing out and can’t walk straight or even complete sentences? absolutely. but because the latter kind of “illness” cannot be measured it’s SO important we build a system where we feel safe to just talk about it. the answer does lie in open, honest communication. for example, i called my supervisor that day and talked through the situation. I was encouraged to take the day off due to the degree of impairment and resulting physical illness. But any other days where i’m simply “sleepy” (lol) I don’t call in. But I still talk to my team about it - “hey guys, I’m feeling a little slower today from lack of sleep. Pharmacy, pay a little more attention to the orders I’m putting in today. Nursing, page me immediately if there’s something I forget to do…” those sorts of things. Open communication is key. but when we perpetuate the stigmatizing message that “wellness culture = weak” we discourage these necessary conversations. And then patients can suffer from it. You’re right that systems dealing with human life must be predictable and efficient - a cognitively impaired doctor refusing to take the day off because of fear is a sure fire way to quickly affect such a system.
Also, to say you are either “built for it or not” is FAR too extremist and is the reason why we have to fight to have diversity in medicine these days. Maybe I am going to call out 1-2 more times a year than another colleague who is intrinsically less affected by sleep. But, on the flip side, maybe I have a better immune system and I DONT call out as much for getting a febrile illness. There is a reason we are all allowed the same # of sick days. My original post was to encourage people to use theirs when truly needed / when patient care would be compromised, regardless of the reason.
Also re: “being cut out for it”: I have only been a doctor for a year now and having these intrinsic “issues” or “weaknesses” have allowed me to deliver more compassionate, patient-centered than I’ve witnessed the majority of other peers be able to do. And why patient-centered care = practicing excellence/ improves outcomes is a whole other post. The point is we all have our different strengths and weaknesses.
The Norwegian system sounds good. The UK system is supposed to work a bit like that but because the "penalties" are so small there are still some pretty unpleasant shift patterns.
Surely the issue is:
1 historically the US training system was established by doctors who infamously used cocaine to stay awake, but it's now become tradition.
2 the system relies on long hours because there are not enough clinicians to staff more rota slots.
3 the tradition has become a right of passage and initiation into the profession. Even though it is probably harmful for staff and patients. It will fake some senior people a lot of moral courage to change this.
4 if American doctors work fewer hours per week then they will either have to prolong their training... or accept that a lot of that time is actually wasted effort. Like rounding twice a day! No one else does this.
As to the last one, I suspect that the benefit of training plateaus well before most training programs end. You never stop learning new things for your entire career of course, but during residency you reach a point where you feel like you get it, and you’re just playing out the string thereafter.
Actually, it should be acceptable to take off a day if you are sick or tired, but never in a million years would the insane system of medical education allow for that. After all, humane hours might decrease the rate of depression and suicide in doctors and the system could never allow that!
The sorta funny, mostly tragic fact is that the insane hours have always been used as a symbol of how much doctors “care” about their patients. I remember finally getting off after a 36 hour run (day and night “on call” and then the 12 hour day that followed) barely being able to speak or think. Did I still care about patients at that point. I was too numb to know.
You know, in many other professions (law, psychology, teaching) people do care most of the time about their “clients” and strive to do right by them. And you don’t see any of them staying up for 36 hours to prove it. And staying up proves nothing like caring—it certainly doesn’t prove that one cares for oneself, even minimally.
Yeah, despite being a psychiatrist, I did the complete tour of masochism and sadism that comprises medical education. 4 years of medical school followed by a “medicine” internship followed by a 3 year residency featuring every 3rd night call. I also moonlighted in a state psychiatric hospital that offered an excellent insurance plan that covered the cost of a psychoanalysis. An in depth psychotherapy or psychoanalysis at least used to be recommended for psychiatrists who, after all, do use their personalities in their work. It turns out to be a good idea to understand oneself before attempting to understand and help another.
Of course, by the first year of residency, it wasn’t really much of an option for me. My life had become a total, painful mess, in part due to my experiences with my crazy family of origin which was certainly amplified by my 5 year (at that point) immersion into the madness of medical education.
And I was a glutton for punishment, it seems because I OPTED to do my internship in the city/county/university general hospital and the VAH instead of choosing a milder experience in a private hospital. You see, I wanted to be TAKEN SERIOUSLY by proving I was the REAL DEAL—a competent physician who hadn’t gone into mental health because I couldn’t tolerate the other stuff.
