[haldujai]

As a physician, shift length is honestly a red herring.

As much as I hated doing 24-28 hour shifts on inpatient services, continuity of care does matter and errors do occur in handover.

You have to keep in mind that medicine between 12am and 6am is what we call “keep people alive.” 6am to 12pm after an overnight is for handover.

You’re not trying to diagnose a new illness overnight or make changes in management, your job is to deal with acute overnight concerns only. Furthermore, you’re supported by services such as RACE (an in hospital emergency response team) so you’re not dealing with critically ill patients alone. If you’re on a surgical service and need to go to the OR, staff/fellow + senior residents come in to help.

Acute care services where you’re seeing new/undifferentiated patients and need to be on your game, such as ER and radiology, tend to limit shifts to 8-12 hours.

[gus_massa]

> As a physician, shift length is honestly a red herring.

This is how the Stockholm syndrome feels. I manage a few T.A. in the university, and they barely can think after a 6 hours of teaching (two consecutive classrooms, with like half an hour of rest in each one for the students, and perhaps another informal half an hour in the middle). Sometimes they have to speak in the blackboard, sometime grade informal take home exercises, sometimes reply questions on the spot, and they get very tired. So we have a strict 6 hours per day rule. And if they make a mistake, nobody dies!

[haldujai]

It’s essentially unheard of to have someone die because a resident made a mistake on call.

On-call medicine is so rote as to not require much, if any, thinking. Ward medicine is far less intellectually challenging than teaching.

Patients who are active/critical are not managed by a single tired resident overnight.

[gus_massa]

We had a case a few years ago in Argentina, when a child got an overdose of Potassium Chloride. The nurse was new in the hospital and in the previous hospital they had a different concentration, so she prepared a wrong dilution. [1]. Anyway, it's a problem that is common enough that the English NHS added it to a list of recommendations [page 8] https://www.england.nhs.uk/wp-content/uploads/2020/11/2018-N...

It looks like a random accident, but it's one of the silly mistakes that are more common when someone has worked 12 or 24 hours straight and has no checklists.

[1] I tried looking for the case, because the details matter, but most of the recent news are about a case where it apparently was intentional https://www-telam-com-ar.translate.goog/notas/202208/602435-...

[haldujai]

Not sure what this has to do with resident/physician work hours.

Nursing errors (i.e. administering the wrong dose) can certainly kill people. They also don’t / shouldn’t work 24 hours shifts (infrequently a nurse might work a double due to emergent staffing requirements, this is a systems issue though and not by design).

There are both technological (EMR and ordering systems) and human safeguards (nurses and pharmacy) protecting against “silly mistakes” by physicians.

Once again, resident physicians’ roles overnights are no where near as mission critical as a nurse.

You also identified a key point in why 24 hour resident call shifts are safe - we have checklists.

If I order the wrong med on the wrong patient on an overnight call shift this will be flagged by the nurse who’s checklist includes verifying order accuracy. This is especially true of medications that can have life threatening complications (e.g. insulin, potassium, hypertonic saline).

Please also note I’m only talking about places I’ve trained (US and Canada) where all of these systems exist. I cannot comment on other countries where the infrastructure is different, perhaps this is more of an issue in Argentina than it is here.

[gus_massa]

Probably the system is not so difference, because here sometimes they just copy whatever the FDA says (or whoever is in charge of that).

It depends a lot on the hospital. There are good hospitals and bad hospitals.

There was a recent strike of the residents doctors in the capital of Argentina. https://www-lanacion-com-ar.translate.goog/sociedad/no-llega...

> By contract, [...], a resident has to serve eight hours a day, Monday through Friday, and do eight 24-hour shifts per month.

> “We work shifts of more than eight hours, which can reach 15 or more and with guards that are also on weekends. There are colleagues who work 40 hours straight,"

(The last one is a quote of one of the union leaders, so it may be a corner case.)

If it were so automatic and repetitive, it would be easy to pass the information to the next medic and have normal length shifts.

[haldujai]

> If it were so automatic and repetitive, it would be easy to pass the information to the next medic and have normal length shifts.

Ward call for residents generally works like this:

I have an inpatient list of 15-20 patients I’m covering overnight, some of them I likely know as I’m often part of one of the relevant day teams (unless I’m flying in from another clinical service to help out).

I start by receiving handover from one of the day team members. We sit down together (or by phone) and go patient by patient on the list asking what their reason for admission is, any labs/results I need to follow up on from the day (e.g. patient A had a fever and a cough, we ordered a chest X-ray if it shows pneumonia start antibiotics), patient specific management plans (e.g. patient B may have a seizure overnight, he’s known for this and if it happens give drug Y.) and any patients that I specifically need to see (e.g. patient C was complaining of some belly pain this morning but has been fine the rest of the day, eyeball him in the evening and make sure nothing is brewing).

I then write these action items and notes down (either on paper or in an EMR patient list) for my shift and carry out the relevant actions from 5pm to ~10pm.

Between 5pm and ~10pm I’m following things up and seeing any patients I need to see. Depending on my service I may be taking ED/inpatient consults but that’s not the point here so I won’t get into that.

At 10pm I do what’s called “tuck in rounds” and call up to the nursing station and ask if any of the nurses have issues they want me to address. Often this is something like morning labs that haven’t been ordered, laxative orders, etc. If there are any patients I’m worried about (uncommon on routine inpatient wards) I will pop my head in the room to make sure everything is alright. Cumulatively, the evening usually represents 1-2 hours of active work (again disregarding consults because that workflow is very different).

After that, and until the next morning, I am either asleep in a call room bed or at home. I will only be practicing medicine if there is an overnight issue that needs addressing (e.g. a patient is short of breath, their heart rate is elevated, decreased level of consciousness). These acute ward issues are beaten into every physician from the beginning of medical school and we follow very routine diagnostic workups (i.e. CBC, lytes, glucose, VBG), many of which are codified in algorithms such as ACLS.

If a patient is really unstable I call the RACE/code team (an in-house service to deal with unstable issues staffed by an ICU trainee, RT, and ICU nurse with advanced training) who assume care while I provide support and context as the home service/MRP resident.

This is a very safe system. It is really hard to kill an inpatient with a medical error in an acute setting.

Now let’s pretend I handed over to a night resident starting at 11pm. Two potential sources for error arise:

1. We would go over the same process of “running the list” and discussing patients, except now it’s second hand information I’m relating (versus my initial handover was from the primary team/MRP who knows the patient intimately). Broken telephone / forgotten action items becomes more likely.

2. An acute situation happens overnight and the 3rd shift person alerts the RACE service, except now the resident from the home team/MRP has never actually met the patient (you don’t go round and familiarize yourself with sleeping patients) and has no idea what they’ve been like all day except from what I’ve told them. This creates a huge problem because now they’re reading through the chart/notes to make sure this is a new symptom and not something I forgot to tell them about, they’re also reading the chart to see if there were any action items I addressed in my evening shift that didn’t merit handover but may be related to the acute concern. Whereas with the same resident on a 16-24 hour shift you have a much better understanding of the patients and their unique circumstances.

Many, many, many studies have shown medical errors happen a lot more due to handover than physician fatigue. You can argue that we should have better systems/IT in place to make handover safer, but we do not. Even places with systems like Epic/Cerner, it takes too much effort to maintain the handover list with accuracy and direct verbal communication remains the mainstay.

Furthermore, it’s important to keep in mind that dealing with ward issues between 12am and 7am is also pretty uncommon unless there is a late admission or someone that’s active, but that’s atypical. On-call is for emergency coverage not active medical practice.