An ongoing dialogue on HIV/AIDS, infectious diseases,
March 14th, 2017
Poll: Should We Allow 24-Hour Shifts Again For Interns?
Over on Boston’s NPR site, I wrote a piece about the decision by the Accreditation Council for Graduate Medical Education (ACGME) to allow 24 hour (or longer) work shifts again for interns.
My goal in writing the piece was to relay what I experienced doing these long shifts way back when during my internship — the good and the bad.
Not surprisingly, most of the comments I’ve received from non-MDs are highly skeptical that there could be anything good about working such a long shift. And if you listen to the linked radio segment on the site, you can sense the incredulousness of the hosts, neither of them doctors. Their tone is practically dripping with, “You’ve got to be kidding me.”
From my friends and colleagues in medicine, however, what I wrote seems to have resonated — here are a few of the emails I received:
“Great piece on 28 hour shifts! Wonderful description of our days as interns. Forwarded to my daughter who is in her third year of med school.”
“Paul, I loved reading your piece. I had the same set of experiences and thought you captured the highs and lows perfectly. Thanks!”
“GREAT piece…I wish I could call you ‘old’ [ahem] but, alas, that was me in that description of internship too.”
“Your article – truly wise and wonderful, by far the best treatment of such a complicated topic that I have read, ever (I crossed out in years).”
“Spot on, Paul! We learned the cycle of illness, both to recovery or to progression of disease. And, we were the patient’s doctor from day one.”
I don’t cite those just to toot my horn (obviously that’s a little bit of it), but also to emphasize that this experience we had with long shifts wasn’t exclusively terrible. Some good came out of it as well.
But did these positives actually outweigh the very substantial negatives, which I also outlined in that piece? I just don’t know, and hence am not sure if the ACGME should be applauded for allowing more flexibility in training, or — and this is the mainstream view — should they be criticized for bringing back work shifts that put patient safety in jeopardy?
Since I’m now back with this readership, I’m dying to know what you think. Based on the NEJM Journal Watch sophisticated reader metrics, you are predominantly practicing clinicians — doctors, nurses, PAs. And we also know that 22% of you have dogs, 14% cats, 6% both, and 0.0412% have ferrets. (Yuck.)
Please read the piece, vote in the poll below, and feel free to provide your comment or comments. We’ll stratify the results by pet ownership.
Thank you.
30 Responses to “Poll: Should We Allow 24-Hour Shifts Again For Interns?”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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28 hour shifts don’t sound so bad. It was the 36 hour ones that were soul and mind crushing, when I might fall asleep trying to write a note.
On the other hand I’m not convinced there is compelling
educational value in long shifts and I think it does increase risk of dehumanization.
I ditto this
Although for me it means a no vote
In favor of 24 hour shifts as well for more longitudinal continuity of care.
Great piece in NPR!
JC
I agree with Tom–28 hours wasn’t too bad, and I rarely went a full night without sleep. It was staying through the entire next day for a total of 36 hours that was hard. By the end of the day, I had paresthesias in my arms and was getting pretty cranky. It wasn’t always fun, and I never saw a movie that year that I didn’t sleep through, but I do think it made me a good doctor. Did my sleep impairment hurt patients? I’ll probably never know, though it’s safe to say that my compassion and bedside manner would have been better if I’d been well rested.
I do remember writing a note (yes, on paper) the afternoon after having admitted six very sick patients and slept for one hour. I had reached the assessment & plan section, but began to drift off. When I woke up, I realized that I’d been transcribing a dream, in barely legible handwriting, into the patient’s chart. Fortunately it was on a fresh page, so I didn’t have to start over. I wish I’d saved the page!
Joel, I uncannily had the same experience. In my almost unintelligible scrawl, I wrote: “Impression: Alcoholic cardiomyopathy” — which had only two things wrong: The patient’s heart was fine, and he did not drink. And then came: “Plan: Fresh fruit.”
I voted yes for continuity – there are some processes in life and care that you are more likely to see if you are on longer. Having spent my life in OB, I know that you will never learn the rhythm of labor and birth unless you can see it through.Having said that, 24 needs to mean 24 – not 28 or even longer. And the break before next shift needs to be long enough for sleep (and food, and laundry). We are caught in many of the health professions between wanting to produce the best possible physicians, midwives, etc., and the crushing debt load that makes longer training at low wages seem like an impossible burden.