Oh, and I could do a chest tube and intubate and start Swann-Ganz lines and all the rest. I could deliver babies nearly solo and i could thoughtfully suture epidural tears after a “rough” delivery.
So, ok, I emerged, started practice, and a mere 2 years later, “managed”care came in like gangbusters and in a mere decade brought the entire profession to its knees.
Physicians were replaced willy-nilly by lesser trained, less expensive, and certainly lesser educated people—and you know what? The entire world did not care that we might have been better. Patients didn’t know the difference.
So hard work and endeavor, as good as they might look on resumes, turned out to be worthless.
And bit by bit, sometimes still loving to care correctly for patients, physicians began leaving. Finally they were opting to save themselves from the corrupt, meaningless and abusive trance that medicine had become.
I could be very bitter and angry about this but mostly, I’m not. I mostly accept that like many other, innocent, people, the younger me was taken for a ride.
The partial remedy for the powers that be destroying what we love about medicine is to UNIONIZE—the modern way to demand respect by work slowdowns and stoppages. Of course patients will suffer. We are suffering, too, while the insco and governmental fat cats profit off our labor, education and experience.
Some doctors opine that this is all our fault because we “allowed” it to happen. Excuse me, but I didn’t get the memo about how we were supposed to fight back against insco and governmental intrusions. It’s laughable, really, that any would think they personally were responsible for the mess medicine has become. Adding guilt to an insane training will get you exactly nowhere.
All I know is that I should’ve attended to myself appropriately during training. I’m making up for lost time now, tho’. I suggest you do the same.
Most work too much but also most work poorly. I'm sure some few can endure those rithms (for how long though?) & perform well. But I doubt this is sustainable or applicable to most.
We should ensure that the great part of professions can be well performed by anyone with the required know how - while possibly leaving the door open if you feel like you need less or want more hours.
Which increases the number of people employed as well (and decreases the salaries of those working less).
There's a toll to pay in training costs but IMO it's way lower than the benefits in quality of life & service.
Still every country has its own labor laws so going into the details probably leads nowhere.
It’s a slippery slope. I’m tired most every day and working as a nurse in the emergency department is mentally and physically exhausting… how many times should I call in each week? 🙄
i’m tired everyday too, Julia. but this post was about specifically severe insomnia that interferes with your ability to provide competent care. not being “sleepy” as this post would suggest in efforts to target and bully
Stephanie, you’re right. The fact that you directly became the target of this article by commenters including myself is not right. I made a comment earlier that was disparaging and all I can do is apologize. The debate is obviously a live issue, but we shouldn’t be hashing it out with you as this sort of totemic figure caught in the middle. Hopefully you see this, hang in there.
Thank you so much, no hard feelings at all. I appreciate the apology, and also appreciate the comments that oppose my point of view yet do not target/bully. Thanks for sharing your thoughts :)
2020 paper. Some interesting conclusions to digest for those who want to believe that reduced or restricted duty hours is the be-all and end-all. Also references many earlier works as well as some contemporary papers which also cast some doubt on that premise.
" a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors." Ya it appears the reduced hour "intervention schedule" was worse at sites without proper coverage. IE sites where they basically said due to reduced hours, you will see more patients and as a result more mistakes were made. We didn't need a study to come to this conclusion. Frankly it is obvious if you see more patients in less time you will make more mistakes. Truly programs need more staff.
It would have been humbling for her to realize there are many people that don't have the ability to 'take off' because they are tired. They work more than one job and are often tired. They have families to take care of. Taking a day off may mean they lose their job and their income. Too bad she didn't learn that lesson.
I think most people are aware that abusive labor practices and poverty exist. That's why there's a labor movement. Don't really see that as a reason why one should not use the leave time that they are allowed to take.
I wish I could stop reading these comments but they are truly hurtful. Please understand you are shaming a new doctor who cares deeply about her patients and all other humans. Who is still too naiive to consider that grown professionals may not act as such. People are being bullies and misconstruing the message, making it seem like i took off work for a "nap;” surely it’s obvious i meant otherwise but the title of this post was PURPOSELY extreme to confuse and polarize people.
Luckily there is more support in these comments than hate but it’s still discouraging and just goes to show why residents are scared to be vulnerable despite the millions of messages that flood in after someone dies by suicide telling us how we should ask for help if needed. Intense sleep deprivation is absolutely no different than having a febrile illness. However, calling out for “insomnia” or any other issue related to mental health is somehow viewed completely different.
