Why do medical doctors do this?

[The Great Sun Jester]

When it's time to play inthe ER they get to pull 24 hour shifts. Why is that? Does trauma medicine become easier when you're fatigued? Is this a bravado thing that puts patients at risk?

[Qadgop the Mercotan]

ERs need 24 hour staffing. But doctors qualified to staff ERs are in short supply, and often travel far to staff an ER. It makes more economic sense to drive 150 miles to your job, work for 24 or 48 hours, sleep when you can, then leave for home, than to do that for multiple 8 hour shifts.

That's just one consideration. There are others that drive this staffing pattern.

I'm sure Chief Pedant, with far more ER experience than I, will be along soon to comment.

[Bijou Drains]

OB/GYN docs are on call for long shifts too since babies can arrive at any time. My 2nd son was born on a Friday and the same doc for the practice was there Fri., Sat, and Sun. Don't know how many kids he delivered but it is a big practice with about 6 doctors.

[Chief Pedant]

Originally Posted by Inigo Montoya

When it's time to play inthe ER they get to pull 24 hour shifts. Why is that? Does trauma medicine become easier when you're fatigued? Is this a bravado thing that puts patients at risk?

I'm not sure I understand the question...trauma centers are staffed by a variety of physicians including various attendings (the top level) and residents (in training) plus specialties of various types on call to the ED as backup.

In a very busy ED (say a city trauma center), doctors don't work 24-hour shifts as the only attending physician unless they have other help or are seeing patients intermittently. Of course it does happen that you might draw a 24 hour shift where it happens that the particular patient load for that day is so heavy you are busy non-stop the full shift. That's the nature of medicine and not particular to the ED, though. Say, for instance, you have trauma call for a 24 hour block and you get one really sick patient that consumes you the whole 24 hours, or a series of patients--just the luck of the draw.

In recent years, efforts have been made to look at the effect of long hours on patient care, but the data is not in. Plenty of opinions on both sides. While fatigue is a factor, it's not the only variable and medicine does not lend itself easily to shift work. Total hours per week is another consideration, but even truncating that too much is controversial; we have a saying that the problem with being on call every other nite is that you miss half the good cases. There's a germ of truth in that; there is no substitute for experience so if we really cut down the hours to be more humane, we've also cut down the total training experience. We'd also like to maintain a process that selects out the namby-pamby. No one wants to be a sick patient whose doctor suddenly decides his shift-is-over-we'll see-ya. An argument can be made that rotten hours during training selects out those who think medicine should be 9 to 5.

Some very low-volume ED's (typically small rural facilities) might be staffed by a single physician working 24 or even 48 or 60-hour shifts, but those have sleeping rooms and time to sleep as well due to the low volume.

Many physicians prefer 24-hour shifts where the workload distribution is reasonable. It's much more efficient in the ED because there is a lot of time wasted just signing over patients and learning new ones. It also gives a bigger block of time off. This dynamic is true throughout medicine--working 24 hours on and getting 48hours off might be more attractive to some people than working 8 hours a day for three days, for example. As a rule of thumb 24 hours in a row on is about the reasonable upper limit in most minds...nearly every facility and program has its own rules and opinions about this, and there is even a fair body of literature looking at the issue, especially in the ED.

[St. Urho]

Not all ER doctors work 24-hour shifts. I'm not aware of any ERs in the Denver area that have docs working any longer than 12-hour shifts.

[toadspittle]

Blog article from NYTimes.com:

Panel Calls for Changes in Doctor Training

Good overview on recent recommended changes. Apparently 30-hour shifts (!) are not uncommon. The panel recommends limiting them to a mere 16 hours, followed by a 5-hour nap.

Downside: expensive.

[Markxxx]

I know three staff ER physicans and all of them told me they actually took those jobs because of the schedule. They said, a doctor with a practice has all sorts of hours, but they have a set schedule in the ER. (Two work in Chicago and one in Aurora)

They work 8-10 hour shifts

[Nametag]

Staff and attending physicians have less demanding hours than residents, who work long hours with little rest for at least two reasons. First is that it saves money; second, judging by what I've read, is that it's always been done that way. A possible third reason, or perhaps part of the second, is that that established doctors regard this rugged apprenticeship as the final stage of producing an effective physician -- once you've learned to make the right decisions when you're exhausted and rushed off your feet, you're ready to handle anything patients can throw at you. A doctor who's been through this, even if she consciously disapproves, may find herself unable to completely trust a young colleague who's never proven herself this way.

