They may also be running into the issue that physicians and residents do: hand-off errors. I have seen arguments that it's better to have an exhausted physician who has been monitoring you for 12+ hours than a fresh one who just started their shift. There's a lot of state of the current situation that can't be easily transmitted from one shift to the next.
And as an aside, I think the long-shifts thing is a slightly different case. I've talked with doctors, and one pointed out that a big threat to patients is information loss during handoffs. The more you change shifts, the more information gets lost.
It's similar to how we developers will often keep working on a problem until it's solved. That's especially true in incident response, where the same people tend to keep working on an issue until it's solved, rather than saying, "Oh, it's 5 pm, I'm going home; somebody else can figure out why the site is down."
That's not to say doctors have the right balance now; they definitely have a macho-culture problem where people tough it out when it isn't necessary or beneficial. But it's definitely not as simple as I thought at first.
Could the reason handoffs are so bad be because the person doing the handoff has been working for 16-24 hours straight?
I mean in IT i see first hand the notes left by people on pager duty in the middle of the night, and they differ significantly from the same peoples notes after a restful night of sleep.
Has there been any controlling in these studies i see mentioned through this entire thread for sleep deprivation present in people performing the handoffs? If they arent controlling for the amount of rest the people in the handoffs have had in the last 24 hours, im not sure i am willing to put much weight in these studies.
>I'd prefer single physicians for 24 hr shifts rather than 2 or 3 handing off to each other per 24 hr shift.
But if you came into the ER at 3am and the doctor you get has been working 23 hours, youre still going to need ot be handed off, and now youve received sleep deprivated care in the interim while waiting for a fresh doctor. Sure, for the guy who arrived just as a fresh doctor arrived, it might be beneficial to have them there for 24 hours, but how many new patients are they seeing in hours 12-24?
> There is no logic in that, i'm not sure why you asserted that. I noted that long shifts reduce handoff errors.
Consider two scenarios: Scenario 1: 8 hour shifts: Doctor 1 hands off to Doctor 2 at end of 8 hrs Doctor 2 hands off to Doctor 3 at end of 16 hrs Doctor 3 hands off to Doctor 4 (or perhaps 1) at end of 24hrs
Each handoff is a game of telephone.
This is not how this works. You either have acute patients who would indeed need handoffs between day and night teams, and you have programmed patients who usually do not need any handoff. Acute patients are usually managed by very specialized teams both in terms of managing physicians, nurses, and usually residents are not alone at night. Those patients are also indirectly managed by other specialists, wether it be the surgical teams, or the imagery team on call. They are also hooked to at least an EKG machines, and depending on the condition will have more invasive surveillance system (arterial catether, articial life support, dialysis etc...). Those patients might die from a medical error, but actually the handoff are not the problem, those are repeated, digitalized, supported and surveillance is maximal. Errors are due to the team's reactivity and knowledge in front of the severity and extremely fast time course of their condition. That is the deciding factor, of course if the doctors are exhausted, they forget things, they miss the jugular vein, they take more time cauterizing the bleed, or closing the wound, they are afraid to wake up their senior because they know he has not slept since yesterday.
On the other hand you have chronic patients, who are under light surveillance by the nurses at night, who sometime call the doctor on call who knows absolutly nothing of the patient, and is sometime not even of the speciality. If things get rough, the patient becomes "acute" and is managed by the acute team. At night for those patients, handoffs WOULD have been nice, be they were none, not because the residents did not do their 12-15 hour day but because those patients are not supposed to have handoffs to the night team, and because no doctors are paid to stay at night in all chronic services.
> Regarding your other point: > In every country except maybe Switzerland, residency programs last 3-5 years, whatever the number of hours worked per week,
That makes no sense. If that were the case, residents would choose to work an hour a week and easily graduate in 3-5 years. But that would make for a poor doctor, as they need a certain # hours of training.
So they do finish in 3-5 years, and make for as good doctors as US doctors, although they work more reasonable hours which is around 60 hours a week. Although I believe that is still too much to insure quality of care.
The counter argument that I have heard is that patient handoffs are where a disproportionate number of errors occur. Increasing the number of shifts means that more patients in the ED or on the floor will have care fragmented between providers, making it more likely that results will not be followed up or that changes in a patient's status will not be recognized.
I don't know at what point the errors from sleep deprivation exceed the errors from patient handoffs. People seem to take different views depending on what side of the work hours debate they fall on.
Seems to me like the solution is to work on improving handoffs rather than trading the risk of handoffs for the risk introduced by sleep deprivation.
From the medical professionals I know, handoff problems are partly because of missing/difficult to find/ignored information in charts and in healthcare IT systems. Improving on that front might be a way to allow a switch to more sensible schedules that don't invite bleary-eyed mistakes from doctors/residents.
I've always wondered if the problem might be in the handoff procedures. Those studies about mortality in the event of a handoff always make it sound like obviously handoffs are an inherently dangerous thing, but perhaps the modern way of doing them is just poorly implemented? It feels extremely unlikely to me that absurdly long hours are the only solution.
I feel like this is an excuse more than anything. If there are higher complication or medical error rates as a result of patient handoffs, the solution isn't to make the medical team work longer hours, it's to fix miscommunications wrt the handoff process.
That's a really interesting point. I wonder if it'd be practical to address the handoff problem with rolling start times. So if average ER patient takes 3 hours to treat from start to finish, for an 8 hour shift, you stop taking new patients at the 5 or 6 hour mark. That being said, if an ER doc is in the "graceful shutdown" part of their shift, and a spike in patients rolls in the door, it'd be hard to say no to helping out.
1. That's weird, what the heck ED do they do 30 hour shifts in? Non-US? My wife is an ED physician in the US and that does not ever happen in any ED she's been in.
