Comments on: Are your doctors awake? http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/ Mon, 21 Dec 2009 21:13:33 +0000 http://wordpress.com/ hourly 1 By: Georgia http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5954 Georgia Fri, 12 Dec 2008 00:51:14 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5954 Having worked with residents in a hospital setting, I was well aware of the problem with lack of sleep. When the doctor for whom I worked was giving a lecture, I would actually have to tap various residents on the shoulder to awaken them. Also, I did most of their transcriptions for that department and many times had to correct them because they were so sleep deprived. I would even alert while napping in a private room, when they were needed. It was scary to watch, and I am happy that residents are now getting the attention they need to be able to be alert during their residency. It is also to our benefit as patients. Having worked with residents in a hospital setting, I was well aware of the problem with lack of sleep. When the doctor for whom I worked was giving a lecture, I would actually have to tap various residents on the shoulder to awaken them. Also, I did most of their transcriptions for that department and many times had to correct them because they were so sleep deprived. I would even alert while napping in a private room, when they were needed. It was scary to watch, and I am happy that residents are now getting the attention they need to be able to be alert during their residency. It is also to our benefit as patients.

]]> By: Matt http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5867 Matt Mon, 08 Dec 2008 04:35:00 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5867 As a current resident in the middle of my internship, I have to say I have really appreciated the 80 hour work week/30 hour max shift thus far. At the same time, I personally would worry about decreasing it much further at this point. Recently my residency program tried a new call schedule which included staying in the hospital fewer nights but necessitated picking up new patients in the morning who had been admitted overnight. There is something about admitting your patients yourself that is tremendously beneficial, you can just never get to know a patient's history and medical problems as well when you don't do the work personally, and I noticed that although I was much more well-rested, my patients' care suffered. I simply could not work as well for them. I fear something like this could result on a bigger scale if the work hours are reduced too much. Yes the point is education but the fact is there is a lot of work to be done and the more you break the continuity of care, the more things will fall through the cracks. I agree with the comment that the key is not so much about hours as it is about adequate supervision. As a current resident in the middle of my internship, I have to say I have really appreciated the 80 hour work week/30 hour max shift thus far. At the same time, I personally would worry about decreasing it much further at this point. Recently my residency program tried a new call schedule which included staying in the hospital fewer nights but necessitated picking up new patients in the morning who had been admitted overnight. There is something about admitting your patients yourself that is tremendously beneficial, you can just never get to know a patient's history and medical problems as well when you don't do the work personally, and I noticed that although I was much more well-rested, my patients' care suffered. I simply could not work as well for them. I fear something like this could result on a bigger scale if the work hours are reduced too much.

Yes the point is education but the fact is there is a lot of work to be done and the more you break the continuity of care, the more things will fall through the cracks.

I agree with the comment that the key is not so much about hours as it is about adequate supervision.

]]> By: VenkER MD http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5858 VenkER MD Sun, 07 Dec 2008 05:22:50 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5858 The enthusiasm and passion shown in this chat is wonderful. Everyone obviously cares greatly for the well-being of the medical students, residents, attendings, and of course the patients. There is likely no easy solution as fewer hours does mean more rested providers it means longer time to acquire the experience; the inverse is also with problems. The answers are likely not be as simple as creating regulations on a truck driver because of the factor of acquiring experience which takes significant time. Like many who posted here, I think before the pendulum was too far in the way of over worked providers. I do think shift hours is a solution that may be well suited to accomplish training, and well being for the provdiers. I do not think health care providers who use shifts are as "gasdoc" implies without dedication...is it a perfect answer, likely no. It does leave room for error every time there is a handoff. Shifts is one way, but I also think we are currently at a nice balance. One other solution is to have two residents on call who alternate periods of sleep and function, but for longer hours. I guess we will see what comes of the system in the coming years. The enthusiasm and passion shown in this chat is wonderful. Everyone obviously cares greatly for the well-being of the medical students, residents, attendings, and of course the patients. There is likely no easy solution as fewer hours does mean more rested providers it means longer time to acquire the experience; the inverse is also with problems. The answers are likely not be as simple as creating regulations on a truck driver because of the factor of acquiring experience which takes significant time. Like many who posted here, I think before the pendulum was too far in the way of over worked providers. I do think shift hours is a solution that may be well suited to accomplish training, and well being for the provdiers. I do not think health care providers who use shifts are as "gasdoc" implies without dedication...is it a perfect answer, likely no. It does leave room for error every time there is a handoff. Shifts is one way, but I also think we are currently at a nice balance. One other solution is to have two residents on call who alternate periods of sleep and function, but for longer hours. I guess we will see what comes of the system in the coming years.