And regardless of whether or not you believe asking a colleague for help makes a resident [insert any degrading adjective mentioned], the fact is that patients should NOT be receiving care from someone unfit to work. At my residency program, we do not take calling in lightly. We all get the same # of sick days and are encouraged to use one of those sick days if we are in a state that will significantly compromised patient care. To my program, and to me, patients always come first.
I appreciate the discussion but the targeted messages are just cruel. At the end of the day, maybe it WAS a dumb move on my part to write that post, even if the message was well-intended. Though while my words have opened my character to judgment, at least they do not judge or harm others.
And frankly, if we could find the average age of the people who are outraged by this, I'm guessing most of them are a lot older than Vinay.
Your approach of putting patient safety first is the way things are headed, for better or for worse. I think more better, though I acknowledge that some rigor is being lost.
Transport does indeed run 24/7. You ever drive on a highway in the wee hours of the morning or work a gas station during third shift?
I am not talking common sense, I am talking common knowledge. There are institutions that study nothing but sleep. I myself have and continue to get too little sleep. I have been surrounded from time to time with those who are long on hours and short of sleep. It appears that the only field of the many we humans go into who do not understand the need to get a certain number of hours of sleep each and every 24 hour period is the medical field.
Handover errors are communication errors. What the Fauci you guys do at turn over, “I had it, you got it.”, and leave? If handovers are such a problem with you, adopt the Japanese way and do away with them all together and stay with your patient until they leave, either to the crematorium or to home.
Taxi vouchers? Are you Faucing kidding me? In my home town, there we do not have a taxi service in the entire country. Guess you could hitch hick back home. Ride a bicycle or just walk.
We, your customers, do not like being seen by people who are just as sleepy as we were when we got into the accident that brought us to your hospital at 3 am.
Interesting question (should residents take the day off when they are tired), but it's framed so as to invite a binary response and a dialectical discussion. The unsatisfying answer, considering all trainees, is "maybe." Should the resident who has a long commute and a chronic health condition take the day off when he or she is tired? Sure. Should a resident on the exact same team, who lives within walking distance of the hospital, and has no health conditions take the day off when he or she is tired? Maybe not. I worked a 30 hour shift as a resident and then drove to San Francisco a few hours later; to be honest, I wasn't particularly tired, but I'm a heavy coffee drinker. I still got pulled over for suspected drunk driving and had to do a sobriety test, suggesting that my driving stood out as impaired. Another resident I worked with worked 36 hours straight, drove home a short distance from the hospital, and fell asleep at the wheel- driving into a ditch in the process. Perhaps these were learning experiences, but they weren't safe, nor did they show commitment to helping save lives. Some people seem more impaired without 7-8 hours of sleep per night than others, and many of the rest of us are probably more impaired than we think we are when we try to get by with less. I used to brag that residency taught me how to be highly effective even when highly sleep deprived; but I suspect that it really taught me to THINK of myself as a "highly effective person" when highly sleep deprived. In other words, residency taught me, among other things, to be highly delusional. And I would argue that we are deluded when we think we know how tired another trainee is, and how that feels. They are more likely to work hard and be dedicated if we respect them and believe them when they say they need a break.
27 hours is definitely a long stretch, but it’s worth noting that many specialties, especially those with busy on-call shifts like anesthesia, have already eliminated shifts beyond 24 hours. Nowadays, many call shifts range between 12 and 18 hours.
It seems you might be skeptical of the research, likely because it contradicts what feels like "common sense." However, I think the truck driver analogy might not be the most appropriate comparison. Driving can be monotonous and hypnotic, while medicine tends to be highly stimulating.
So, why might the research be correct? Can the debate be reframed to make sense from a common-sense perspective?
Patients who come into the hospital or experience an issue at 3 a.m. still need treatment, and the doctor who attends to them has likely been awake since 6 a.m., regardless of when their shift starts. Here are some questions to consider:
1. Will a doctor who normally starts at 7:30 a.m. significantly adjust their sleep schedule on the day of their call shift, which begins at 6:00 p.m.? In other words, will they actually be more rested?
2. At 3 a.m., will the doctor who started their shift at 6:00 p.m. be in better condition than the one who has been at the hospital since 7:30 a.m., given that they likely woke up at roughly the same time?
3. If you’re already admitted to the hospital, will the doctor who knows you (the 7:30 a.m. doctor) perform better than the one who doesn’t know you as well (the doctor who received the "handover" and started at 6:00 p.m.)?
