The 36-hour shift

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I was reading the paper this morning over my tea and crumpets when this headline caught my attention:

“First-year doctors would be allowed to work 24-hour shifts under new rules”

For web Dave Hilden

An old picture of me

Now there’s a topic near to my heart, so I decided without much forethought to subject you to my ramblings about physician training and the unbelievably long work hours that our society subjects physicians to all the time.  But you may be surprised about what my conclusions are on the topic.

For those of you who read my last post Insomnia Part 1 and are looking for Insomnia Part 2, please bear with me because that second part is coming next week, complete with more insights from Samantha Anders, sleep expert from the Sleep Center at HCMC.  I’m hoping to get some video interviewing done with Dr. Anders about behavioral therapy for insomnia, so stay tuned for that.

Why should you care about work rules for doctors-in-training?

That headline was from a Washington Post article covering the a proposed relaxation of work-hour restrictions for interns in hospitals.  So here are some stories from my own experience about the rigors of medical training.  Hopefully you’ll find something in here to get you thinking.  

24-hour shifts?  That’s all? We did 36-hour shifts back in MY day.

Every time somebody hears about the work schedule of doctors-in-training (residents and interns), they get that look of incredulity on their face.  How can that possibly be safe?  Why would any sane person advocate for such a system?  Aren’t doctors smart enough to know that people need to sleep for Pete’s sake?

And now, why is the ACGME (the accreditation body for residency training programs) even considering rolling back the prohibition on 24-hour shifts for interns?

All good questions.

But as someone who did his residency training before there were any restrictions on work hours, I have mixed-feelings.

Here’s some memories from my medical training.

1996:  Medical student

I remember my first rotation as a 3rd-year medical student.  This is the part of medical school where students get to immerse themselves in what we call clinical rotations.  I set my schedule so that I would rotate through Surgery first, since I knew that I wasn’t going into surgery as a specialty and hence I thought it would be a low-stakes way to start my clinical training.  Hey, I would never need a recommendation from a surgeon (since I was going into a non-surgical specialty) so it seemed a wise move to start with surgery.  If my surgery knowledge and skills didn’t prove all that great, well, that would be OK.

OK, this is going to hard . . . 

So I showed up to my first day on my surgery rotation, 6:00 on a Monday morning, which happened to be at Hennepin County Medical Center, where I still work to this day. Like most medical students, I was looking forward to the most important part of medical training: the day I finally get to wear scrubs, just like the doctors on TV!  (The show “ER” was really popular at the time and I was going to be the studly George Clooney character.  Alas, I look more like the dorkier Anthony Edwards character I’m afraid.)   I just couldn’t wait to “scrub in” to my first case in the Operating Room.  And indeed, I did get to do all those things.

But what I remember most about that first day of my surgery rotation in June of 1996 was when my senior resident told me that our team was on-call that day.  Which meant that I wouldn’t be going home that evening.  Or even the next morning.  I would be on duty for 36 hours.  Wow, didn’t see that coming on my first day.   So I called my wife who was at home with our two pre-school children and told her I would be home in time for dinner . . . on the following day.  And yes, if you are wondering, my wife is a saint.

I had to borrow a toothbrush from the supply room that day.

So is there anything good about a 36-hour shift?  Actually – yes – there is something good about it.  In a word: continuity.

But something good comes out of it . . .

I recall a man on that surgical service who had severe peripheral artery disease.  He was admitted to our surgery team which consisted of the attending surgeon (a man I know to this day who is simply an outstanding teacher and surgeon), a senior resident, a couple of junior residents, and me the lowly medical student.  Peripheral artery disease, or PAD, is when the arteries to your legs are blocked up which leads to pain in the legs and if severe enough, threatens the viability of the limb.

Well, this guy’s leg was so compromised that he needed it amputated.  Like right now amputated.  So our surgical team, after evaluating him in the morning, took him to the OR later that afternoon where the surgeons skillfully amputated his leg.  We monitored him all night long for signs of complication.  I think I caught a couple hours of sleep in the call room but I’m not sure on that.  The next morning we rounded with the team – the same team as had been caring for him all night – and checked his wounds and gave him medications for pain.  Never once during the first day and a half of his cares did we have to pass him off to another team of doctors.  That is continuity of care and we can’t minimize how important it can be for patients.

