24+ hour shifts for hospital interns: good idea or bad?

Scary if true:

"On duty at a San Francisco hospital for nearly 29 hours, he (the doctor) was at the bedside of a very sick patient when the man's oxygen level began to plummet. He stared, transfixed, at the monitor. "I knew something was wrong, but I couldn't make myself think," he recalled. Only after a colleague walked into the room, pushed him on the shoulder and said "Get going" did the exhausted doctor spring into action."

I had heard that this sort of thing could happen, perhaps you had too. It made me wonder if the practice of interns working long, sleepless shifts, some reported as long as 24 hours straight, could lead to this sort of thing, or if the practice actually had justifiable reasons. Or maybe it was almost just a sort of "initiation ritual" to becoming a hospital doctor. (Senior doctor: "I had to do this, so you're going to do it too!").

The first article linked below is pro on this issue. The second one is con.

Reasons in favor from the pro article:

Interns must do this so "... that they learn to effectively manage fatigue."

"... shorter shifts have resulted in greater work compression, forcing interns to cram more work into fewer hours and depriving them of valuable education by limiting the time they can spend treating patients whose illnesses evolve."

Reasons against from the con:

"A single night without sleep results in a less structured method of processing information; interferes with the ability to remember and identify details."

"(During a 24-hour in-house call) ... (residents) make 36 % more serious medical mistakes, and they are nearly six times more likely to make serious diagnostic errors."

But perhaps steps have been taken to address the problem. The first article states that "... the Accreditation Council for Graduate Medical Education reduced the maximum allowable shift for the least experienced doctors from 30 straight hours to 16." (Still, even 16 hours seems like a long stretch).

Presumably, even when those interns have been working those long shifts, there was always some kind of monitoring system in place, perhaps from afar, to insure that the person wasn't making serious errors due to sleep fatigue.

Finally, the Wikipedia article on this topic, though lengthy, seems pretty definitive on the matter:

https://en.wikipedia.org/wiki/medical_resident_work_hours

Let's hear it if you have an opinion on this practice, agreeing or disagreeing with it.

Speaking for myself, I would really, really like it if the physician attending to me, assuming I was in the hospital for something serious, was pretty much wide awake, and didn't close his eyes, nod his head, and start snoozing standing up, while standing over me, due to long shift or otherwise.

But maybe that's just me.

Thoughts?

pro:

https://www.washingtonpost.com/national/health-science/medical-interns-may-be-more-awake-but-are-they-getting-enough-training/2013/07/08/e7886116-cec9-11e2-8845-d970ccb04497_story.html?utm_term=.957bdacad87c

con:

https://www.cfp.ca/content/58/5/e296

24 hour intern shifts works GREAT for the hospitals and emergency rooms but it sucks for everyone else involved..250,000 people die from hospital errors every year. Hospital errors are the third leading cause of death in the U.S.

God help you if you are injured or get sick after noon on Friday ...You're likely to be treated by a non-English speaking intern who has been on duty for over 12 hours already...The "A" team won't be back until 9AM Monday morning...

Interesting this came up because my niece always posts about her and her intern peers pulling 24 hr. shifts. And I'm always the one that seems to think that it's a bad idea while everyone feels they must "like" everything. I think its flat out ridiculous, and this is coming from someone who worked in a children's hospital.

I have tremendous respect for any student who can survive the rigors of a medical school education at a quality institution. No doubt most of them already pulled many 24 hours shifts studying for medical exams. So it's nothing new for them. The fact that they made it through medical school demonstrates that they can function under significant pressure. Now they have to put it into practice as interns. And their internships should be a medical 'boot camp' of sorts so they can evaluate themselves and be evaluated by others on how well they work under not-so-ideal conditions. Why? Because it's very possible during their careers they will experience similar or same working conditions. When I was in the military I went through boot camp and came out a much better person. I quickly learned my strengths and weaknesses. Once I knew my weaknesses that were exhibited under pressure - I could work to alleviate or mitigate them. Why was that important? Because the lives of my fellow soldiers might count on my sound actions for survival in the field in future times of crisis. No different for a medical doctor. One never knows what the future holds. For that reason I believe interns should work 24 hour shifts. An invaluable self-learning experience.

halbert said...
The 24 hour shift for interns is archaic and stupid.

Yeah, that says it all for me.

Jim

Fairwind suggested: a "white cross" maybe helps them make it through the night.

I was wondering about that myself, how often that kind of "self-assistance" might be going on. (For one thing, we're talking about a group of people who are going to have pretty broad access to such "mother's little helpers," and who will know exactly which one does what).

I would be very, very concerned if we are in a system that would enable that sort of thing in young doctors just starting out in their careers.

And if they're caught, I suspect the consequences for them would be pretty severe.

There are more errors from the increased number of case "handoffs" from shorter shifts than there are from extended shift fatigue.

I can only relate to my military career. I worked many shifts that lasted up to 3. days straight. My worst mistake during the cuban missile crisis was to load a ten megaton atomic bomb on an atlas icbm after 4 days straight of work. We didn't remove the hold down bolts on the launch platform. Had we launched that missile, all of Salina and Wichita Kansas would have been destroyed. 24 hr shifts do create mistakes. Sometimes small and sometimes large.

Haha. Googling is not “research.”

Blackjack said...
Haha. Googling is not “research.”

Jack, have you EVER posted a link here? One that perhaps began with a google search?

Regardless, as I noted above, the research into sleep deprivation, circadian rhythms, and the effects on human performance is real, it's solid, and it's unequivocal. Requiring people to work 24 hour shifts is bad. It leads to terrible errors of judgment, and it costs lives. It doesn't make you "tough". It's not a rational "rite of passage" (but are rites of passage ever rational?). Medicine and the military are the only two remaining professions that function this way--maybe it's time to be serious about it. (It's not about an occasional all-nighter--it's about doing it repetitively and cycling from days to nights to back to days)

I've been there and done that.

As a non-doctor but someone that worked all shifts on an "around the clock" construction project early in my career, it is pretty clear that the night time activities are not done with the same level of precision as the daytime activities so you tend to do labor and machinery work at night and concrete and electrical work during the days. And yes, I was too tired at times from all the schedule changes but survived with some fond memories of those I worked with in the wee hours.

Personally, I want the emergency medicine people to go through this type of training. Not everyone is cut out for this type of medicine so having the opportunity to be tested and making it through is good. Not everyone can be a PCP with regular hours. There is a strong case to be made for trying to reduce hours for interns/residents but then no one could get sick and miss a day at work so longer hours or using substitutes, if available, who come in cold are a part of the deal.

That being said, if everyone can schedule their medical maladies to occur Monday - Friday between the hours of 8 am and 5 pm and do not mind the interstates and highways being closed during the day for constructions or taking twice as long to complete, we can solve this problem quickly.

I have a son that was/is in Special Forces. I definitely want him to be near me if trouble breaks out. Been there, done that, really helps for most jobs.

Typically when we make a claim, we back it up with what we found.
We don't suggest people search for it themselves.
We provide a link or links.

In school, when we answered a mathematics question, frequently the professor would ask how we came to the answer.
We never answered them with, you can look it up yourself.
We provided our proof.

I can't find any evidence to back up your statement. Therefore I reject it.