[Bayard]

Originally Posted by Nametag

...second, judging by what I've read, is that it's always been done that way...

I am not a doctor. My wife is. When the residency rules started to require shorter shifts, some physicians objected based partly on this reasoning. Among my wife and her colleagues (who got out of residency just before the new rules went into affect), there was a fair amount of "We went through this, so they should too" kind of sentiment expressed. I suggested (once) to my wife that this was the same mentality that fuels fraternity hazing.

[Tom Tildrum]

I'd be curious whether the doctors working 24-hour shifts would be comfortable riding an airline flight captained by a pilot who had been on the job that long.

[DSYoungEsq]

Originally Posted by Tom Tildrum

I'd be curious whether the doctors working 24-hour shifts would be comfortable riding an airline flight captained by a pilot who had been on the job that long.

Why do you think that is an apt comparison? An airline pilot directly controls what is going on with the airplane. A doctor's job, even in an ER, is rarely comparable. A heart surgeon, now, that might be different.

[Bijou Drains]

Doesn't the ER doctor directly control the treatment of the patient? So what makes it different than a pilot? The only thing I can think of that is different is the ER has a lot of people there involved in treatment while a plane only has 2 people controlling the plane.

[The Great Sun Jester]

The plane is contolled by machines 90% of the time, I wonder if piolots get better naps too. An ER will see crash victims, heart attacks, lawn mower accidents, bee sting allergies...and nobody knows when they're coming in.

[Qadgop the Mercotan]

Originally Posted by Bayard

I am not a doctor. My wife is. When the residency rules started to require shorter shifts, some physicians objected based partly on this reasoning. Among my wife and her colleagues (who got out of residency just before the new rules went into affect), there was a fair amount of "We went through this, so they should too" kind of sentiment expressed. I suggested (once) to my wife that this was the same mentality that fuels fraternity hazing.

That's part of it, it is true. And gratuitously long shifts done just to save the hospital/institution money while loading the resident with relatively mindless 'scutwork' that trained medical assistants/aides could do, must stop. I learned little from drawing blood on patients after my first few hundred. Same with starting IVs.

But speaking as a physician who went through the long hours in training, I must say that there is really no good substitute for just being there hour after hour after hour, seeing how your critical patients do, either getting better or not, as you work to help them.

Or being there long enough to see a patient who you thought was stable suddenly crash and burn, while you deal with that situation.

The practice of medicine requires a lot of first-hand experience that just does not come quickly (or too often, at all) when obtained piecemeal.

[DSeid]

There is also no substitute for learning how to sign out well and how to make a treatment plan that can transcend doctor shifts, i.e. learning to work as part of a team. Or for getting enough rest that you can actually communicate with patients effectively.

I don't know about your training days but in mine I rarely spent hours sitting at a critical patients bedside learning. Me, I was spread out cross covering multiple teams' patients on long call shifts, trying to keep up with checking what needed to be checked and putting out fires. The sitting by the bedside of critically ill patients and being aware of when things were not going as we expected or watching as they did? That was the ICU nurse. Thank god for the ICU nurse! And heaven help the resident foolish enough to dis one.

As for ERs, I am not an ED doc but I am not too familiar with 24 hr ED shifts. I am sure that 90% plus of what presents is so knee-jerk that a sleep fatigued doc can handle it just fine, but as a doc who gets calls from ERs, some isn't and some less than ideal choices (and case presentations) get made even by rested docs. I'd hate to be getting the call from one finishing up 24 hrs working straight through.

[Qadgop the Mercotan]

As a second year resident, I was on call about once a week, covering the ICU and CCU, and generally not moving far from those adjacent units for the 24 hours. I certainly put myself in the hands of the ICU RNs, and had a good working relationship with them. And learned a hell of a lot dealing with those patients in conjunction/consultation with the cardiologists, pulmonologists, etc. And after 5 or 6 PM or so, I was generally the only doc there to deal with issues as they arose.

It was a very good training experience; The fact that it was once a week made it about right for me. On non-call days, I generally worked 8-10 hours in various rotations, sometimes less.

Call on the general medical floor every 3rd or 4th night (intern duty) was much less rewarding educationally.