2. She's also boarded in internal medicine, where she did have to do 30 hour shifts. They are terrible for patients and physicians, and I've been in heated arguments with physicians because I think the primary reason they exist is as hazing.
3. Handoffs are a legit problem; much more in other fields than in the ED. (Though handoffs do exist in the ED). It is a balancing act for that reason, though physicians could do a lot better with the handoff process IMO.
> Handoffs, the transfer of patient care from one health care provider to another, are known to be vulnerable to communication failures8 and have been called “remarkably haphazard.”
and
> When looking specifically at malpractice cases with communication breakdowns, 43% involved handoffs.
5. It's my belief that patient-centric design and communication could eliminate nearly all of these issues while reducing the need for long shifts, but there's a big [evidence needed] tag on that
Thank you! I kept hearing this "doctors need to be on call 30+ ,40+, 50+ hours because of handoff issues." Rarely has anyone mentioned they need to fix the handoff issue instead they prefer to keep the status quo.
2. They themselves had never made a mistake due to tiredness.
3. They didn't want to change their schedule. Either they liked having 4 days off every week, or they thought it wasn't a significant problem.
I think those two items and the tribal knowledge that handoffs are more dangerous to the patient helps the overwork model persist. Sounds like it's past time the medical industry prove that handoffs are more dangerous to patient outcomes. Doctors are trained to be problem owners and problem solvers, but that doesn't make them good team players. And lowering handoffs also limits oversight and prevents second guessing which is great if you're convinced you're always right, but clearly doctors are not always right and patients often pay the price.
At my hospital, residents take 24-hour calls. The trouble with shorter calls (say, 12 hours) is increasing the number of transfers of care. With 25 patients on a service, spending even five minutes on each means each "shift change" would take two hours. So you spend closer to one minute on each, and at that point it's easy to miss important details. We are skeptical of the "scientific research" because we've all seen errors made because of poor signout that were not happening before work hours were so restricted.
For the record, attending ER shifts at my hospital are closer to 8 hours, and residents do 12 hours.
I'm not a medical professional, but the whole discussion of handoff risk always seemed to me like it was side-stepping the real issue presented, which is poor documentation and/or communication between peers. Instead, the premise is offered by the AMA that handoff risk can only be minimized by insane shift lengths.
n8henrie summarized it well. Its a basically a bandwidth issue. You might sign over 25 patients in 30 minutes... things get lost or miscommunicated which cascades to errors vs. being sleep deprived. Sick/new admissions get more time but still can only say so much. There is decent literature on signover tools to guide this process too. I used to joke second and third Mondays of working in a row should have a different name like SecondMonday and 3rdFnMonday. Thankfully never did a 3rd weekend in a row on call like that.
There is two ways to deal with that problem, either fewer handoffs or better handoffs. I suspect focusing on more efficient handoffs and practicing more may be better than simply having longer shifts. Because 6h vs 12h shifts might cut handoff mistakes in half, but with 6h shifts good record keeping becomes more obviously important, and fewer things need to be communicated at handoff aka 6h worth of info vs 12h worth of info.
The trade-off is whether patients see tired staff vs patients rotate through more staff with no context (= multiply chance of onboarding mistakes, more delays, ...). Tempering this a bit, a lot of smaller-staffed late shift care is more about handling emergencies and otherwise keeping folks fine until the bigger day shift comes in.
Most software IT/ops is luckily generally much smaller in time scale of most incidents, and much more tolerant of hand-off errors and delays. Ex: For 24/7, you get an instant email acknowledgement of ticket receipt, someone triages it, and if on a boundary, OK for current shift to ignore and leave for the next one. Likewise, for bigger incidents, better for throughput for the same person to pick across shifts to avoid hand-off errors, even if that introduces delays when it spans shifts. But not universally true across orgs, nor for incident types. Ex: For tricky & sensitive incidents that take 8-24 hours, the hospital results show longer shifts might make sense, so I'd want to see experiments before making assumptions!
There's a big problem with being on call for one week out of 6 or 8: you lose touch with the procedures. Sure, your four year veterans know everything by heart - but the first few shifts of a newbie are going to be perilous. I recommend making the shifts shorter and more frequent.
Presumably one person is on-call and everyone else can be called in / woken up as necessary. So - split each day into two halves, and ask people to be on-call for a 12 hour period.
Rotate the roster around so that Jane doesn't always have the same Friday-afternoon shift, nobody has 2 shifts in a row, and put it in a shared calendar so you can always see who has the watch.
With 6 people, you'll take 2 and a seventh shifts per week. At 7, it's an even 2 shifts per week.
Benefits:
- much less of a burden that a whole week of readiness
- brains work better when they haven't been pummeled for a week at a time (at least, mine does)
- easily scales fairly when you have more people, or when someone leaves, but keeps everyone in the loop. When you have 14 people in Ops, you only have one shift a week, but you get one every week.
- much more family-friendly
OK, why 2 12 hour periods instead of splitting the day into 8, 6 or 4? Because people lose track too easily. Trying to schedule around your kid's concert or music lessons with smaller chunks is hard to keep in your head - and trying to work that in with a one week shift is nigh-impossible.
Why not a 24 hour shift? Because it's really hard to recover from that. Humans are generally awake for about 15-17 hours a day. Shifting a few hours is generally doable.
I would recommend that for anyone who took an alert call during non-core hours, you automatically expect them to take the next normal day to recover. I know that when I get woken up at 4AM, I'll run out of steam by 2 or 3PM.
My brother was on call this weekend and got called in Friday night at 10 P.M. and Saturday night at 2 A.M., then had to be back to work at 7 A.M. Sunday. Obviously sleep deprived, but there's nothing he specifically could do. This needs to change at an institutional level.
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