4. If the 6:00 p.m. doctor is more rested throughout the night, is that benefit enough to compensate for the potential errors that could occur during handover?
5. What shift duration is the right duration? Can shifts be too short? Too long? At what point?
6. Is the problem the long shift, or is it simply the overnight hours, regardless of when the shift starts?
I happen to believe the research because it makes sense to me, and there is a respectable amount of it. But I also understand why some might find it hard to accept, as it contradicts what seems like common sense—a little like mask mandates. ;-)
No doctor enjoys extended-hour shifts, nor do we particularly like regular-length shifts that go overnight. But medicine isn’t about what we like or don’t like.
As for the concern about car crashes after extended shifts, it’s a valid point, but I’m not aware of research showing an increase in actual crashes. There are ways to mitigate this risk; for example, many (if not all) residency programs have provided taxi vouchers to residents for over 15 years now.
People who consider taking a day off for being tired think the the valuable part of medical education is the didactic stuff and what the learner does with that in their own head.
Alternatively, the valuable part of medical education might be the experience that people get seeing patients, listening to their stories, seeing what happens when you do stuff to them. The classroom material can be taught differently, or more efficiently, or tomorrow if you’re tired today, but today’s experience is obtained only today. Experience is by definition working a bunch of hours and seeing a bunch of stuff.
In my opinion, the important part of learning is how you integrate what you saw today with the patient with what you knew previously–whether it was from the classroom or bedside. A real doctor is infinitely more valuable than Dr Google. Experience with patients is what separates us.
I'm an NYC RN who after 35 years can say from experience there is an unmentioned consequence or even an acknowledgement by these residents.
That is that by taking that day, your patients often express the disappointment or anxiety they feel when they look forward to, and expect to see you, and an unfamiliar face comes into their room. Hospitalization is stressful enough.
Ultimately, the work has to get done or the patient suffers. If there's a team behind you, great. The day MAY come where you're the only one around, no way out, you're the attending. No other resident, no PGY1, no med students to help out. What then? Training to occasional extremes lets you know you can do it. I'm certainly not comparing myself to a navy seal, etc, but they train them to extremes for a reason, so when the world gets real, you've been there before. I worry we're getting a whole new generation that has never really been stressed....
Partly not their fault. They were raised by a generation of helicopter parents.
However, this is, as a broad brush, a generation that is fragile, coddled, anxious, a little bit entitled at times, and lacking in some resiliency, as an effect of their general upbringing.
The helicoptering is outrageous. I've seen one of my sisters get involved in college roommate problems afflicting one of her daughters. I can't get my head around that.
It's one of those careers you are either built for or you are not. Intrinsically rough and seemingly unfair. The major issue with "Wellness" is that it allows a liberal and subjective definition of fatigue and burnout. One persons unrested sleep is another's "insomnia". A series of URI's is someone else's "long COVID". Being asked three questions in rounds is often "psychological trauma requiring a wellness day off". Systems that deal with human life have to be predictable and efficient, and cannot allow staffing absences from subjective self-defined stress, anxiety, fatigue, and insomnia. We are doctors. We are not doctors if we are not reliable.
I agree Srinath, but unfortunately we do not have ways yet to make these issues objective. Should a healthcare worker call out for a 102 fever? absolutely. should they call out after a string of days with only 1-2 hours of sleep where they are passing out and can’t walk straight or even complete sentences? absolutely. but because the latter kind of “illness” cannot be measured it’s SO important we build a system where we feel safe to just talk about it. the answer does lie in open, honest communication. for example, i called my supervisor that day and talked through the situation. I was encouraged to take the day off due to the degree of impairment and resulting physical illness. But any other days where i’m simply “sleepy” (lol) I don’t call in. But I still talk to my team about it - “hey guys, I’m feeling a little slower today from lack of sleep. Pharmacy, pay a little more attention to the orders I’m putting in today. Nursing, page me immediately if there’s something I forget to do…” those sorts of things. Open communication is key. but when we perpetuate the stigmatizing message that “wellness culture = weak” we discourage these necessary conversations. And then patients can suffer from it. You’re right that systems dealing with human life must be predictable and efficient - a cognitively impaired doctor refusing to take the day off because of fear is a sure fire way to quickly affect such a system.
Also, to say you are either “built for it or not” is FAR too extremist and is the reason why we have to fight to have diversity in medicine these days. Maybe I am going to call out 1-2 more times a year than another colleague who is intrinsically less affected by sleep. But, on the flip side, maybe I have a better immune system and I DONT call out as much for getting a febrile illness. There is a reason we are all allowed the same # of sick days. My original post was to encourage people to use theirs when truly needed / when patient care would be compromised, regardless of the reason.