Under newer work rules that we have today, the team of doctors that admitted him to the hospital may have handed him off to a night team who then would hand him back to a day team the next day.  Every time that hand-off occurs, information gets lost, the doctor-patient relationship becomes harder to solidify, and care becomes fractured.  The patient may see 2, 3, even 4 doctors in just a couple of days.  Confusion reigns.

And I learned so much from our team caring for that patient from the beginning to the end of his cares.  And yes, I was dreadfully tired.

2000: Intern and residency

I started my intern year in the year 2000 shortly after graduating from medical school.  Interns are the worker bees of any teaching hospital.  Basically your job as an intern is to carry out orders, document your cares, and do what your senior residents tell you to do. Interns are also supposed to hone in on free food at every opportunity, especially if donuts are in the vicinity.  But I digress.

Interns are endlessly getting paged by nurses and pharmacists and lab technicians and just about everybody else at all hours of the day and night to address patient needs.  This first year of medical training is really intense and represents one of the periods with the steepest learning curve of medical training.  (Steep learning curve = moving from knowing virtually nothing to a great deal in a very short period of time.  That’s internship in a nutshell).

OK, this is also hard . . .

When I did residency, there were no restrictions on how much interns and residents could work.  So our work week was typically about 100 hours.  I kid you not.  One hundred hours.  In a week.  There were no restrictions on the length of a “shift” either.  In fact, we didn’t refer to our work as shifts at all.  Our mindset was simply that we were in the hospital essentially all the time.  We were not truly residents of the hospital, I mean, we didn’t actually live there as they did in past generations.  But we were certainly at the hospital more than we were at home.  We felt like we resided there, I know that for sure.

Every 4th night we worked that dreaded 36-hours in a row.

But at least we got 4 days off per month.

But again, something good comes out of it . . .

My training hospital, HCMC, used to open the cafeteria from midnight until about 2:00 a.m. with a limited offering of snacks.  I remember the unofficial gathering of resident physicians during this time in the cafeteria.  Doctors from all over the hospital would gather for smoothies at around midnight many nights.  There would be 10-15 of us:  internists, surgeons, emergency doctors, ob-gyns, family doctors – all sharing stories, supporting each other, discussing our patients, and in essence becoming better colleagues for each other.

I loved the midnight smoothie hour.  Since we were there for so many hours, we could afford to take a few minutes in the middle of the night to hang out with each other.  I think it made us better doctors in some intangible way.  Collegiality and support among physicians is a key to reducing physician burnout, which in 2016 is a HUGE PROBLEM that should concern us all.  The funny thing is, I think physician burnout is a bigger problem now that it was 20 years ago when we were working ridiculous hours.  Hmm.

With shift work, there isn’t time for such frivolity I’m afraid.  And the cafeteria is no longer open at midnight.  I miss that.

2016:  Attending physician

Things are different now.  Somebody finally took notice of the lunacy of 100-hour work weeks and 36-hour shifts.  The public got upset about it.  I guess that seems entirely reasonable.  The reasoning goes that any doctor who has been working upwards of 24 hours without a break must be sleep-deprived and this simply cannot be a good thing – for the doctor or the patient.

So a fix was put in place . . .

Work hour restrictions were put in place all across the country over the past decade or so.  Now, as an attending physician, the residents that I work with have certain rules they must follow.  Among them, their work-week cannot be more than 80 hours.  I know, that still seems a bit long to most normal people but to me it seems totally do-able.  They cannot work more than 16 hours in a row during their intern year.  There are rules about minimum amount of time they must be out of the hospital between their shifts.  And so on.

All makes sense, right?  So why in the world is the ACGME (the accreditation group for medical training) considering relaxing these rules a bit by doing away with the 16 hour limit to an intern’s work shift?

I am convinced that the residents and students that I teach are just as smart, just as committed to learning, just as committed to their patients, and just as hard-working as we were back in my training days.  But I think that at some level we are teaching them to be shift-workers.