[smiling bandit]

IIRC, don't most places have their residents run in 36-hour shifts? I recall seeing some rather nasty statistics about mistakes tending to be made towards the end of those, and even in the 24-hour shifts it wasn't good.

As nice as it is for the doctors, I think I'd rather have mine fresh and see him only once a day.

[VunderBob]

I did 18 hours in an ER while for the clinical part of my EMT education, and that whipped my ass. My hat is off to any MD that can handle 24 or 36 hour shifts for a couple of years.

[Tom Tildrum]

Originally Posted by smiling bandit

IIRC, don't most places have their residents run in 36-hour shifts?

Some specialties in some places run 60-hour shifts, at least in residency.

I respect QtM's point about just being there; it makes sense, and obviously I'm not qualified to disagree. But it strikes me as open-ended. No matter how long you're there, isn't there always a risk that the patient will crash right after you've left? Also, in the specific situation of ED doctors, if the patient is going to be there for 24 hours, wouldn't he or she typically be admitted, and thus transferred to another doctor?

[toadspittle]

Originally Posted by DSYoungEsq

Why do you think that is an apt comparison? An airline pilot directly controls what is going on with the airplane. A doctor's job, even in an ER, is rarely comparable. A heart surgeon, now, that might be different.

A better comparison: An air traffic controller.

[Typo Knig]

The pilot comparison reminded me of an article in the Washington Post Magazine a few years ago. The B-2 bomber is only based in the US (and possibly on Diego Garcia) for security reasons. Therefore any combat mission is most of 24 hours long or longer. How can the B-2's crew of two deal with the sleep deprivation, and still be at peak, combat-ready efficiency when the action starts? The Air Force studied this and came up with naps.

The article was titled "WAR and SLEEP; Why an $8 chaise lounge became a prized accessory on the B-2 during the bombing of Yugoslavia" by Dana Priest, Washington Post Nov 19, 2000. That was longer ago than I thought! My insomnia must be futzing with my memory. No wonder it was so hard to find via google! The article does not appear to be available on line. I guess the millennium did not start until 01/01/01.

I think the medical profession needs to look at issues of wakefulness and attention, and leave the machismo games to the college fraternities. How can the experience and career filtering aspects of long shifts be kept without compromising patient care?

[threemae]

Originally Posted by Tom Tildrum

Some specialties in some places run 60-hour shifts, at least in residency.

This is no longer true.

In the past decade, the ACGME (the organization that accredits residency programs in the United States) restricted work hours to 160 hours every two weeks (i.e. an average of 80/week over two weeks) and 30 hours of direct patient care in a single shift.

More that you"ll ever want to read on the issue:
http://www.acgme.org/acWebsite/dutyH..._articles2.pdf

[outlierrn]

Docs work 10 hour shifts in my ER (in theory, the mid-shift often gets hosed), nurses 12.

[irishgirl]

When I worked in the ER we had some sort of crazy rolling shift system. The longest shift was 13hours, but the shifts were very anti-social. Two weekends on, two off, leave built into the rota, not family friendly at all.

Legally here, doctors can work no more than 56 hours per average week (48 from August). That does mean that you can work 112 hours every other week and still be legal though...

My ER rota:
Week 1: 8am-5pm mon-sun
Week 2: OFF mon-fri, 10am-11pm sat&sun
Week 3: 10am-6pm mon-fri
Week 4: OFF sat- thursday
Week 5: 5pm-2am fri-thursday
week 6: 11pm-8am fri-thursday
Week 7: OFF fri-fri
Week 8: 2pm-11pm mon-fri

There is a difference between resident shifts (when you have to be in the hospital) and non resident shifts (when you're at home with a beeper...as long as "home" is 20mins or less from the hospital).

Non-resident shifts only the time you're actually answering the phone or in the hospital count as work- so a 24, 48 or 72 hour "on-call" is usually do-able.
For resident shifts you can legally only work 13 hours straight, so most rotas have switched to night/day shift systems similar to nursing rotas. Usually for doctors this means seven 13 hour night shifts every 4-6 weeks with 5-7 days off afterwards to make the rota legal.

Personally, I'm thrilled to only have 6 months more of hospital medcine when I get back fom maternity leave, after that I'm out in the (mostly) mon-fri 8am-6pm world of GP...yeay!