]]> By: rekha http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5854 rekha Sat, 06 Dec 2008 22:57:54 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5854 working long hours hurt the doctor and patients. No one's brain can function more than 12-15 hours a day, then why have only doctors works for 30 hours shift. working long hours hurt the doctor and patients. No one's brain can function more than 12-15 hours a day, then why have only doctors works for 30 hours shift.

]]> By: H.P., MD http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5849 H.P., MD Sat, 06 Dec 2008 21:19:14 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5849 The whole work hours issue has its root in money. Each year there are more patients in general and more uninsured patients in particular, so the health care system is forced to do more with the same amount of money, while the cost of medications and devices increases. Since the can be residents threatened with loss of their career their workload is made as high as possible, which reduces the cost per hour of care. workhour restrictions for residents came about after rich patients died publicly of egregious stupidity brought on by extreme fatigue. So the "workhours" are reduced, in theory anyway, but there are other ways around this restriction, such as home call by pager, which means waking up every 20 minutes or so to answer the phone, and going into the hospital a couple of times a night then leaving so as to not go over the time restriction. Or the more simple practice of just cheating, as when the program director says "work more but log less hours" with the understanding failure to comply with his demands will lead rapidly to the sidewalk. And the programs are safe doing this, since the ACGME's first response to a resident complaint is to contact the same program director with the name of the resident. Or more easily, as mentioned above, by pushing more hours on the junior attending who also faces the same sidewalk if he complains. Nevertheless, there is no good alternative as long as the demand for care increases while reimbursement remains the same. The whole work hours issue has its root in money. Each year there are more patients in general and more uninsured patients in particular, so the health care system is forced to do more with the same amount of money, while the cost of medications and devices increases. Since the can be residents threatened with loss of their career their workload is made as high as possible, which reduces the cost per hour of care. workhour restrictions for residents came about after rich patients died publicly of egregious stupidity brought on by extreme fatigue.

So the "workhours" are reduced, in theory anyway, but there are other ways around this restriction, such as home call by pager, which means waking up every 20 minutes or so to answer the phone, and going into the hospital a couple of times a night then leaving so as to not go over the time restriction. Or the more simple practice of just cheating, as when the program director says "work more but log less hours" with the understanding failure to comply with his demands will lead rapidly to the sidewalk. And the programs are safe doing this, since the ACGME's first response to a resident complaint is to contact the same program director with the name of the resident. Or more easily, as mentioned above, by pushing more hours on the junior attending who also faces the same sidewalk if he complains.

Nevertheless, there is no good alternative as long as the demand for care increases while reimbursement remains the same.