What’s been the point of decades of fatigue research then?
Do providers and recipients really need more risk/damage (think of Chernobyl if you don’t think this is important from a systems point of view)?
Who, EXACTLY, is making these proposals? Have they just come from a 28 hr shift???
The gains I had from these shifts were entirely obtainable by doing (regular ) night shifts, continuity of care (following one patient around the hospital), and interdisciplinary team liaisons. . . . NOT from 100 hour shifts (Yep, the good old days – Interns were sometimes admitted to the ER for rehydration!!).
Hello Paul,
I studied in Mexico and here we have in many hospitals, 36h shifts. But the problem is not the length of the shift as much as the frequency of shifts. Here we have a system called ABC, which means you either have “A”, “B”, or “C” shifts (a 36h shift every 3 days!).
But… as always, humans have a tendency to adapt to any situation an thus our interns survive (and our patients).
Paul, you have articulated what I could not seem to formulate on my own. In my internship, at a huge city hospital in NYC in 1969-70, at the beginning of the year we worked 36-on-12-off shifts, which were criminal and cruel and resulted in such profound fatigue and sleep deprivation that, I am convinced, patient care was compromised. After the first few months, however, the schedule changed from every second night “on” to every third night, On that schedule — which while more humane was still not so easy as even the new proposal specifies — I felt and continue to feel that the kind of continuity of care we provided to our patients and that we experienced as young physicians set a pattern for a lifelong sense of profound individual responsibility. The pendulum has swung from one extreme to another — from that of abusive sleep deprivation to that of frequent hand-offs. I think the new proposal may represent an excellent point of equilibrium. It deserves a try.
Loved your piece on internship. Captures all the good which I believe did outweigh the significant bad (at least in retrospect — I appreciate there are some rosey tints in the glasses). Reflections on the midnight meal brought back some great memories. I still mourn the lack of ownership of the house staff, especially where I currently work. Often the only person that knows the case is the ID fellow!
I would be more supportive of 28h shifts if it were like the old days where some amount of sleep at the hospital was likely. However, in the current age abusing residents as cheap labor, it’s not uncommon to get a dozen or more admissions overnight in many hospitals (particular children’s hospitals).
It would be one thing if hours were expanding because of the educational value, continuity in care, or for patient safety. But, unfortunately, it’s mostly about the money. Residents are cheap labor. It costs a lot more to hire a hospitalist to admit those dozen patients overnight.
We shouldn’t be surprised that the next generation of physicians is even more burnt out than the previous with these idiotic rules.
I think there is a major flawed in comparing the current residency training to those from several years ago. With the rapid patient turnover, higher acuity of care on general wards as well as the very aggressive and advanced treatments available; house officers’ shifts are more demanding and exhausting. I think that transitions of care is a major source for medical error and poor patient outcome but this should not mean longer working hours. It should be addressed through better transition-of-care training and investing in EMRs that facilitate such transition.
I think a forgotten issue in this debate is the effect of sleep deprivation on learning. I have been a quick learner throughout my life, with the exception of intern year. Things just didn’t stick in my memory the same way, which makes sense because I had trouble with even basic tasks in the setting of my “post-call encephalopathy.” I lost my curiosity as well, always trying to figure out the quickest or simplest way to do something rather than the best way. When I became a resident, I was unprepared for handling a number of important clinical issues, and was in the position of supervising interns while managing other patients independently at the same time (“resi-terning”). An unprepared resident, who did not learn enough during intern year, in my estimation, is a much greater patient safety risk than a tired intern.
This issue is complex. I worked my intern year with the “old” hourly limitations and 2nd/3rd year with the new rules. I distinctly remember taking 14 call shifts on a 28 day trauma surgery rotation-there were 2 trauma teams. I also remember suturing someone’s ear at 4 pm the day after I got there. Our team was close, we cared for our patients, even found time to socialize, provided continuity of care, and gave better care (I feel) than was given when all of these patients were handed off to a resident who didn’t know them. Sure there are pros and cons. I found out what I could do while sleep-deprived and found out “what I was made of.” My friends and family would have thought that was ridiculous at the time (and perhaps even now.) Spending more time at the hospital and seeing more patients is what builds on the foundation for our education. This is particularly true with the surgical specialties. The amount of work has stayed the same, even increasing in most hospitals. The amount of money for medical education and number of residents hired stayed the same though. I think we can agree that changing the hourly limits changed none of that. It just shifted work in other ways and all of a sudden, a resident carried 5 or 6 pagers instead of 1.