Also re: “being cut out for it”: I have only been a doctor for a year now and having these intrinsic “issues” or “weaknesses” have allowed me to deliver more compassionate, patient-centered than I’ve witnessed the majority of other peers be able to do. And why patient-centered care = practicing excellence/ improves outcomes is a whole other post. The point is we all have our different strengths and weaknesses.
The Norwegian system sounds good. The UK system is supposed to work a bit like that but because the "penalties" are so small there are still some pretty unpleasant shift patterns.
Surely the issue is:
1 historically the US training system was established by doctors who infamously used cocaine to stay awake, but it's now become tradition.
2 the system relies on long hours because there are not enough clinicians to staff more rota slots.
3 the tradition has become a right of passage and initiation into the profession. Even though it is probably harmful for staff and patients. It will fake some senior people a lot of moral courage to change this.
4 if American doctors work fewer hours per week then they will either have to prolong their training... or accept that a lot of that time is actually wasted effort. Like rounding twice a day! No one else does this.
These are all good points.
As to the last one, I suspect that the benefit of training plateaus well before most training programs end. You never stop learning new things for your entire career of course, but during residency you reach a point where you feel like you get it, and you’re just playing out the string thereafter.
Actually, it should be acceptable to take off a day if you are sick or tired, but never in a million years would the insane system of medical education allow for that. After all, humane hours might decrease the rate of depression and suicide in doctors and the system could never allow that!
The sorta funny, mostly tragic fact is that the insane hours have always been used as a symbol of how much doctors “care” about their patients. I remember finally getting off after a 36 hour run (day and night “on call” and then the 12 hour day that followed) barely being able to speak or think. Did I still care about patients at that point. I was too numb to know.
You know, in many other professions (law, psychology, teaching) people do care most of the time about their “clients” and strive to do right by them. And you don’t see any of them staying up for 36 hours to prove it. And staying up proves nothing like caring—it certainly doesn’t prove that one cares for oneself, even minimally.
Yeah, despite being a psychiatrist, I did the complete tour of masochism and sadism that comprises medical education. 4 years of medical school followed by a “medicine” internship followed by a 3 year residency featuring every 3rd night call. I also moonlighted in a state psychiatric hospital that offered an excellent insurance plan that covered the cost of a psychoanalysis. An in depth psychotherapy or psychoanalysis at least used to be recommended for psychiatrists who, after all, do use their personalities in their work. It turns out to be a good idea to understand oneself before attempting to understand and help another.
Of course, by the first year of residency, it wasn’t really much of an option for me. My life had become a total, painful mess, in part due to my experiences with my crazy family of origin which was certainly amplified by my 5 year (at that point) immersion into the madness of medical education.
And I was a glutton for punishment, it seems because I OPTED to do my internship in the city/county/university general hospital and the VAH instead of choosing a milder experience in a private hospital. You see, I wanted to be TAKEN SERIOUSLY by proving I was the REAL DEAL—a competent physician who hadn’t gone into mental health because I couldn’t tolerate the other stuff.
Oh, and I could do a chest tube and intubate and start Swann-Ganz lines and all the rest. I could deliver babies nearly solo and i could thoughtfully suture epidural tears after a “rough” delivery.
So, ok, I emerged, started practice, and a mere 2 years later, “managed”care came in like gangbusters and in a mere decade brought the entire profession to its knees.
Physicians were replaced willy-nilly by lesser trained, less expensive, and certainly lesser educated people—and you know what? The entire world did not care that we might have been better. Patients didn’t know the difference.
So hard work and endeavor, as good as they might look on resumes, turned out to be worthless.
And bit by bit, sometimes still loving to care correctly for patients, physicians began leaving. Finally they were opting to save themselves from the corrupt, meaningless and abusive trance that medicine had become.
I could be very bitter and angry about this but mostly, I’m not. I mostly accept that like many other, innocent, people, the younger me was taken for a ride.
The partial remedy for the powers that be destroying what we love about medicine is to UNIONIZE—the modern way to demand respect by work slowdowns and stoppages. Of course patients will suffer. We are suffering, too, while the insco and governmental fat cats profit off our labor, education and experience.