To wit:

Interns routinely admit patients on their shift, then hand the care off to someone else at the end of their shift.  They often don’t learn if their initial diagnosis turned out to be accurate.  They don’t hear how their patient did on the second day.  They don’t learn to manage a patient from start to finish.  They don’t get to know the patients they admit to the hospital.  They don’t learn continuity of care.

It’s not their fault.  It is the fallout from turning doctors into shift workers.

Here’s a confession.  I actually miss the era when there were no restrictions on work hours.

There, I said it.


I say this knowing full well that doctors, like all other people, need to sleep.  In fact, the most compelling reason to limit resident work hours is clearly sleep.  Inadequate sleep is known to inhibit performance in so many areas of life that it only makes sense that our doctors shouldn’t be deprived of sleep.  The reasoning goes, by ensuring adequate rest for residents, patient care and especially patient safety would be improved.

In fact, that’s about the only reason for restricting work hours – to ensure patient safety.

So limiting doctors work hours must have improved patient safety, right?  Here’s the shocking part and you may be surprised to learn that the evidence that patient safety would improve after restricting physician work hours never materialized.  We may have simply substituted one problem (inadequate sleep for physicians) with another (increased “hand-offs” of patients from doctor to doctor leading to fractured care).

For interesting reading on this, check out this article which appeared in the LA Times in 2014 which summarizes these surprising findings.

For another take on the topic, check out a Washington Post piece from 2010.

Which leads us to the Washington Post article from this week and an audio NPR story which lay out the issue at it stands now in 2016.

So I confess to being ambivalent and I’m aware that this whole discussion of mine may sound like a bunch of nostalgic drivel.  But I’m a medical educator and this stuff matters to me and I think it matters to the patients of this country.  Do I really think we should go back to the days of sleep-deprived doctors?

No, I don’t.

But I come to that conclusion with a bit of a sigh.

2002:  One last story from my residency

It was about 4:00 in the morning in the Intensive Care Unit and I was approaching my 22nd hour of what was to be 36-hours in the hospital.  A woman was actively dying on my service and she had no one else with her.  Just me.  I was exhausted but it was becoming apparent that she would not live to see the sun rise that morning.  So at her request, I sat at her bedside and read to her some poems that she herself had written and had collected into an unpublished manuscript.  I read her own poems to her as she breathed her last.

I probably spent 3 hours in her room with her.  Those hours taught me that no one should die alone.  That patient of mine, though without any support people in her life to be with her, did not die alone.  I made sure of that and I still remember those 3 hours vividly 14 years later.

But today I think it would be difficult for a resident physician to spend 3 hours at the side of a dying woman.  They simply don’t have the time.  There are other patients to see and they have notes to type into the electronic health record.  And even if they wished to spend 3 hours with a dying woman they couldn’t because we prod them out the door at the end of their shift.

Residents today are just as committed to their patients as we were back in the day.  I have absolutely no doubt that current residents would spend 3 hours at the bedside of a dying woman if they could.  But all too often they can’t – and not only does patient care perhaps suffer – their training suffers.  I learned a great deal about how to be a doctor by reading poetry to a dying woman at 4:00 a.m.

Your thoughts

I wrote this post on a whim after reading that newspaper article from the Washington Post while I was drinking coffee at home today.  I had no idea where I was going with it and now at the end of it I realized this became a retrospective rambling on my medical training.  I just tried to edit it into something more organized and informative with lots of medical information but in the end I decided to leave it just as I typed it from my office here at the hospital.

I’m interested in your reaction.  Do you have a thought about restricting physician work hours?  Leave it in the comments/reply section below.

And look for Insomnia Part 2 in the coming week!

David

 

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4 Responses to The 36-hour shift

  1. Jeanne says:

    Your article was most interesting. I couldn’t help thinking people who can go without sleep and those that that can’t. I come from a family of six, two who almost can’t stay awake past there usual bedtime. These two usually fall asleep within five minutes of their heads hitting the pillow. The other four have no problem with little or no sleep and often have trouble getting and or staying asleep. I wonder how these differences in sleep patterns or needs would effect working 36 hours. Incidentally I am one of those who seem to need little sleep, I married someone who really really needs their sleep. I’ll never forget during a pillow talk when he fell asleep mid work.