]]> By: stephen http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5841 stephen Sat, 06 Dec 2008 05:57:43 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5841 as an answer to several points raised For those who feel the hours should be limited, who is it that is going to take care of the patients at 3 AM ? Most health care does not take place at academic centers, it happens in community hospitals, and the attendings threre do not have residents and don't have the option of "signing out" to someone else at 7 AM. Since there are already hospitals that have a very hard time finding coverage for emergencies with some specialties, limiting hours would essentially mean there would be few mds willing to take call if they couldnt work clinic or perform procedures the next day. also, training should reflect real practice. As someone who has recently completed residency/chief residency/fellowship/chief fellow/junior acedemic attending/private practice, I have seen this from all angles and we will continue to work through the night and the next day if needed because people have to be taken care of - and that is why we have all committed to this profession. What should happen at 3 AM if you need emergency surgery, would you want the surgeon who has been up since 5 AM the morning before, or would you like to wait until 8 AM? I was chief when the new schedule came around, and the majority or errors that I have seen have increased, and are nearly entirely due to poor knowledge regarding specific patient's conditions as the resident was not involved in the admission / initial stabilization/diagnostic worlup done - even when handoffs were done well. Tough situtation, but to "limit the work day to ---- hours" is not a practical solution for physicians, and certainly would not be acceptable to the majority of patients. as an answer to several points raised
For those who feel the hours should be limited, who is it that is going to take care of the patients at 3 AM ? Most health care does not take place at academic centers, it happens in community hospitals, and the attendings threre do not have residents and don't have the option of "signing out" to someone else at 7 AM. Since there are already hospitals that have a very hard time finding coverage for emergencies with some specialties, limiting hours would essentially mean there would be few mds willing to take call if they couldnt work clinic or perform procedures the next day. also, training should reflect real practice. As someone who has recently completed residency/chief residency/fellowship/chief fellow/junior acedemic attending/private practice, I have seen this from all angles and we will continue to work through the night and the next day if needed because people have to be taken care of – and that is why we have all committed to this profession. What should happen at 3 AM if you need emergency surgery, would you want the surgeon who has been up since 5 AM the morning before, or would you like to wait until 8 AM?
I was chief when the new schedule came around, and the majority or errors that I have seen have increased, and are nearly entirely due to poor knowledge regarding specific patient's conditions as the resident was not involved in the admission / initial stabilization/diagnostic worlup done – even when handoffs were done well.
Tough situtation, but to "limit the work day to -- hours" is not a practical solution for physicians, and certainly would not be acceptable to the majority of patients.

]]> By: Harper, M.D. http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5840 Harper, M.D. Sat, 06 Dec 2008 03:49:47 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5840 As an attending physician, since the protected residency hours have been in effect, the more I have seen residents who are less prepared for the real life responsibilities of taking care of patients. As many have already stated, attending physicians are well accustomed to 12 hour days, long weekends of being on call for several days straight, and being ultimately responsible for patient care. While I agree that some of the previous "old school" abuses needed to be tempered and reigned in, the more that we continue to police and limit the vital hours of residency training, the more our future health care providers' education will suffer. Emergencies do happen in the middle of the night and are not predictible--I want my physician to be able to handle this--even if he is paged out of a sound sleep to do so. As an attending physician, since the protected residency hours have been in effect, the more I have seen residents who are less prepared for the real life responsibilities of taking care of patients. As many have already stated, attending physicians are well accustomed to 12 hour days, long weekends of being on call for several days straight, and being ultimately responsible for patient care. While I agree that some of the previous "old school" abuses needed to be tempered and reigned in, the more that we continue to police and limit the vital hours of residency training, the more our future health care providers' education will suffer.

Emergencies do happen in the middle of the night and are not predictible–I want my physician to be able to handle this–even if he is paged out of a sound sleep to do so.