Some doctors opine that this is all our fault because we “allowed” it to happen. Excuse me, but I didn’t get the memo about how we were supposed to fight back against insco and governmental intrusions. It’s laughable, really, that any would think they personally were responsible for the mess medicine has become. Adding guilt to an insane training will get you exactly nowhere.
All I know is that I should’ve attended to myself appropriately during training. I’m making up for lost time now, tho’. I suggest you do the same.
And BTW, VOTE BLUE!!!!
Most work too much but also most work poorly. I'm sure some few can endure those rithms (for how long though?) & perform well. But I doubt this is sustainable or applicable to most.
We should ensure that the great part of professions can be well performed by anyone with the required know how - while possibly leaving the door open if you feel like you need less or want more hours.
Which increases the number of people employed as well (and decreases the salaries of those working less).
There's a toll to pay in training costs but IMO it's way lower than the benefits in quality of life & service.
Still every country has its own labor laws so going into the details probably leads nowhere.
It’s a slippery slope. I’m tired most every day and working as a nurse in the emergency department is mentally and physically exhausting… how many times should I call in each week? 🙄
i’m tired everyday too, Julia. but this post was about specifically severe insomnia that interferes with your ability to provide competent care. not being “sleepy” as this post would suggest in efforts to target and bully
Stephanie, you’re right. The fact that you directly became the target of this article by commenters including myself is not right. I made a comment earlier that was disparaging and all I can do is apologize. The debate is obviously a live issue, but we shouldn’t be hashing it out with you as this sort of totemic figure caught in the middle. Hopefully you see this, hang in there.
Thank you so much, no hard feelings at all. I appreciate the apology, and also appreciate the comments that oppose my point of view yet do not target/bully. Thanks for sharing your thoughts :)
https://www.nejm.org/doi/full/10.1056/NEJMoa1900669
2020 paper. Some interesting conclusions to digest for those who want to believe that reduced or restricted duty hours is the be-all and end-all. Also references many earlier works as well as some contemporary papers which also cast some doubt on that premise.
" a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors." Ya it appears the reduced hour "intervention schedule" was worse at sites without proper coverage. IE sites where they basically said due to reduced hours, you will see more patients and as a result more mistakes were made. We didn't need a study to come to this conclusion. Frankly it is obvious if you see more patients in less time you will make more mistakes. Truly programs need more staff.
You are a rage page churnalist...
It would have been humbling for her to realize there are many people that don't have the ability to 'take off' because they are tired. They work more than one job and are often tired. They have families to take care of. Taking a day off may mean they lose their job and their income. Too bad she didn't learn that lesson.
I think most people are aware that abusive labor practices and poverty exist. That's why there's a labor movement. Don't really see that as a reason why one should not use the leave time that they are allowed to take.
It wasn’t that.. it was that she felt COMPELLED to share with the world.
Being “aware” and being on that end (poverty and abusive labor practices) are two different things.
I wish I could stop reading these comments but they are truly hurtful. Please understand you are shaming a new doctor who cares deeply about her patients and all other humans. Who is still too naiive to consider that grown professionals may not act as such. People are being bullies and misconstruing the message, making it seem like i took off work for a "nap;” surely it’s obvious i meant otherwise but the title of this post was PURPOSELY extreme to confuse and polarize people.
Luckily there is more support in these comments than hate but it’s still discouraging and just goes to show why residents are scared to be vulnerable despite the millions of messages that flood in after someone dies by suicide telling us how we should ask for help if needed. Intense sleep deprivation is absolutely no different than having a febrile illness. However, calling out for “insomnia” or any other issue related to mental health is somehow viewed completely different.
And regardless of whether or not you believe asking a colleague for help makes a resident [insert any degrading adjective mentioned], the fact is that patients should NOT be receiving care from someone unfit to work. At my residency program, we do not take calling in lightly. We all get the same # of sick days and are encouraged to use one of those sick days if we are in a state that will significantly compromised patient care. To my program, and to me, patients always come first.
I appreciate the discussion but the targeted messages are just cruel. At the end of the day, maybe it WAS a dumb move on my part to write that post, even if the message was well-intended. Though while my words have opened my character to judgment, at least they do not judge or harm others.
Honesty is the best policy.
And frankly, if we could find the average age of the people who are outraged by this, I'm guessing most of them are a lot older than Vinay.
Your approach of putting patient safety first is the way things are headed, for better or for worse. I think more better, though I acknowledge that some rigor is being lost.
She posted about it. Maybe she needs to learn not to share to make herself feel better.