  2. Hi Dr. Hilden- Thank you for helping to continue the conversation about resident duty hours. I think one important aspect that you leave out is whether or not today’s residents actually limit their work according to duty hours. (For an interesting read on this topic, see Hafferty and Tilburt in J Grad Med Educ. 2015 Sep; 7(3): 344–348). My own opinion is that the total work done by residents over time probably has been quite stable despite the ACGME duty hour regulations and the ostensible fragmentation in “continuity of care.” It’s just that now we do basically the same amount of work in shorter amount of time, or we do it at home, or we do it without telling anyone because it will get us (and our programs) in trouble. Another important consideration is the fact that GME is nested within a larger ecosystem of hospitals and other health services organizations, and as most doctors will tell you at the end of a long day: it takes always herculean efforts to ensure quality, humane, “continuous” care in the face of the many bureaucratic and economic imperatives involved in medical care today, regardless of your position in the field. This is not a phenomenon unique to GME and it is not new. Paul Starr won a Pulitzer in 1983 for his account of how American medicine has been defined by tension between historical traditions of professional sovereignty and the emergence of corporations and government agencies as the arbiters of who gets what medical care and how they get it. It is that historical tension that sets the stage for today’s thought leaders like Atul Gawande to propose ideas such as the famous “cowboy medicine” versus “pit crew medicine.” It is also the context for changes such as ACGME’s duty hour limits as well as unionization of physician groups (see: PeaceHealth Sacred Heart Medical Center in Springfield, OR) and resident house staff (see: University of Washington). Ultimately the question that we must grapple with as we confront problems in GME is: what is the work of a doctor? My own take is that, best case scenario, the maturation of corporate medicine will eventually compel medical care to look more like Dr. Gawande’s pit crews. And the best pit crews will be focused intensely not on finding and rewarding those individual heroes/martyrs who can work 36 hours in a row, but rather on cultivating resilient teams of people who together to produce consistent, reliable, high quality medical care 24/7/365, year after year, universally available to everyone, from cradle to grave. It’s a tall order–and in the face of it, I think we should have the decency to value both our work and our rest, because no matter how you slice it, I don’t think 36 hour shifts are going to be up to the task. Again, thanks for offering the forum to discuss this important issue–

  3. healthymatters says:

    You bring up so many thought-provoking comments, Benjamin. I actually think the 36-hour hero model is obsolete and ought to be laid to rest, although I realize my post may make it seem otherwise. It was a stream-of-consciousness type of post! I do admit to being nostalgic for good old days even while realizing that, in the words of Billy Joel “the good old days weren’t always good . . . and tomorrow ain’t as bad as it seems.”

    I concur with you about the doing the same amount of work in a shorter time. The residents at my hospital do exactly that. Hence my comments that we used to sit around at midnight drinking smoothies and basically bonding with each other since we did about the same amount of work but in a much longer time frame. And we didn’t have the EHR pressures, quality metrics, or anything like that – all important but definitely presenting new demands on residents time.

    The cowboy medicine piece has to go. I don’t like physician unions though, as I think there are better ways to organize and advocate for both better systems of care and better care of physicians. The burnout factor is higher now, it seems to me, that it was in the past. Hmm.

    I’ll look more into the Gawande pit crew concept.

    I can’t tell you how much I appreciate your comments. Great great insight. Thanks, David

  4. healthymatters says:

    Hi, Jeanne – I spoke recently with a sleep expert who said that although some people can get away with very few hours of sleep, the vast majority need 7-9 hours. But I totally know what you are saying – I need a little less, say, than my wife, I know that for certain. The 36-hour shift stretches it out to ridiculous levels I’m afraid. we did have call rooms back in the day so we slept a few hours here and there but overall we were not operating at a normal level of human functioning. Which is why I surprise myself that I sort of miss those days! Thanks for weighing in!

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