Well-written summary. As one who lived through the 34 – 36 hour shift era, with every 3rd night call, I think the 24 – 28 hour shift idea strikes a good balance, providing the opportunity for the intern to see the disease’s course without as much dehumanization as the longer shifts provide. No choice – 16 hour shifts, 24 – 28 hour shifts, or 34 – 36 hour shifts – provides a perfect solution. I think the ACGME made the best decision they could.
24 sounds great . 36 were the soul crushers and were a 12 hour amount too far. That last 12 hours is when I became the least human and least effective as a physician. What I learned? Who knows? All I remember from those times was the awful attitudes I had and the times the patient and I were rescued by my program director from myself.
I also feel that the 24-28 hour shift is a good balance. One issue that is not often discussed in this debate is what happens when residents graduate and become attendings in private practice. Attendings often work 36 + hour shifts when they take call – especially over the weekends. I worry about patient safety when 1st year attendings are sleep deprived with no supervision. If attending doctors are expected to work long shifts, they should practice longer shifts during their residency while they still have supervison.
How does this relate to research on high levels of depression in doctors in training? Our wise HIV psychiatrist taught me the best “bang for your buck” when treating depression is to help the person get sleep.
I definitely voted no. My internship limited admissions after midnight to ICU patients, so SOME sleep was usual, but I am sure that I made mistakes after being on call and more than once dozed off while taking a patient history the next day (my handwriting dribbled off the page).
Continuity in ICU’s are important, but intensivists work set shifts and have good hand off protocols.
Finally, there is the old surgery saw about call: being on every second night means you miss half the cases!. So much for third and fourth night concerns.
Long shifts contribute to the development of a “God Complex” in young doctors. Having been through such ordeals, during which decision making, however knowledge based it may be, must carry components of sleep deprived emotional bias, doctors’ outlooks tend to drift away from the scientific. The more that a doctor has been through the stress of long shifts, the more likely they are to exhibit PTSD like symptoms, including paranoid ideation and ritual-like superstitious practices; as well as an inflated sense of his or her own worth.
Young doctors need to be able to call upon their instincts, certainly. A long shift or two may even help.
I totally agree with Klasovsky because he has a point that Long shifts contribute to the development of a “Good Complex”. I think long shifts should be ok with everyone.
Longer shifts also mean a longer break between shifts, allowing for adequate sleep, relaxation and human interactions between shifts rather than the all too common 12 days in a row of 12 hour days (way more soul crushing and contribute to cumulative sleep debt). But in my opinion the best way to let residents rest and be at their best is to reduce the work load with hospitalist/NP services to reduce patient load and administrators who assist with scut work like finding outside hospital records. The focus should not be on shift length, it’s just an easier headline.
I think this is the perfect comment.
I’m a Family Med resident in Canada and have had plenty of post-call days after 26-28hr shifts in ICU, OB, Peds, etc, and they saved my soul.
My partner is an OB resident in the US, and 12 hrs x 19 days in a row, for lack of a better word, sucks.
I am an intern in internal medicine.
Essentially, the ACGME is saying we don’t know which system is better, but we’ll leave it up to the programs to decide what works for them and the interns they get. The trial everyone is basing these changes off of said the same thing. Non-superior. So, what changes when we make recommendations off of a nonsuperiority study? The unmeasured outcomes. Patient satisfaction, ancillary staff communication, non-fatal medical errors, patient morbidity, resident satisfaction to name a few.
People are so quick to tell you which side of the story they agree with, especially the ones who had it worse off. Unfortunately, some of those people are the same one making the rules.
I feel sorry for the interns who may be at unstable programs, the programs that don’t put education first and may view your presence as cheap labor or scut-level contribution. The ACGME just hung those interns out to dry by changing standards on a botched study.