]]> By: Trauma Doc http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5838 Trauma Doc Sat, 06 Dec 2008 02:44:14 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5838 1. I am senior surgical resident who is planning a to be a trauma surgeon. I say that work-hour limitations are a good idea but the one-size-fit-all mandates are not the way to go. 2. As a reply to 'Dee Conant'. There is a HUGE difference between doctors and truck drivers' "shifts". Namely, our job requires human interaction, variety, necessity and, particular to my field, adrenaline. Where as truck driving is very monotonous, has limited interaction and they purposely avoid adrenaline stimulating situations. My last patient gets the same attention to detail as the first. Sleep or no sleep. 3. I imagine that most, if not all, of us would gladly go home to our families and children if given the chance.... but the sick and the injured just keep coming. Sickness doesn't know about Christmas or the 80 work week. 4. Most residents that I know have a tremendous amount of guilt associated with leaving the hospital knowing that there are things left undone to the next "shift" resident (who didn't admit the patient or operate on the patient or console the patient). 5. Our population is getting older and the average acuity of patients is getting higher every day. Concurrently our physicians are getting older too. The perfect storm is coming: Supervising doctors retiring and residents having government mandated hour limitation. Who will be left to treat the sick? 6. In reply to the original article. "* Limit shifts to 16 consecutive hours" This is nice on paper, but for most surgical services this is near our regular surgical day as an attending or as a resident: AM rounds, Surgeries from 7am until done, PM rounds then either home or be on call over night. "* Give residents more days off" Who is left to take care of patients? "* Provide transportation home after a long shift." This is also nice on paper... but how do I get BACK to work. I'm broke! I can't afford the taxi the next morning to get back to work, and most suburban public buses don't work that early in the morning. 1. I am senior surgical resident who is planning a to be a trauma surgeon. I say that work-hour limitations are a good idea but the one-size-fit-all mandates are not the way to go.

2. As a reply to 'Dee Conant'.
There is a HUGE difference between doctors and truck drivers' "shifts". Namely, our job requires human interaction, variety, necessity and, particular to my field, adrenaline. Where as truck driving is very monotonous, has limited interaction and they purposely avoid adrenaline stimulating situations. My last patient gets the same attention to detail as the first. Sleep or no sleep.

3. I imagine that most, if not all, of us would gladly go home to our families and children if given the chance.... but the sick and the injured just keep coming.

Sickness doesn't know about Christmas or the 80 work week.

4. Most residents that I know have a tremendous amount of guilt associated with leaving the hospital knowing that there are things left undone to the next "shift" resident (who didn't admit the patient or operate on the patient or console the patient).

5. Our population is getting older and the average acuity of patients is getting higher every day. Concurrently our physicians are getting older too. The perfect storm is coming: Supervising doctors retiring and residents having government mandated hour limitation. Who will be left to treat the sick?

6. In reply to the original article.
"* Limit shifts to 16 consecutive hours"
This is nice on paper, but for most surgical services this is near our regular surgical day as an attending or as a resident: AM rounds, Surgeries from 7am until done, PM rounds then either home or be on call over night.

"* Give residents more days off"
Who is left to take care of patients?

"* Provide transportation home after a long shift."
This is also nice on paper... but how do I get BACK to work. I'm broke! I can't afford the taxi the next morning to get back to work, and most suburban public buses don't work that early in the morning.

]]> By: Dino http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5834 Dino Fri, 05 Dec 2008 23:11:08 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5834 I agree that we work our residents too many hours. I remember in the 60's when I was in nursing school it was the intern's responsibility to mix all the IV's for the next 24 hours. At that time we nurses were not allowed to mix IV's. We would lean the intern against the wall in the med room and let him nap while we mixed the IV's ourselves. We did not trust a sleepy student to do this when we had to hang the IV's. I agree that we work our residents too many hours. I remember in the 60's when I was in nursing school it was the intern's responsibility to mix all the IV's for the next 24 hours. At that time we nurses were not allowed to mix IV's. We would lean the intern against the wall in the med room and let him nap while we mixed the IV's ourselves. We did not trust a sleepy student to do this when we had to hang the IV's.

]]> By: Kathy http://pagingdrgupta.blogs.cnn.com/2008/12/02/are-your-doctors-awake/#comment-5832 Kathy Fri, 05 Dec 2008 22:52:08 +0000 http://cnnpagingdrgupta.wordpress.com/?p=375#comment-5832 Change is absolutely needed. Both patients and residents deserve better. No patient should ever have to suffer the results of a mistake made because a doctor has been awake too many hours. What if it happened to your loved ones?? Change is absolutely needed. Both patients and residents deserve better. No patient should ever have to suffer the results of a mistake made because a doctor has been awake too many hours. What if it happened to your loved ones??

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