I work in a place where there are no 24h shifts. The longest is the 12 hour night shift, which you have for 7 days followed by 6 days off.
I voted no, because in my experience these longer shifts are based on the good old days when patients’ number were lower and half of the treatments not available.
It also helps to have a fresh pair of eyes looking at a patient once in a while.
Furthermore, I think these long shifts are more of a telltale sign of how a health care system is run.
I am a current resident in Internal Medicine. Personally, I think the question of whether interns should be made to work 24, or 28, or 30 hour shifts misses the point. Medicine has a long sordid history led by a toxic superiority complex that just won’t die. How many times have we complain-bragged to our colleagues about how we haven’t eaten in 20 hours, slept in 36, or peed for 14? I bet only a medical resident, an ultramarathoner and a soldier in active combat know the complex mix of concern and satisfaction you feel when your urine comes out actually brown. How messed up is that? What would we tell our patients who regularly neglected their health like this?
I went through internship in the short era of 16hr shifts and not once did I not feel like I was my patients’ doctor. I had many more patients concerned that I was still at the hospital at 10pm when I had woken them up at 6am, than upset that the night intern had come to see them overnight instead of me.
I also know what you mean about the comraderie of the midnight meal and learning (and suffering) together. Even with 16hr shifts, I often notice that inpatient rotations feel a bit like summer camp because it is all-encompassing, interesting, you’re surrounded by friends going through the same thing and it separates you from the rest of your life. Camp is fun, but it is not a recipe for a sustainable career, nor does it support the other parts of people’s lives that exist in adulthood, like commitments to partners, children, or our own health.
I think all this talk about interns misses the point because I do not think that anyone should work for 24hrs straight without protected sleep time. Our current system perpetrates abuse on, and celebrates the self-imposed abuse of, medical residents and sets them up for the idea that medicine and self-care are incompatible. Residency programs should be training residents to build robust and sustainable careers, by modeling the behavior and structure necessary to make this a reality. It is irrelevant to me whether medical errors are reduced by changing our system to make it more healthy for the physicians, though I suspect that with an investment in developing and actually using hand-off strategies that work, we will be able to measure a benefit of having well-rested doctors. Did labor unions in the industrial revolution have to prove that textiles were better made by well-rested workers in order to win the now standard work day and work week? No, they said we will no longer be abused by a system that doesn’t care about us. We have to stand up for ourselves and decide what our healthy limits are. I believe it reveals an astounding lack of imagination* by a lot of smart and well-educated people to say that there is no good solution to the problem of training physicians in a way that is good for doctors, their current patients and their future patients alike. The fact that we have not yet come up with such a system I believe suggests that these are actually not the true goals of the system, as does the fact that I spend at least half of my day doing paperwork for billing and slogging through other tasks that social workers or administrative staff would be better trained to perform. These things, and not some perverse desire to sleep regularly and spend time with my partner, are what gets in the way of my learning and my time with my patients.
*note: I have the sneaking suspicion I have stolen this phrase from another article I read once on this topic. Apologies and thanks to that author!
I have to agree with the recent grads. Having gone through the night float system, I don’t think that I got much more rest. I would have killed for a good long ‘sleep until I wake up’ period instead of another 14-16 hour shift in a row. What’s more, for a busy service, the handoffs are not quick 10 minute chats, they can drag on for a while and if this is happening 2-3 times a day, that is a lot of time lost.
For those of us who admit and take care of our clinic patients in the hospital, a 36 hr shift (work call work the next day), or even a 100 hr week is a reality. Are we training or doctors to become shift workers? Maybe the studies should extend the follow up to attending years.
Paul has captured the issues better than I have ever seen elsewhere. Personally I am glad I did it the “old way,” but nobody who did it says it was all fun (nobody honest, that is). It’s important to understand that resident training is very different indeed today for a variety of reasons. While they don’t have so much old-fashioned scut (drawing blood, placing IVs, hunting for X-ray films, etc.), there is much more time pressure due to the need to get patients out, much more supervision, and a lot of EMR scut to do. I don’t want a doctor who trained for 40-hour weeks and punched out on time every day, nor do I want a doctor who hasn’t slept in two days. There will always be compromises.
Jon,
This is pretty much the perfect comment on the issue.
Thank you!
Paul