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Nov 05 2012

Sleep is for the Weak

There are two schools of thought with regards to sleep (as pertaining to us medical professionals). There is the school of thought where they understand that the human body requires sleep to work. That without sleep, the human body makes mistakes. And that it is impossible to function at peak efficiency throughout the day IF you keep scrimping on sleep.

Then there is the reality of the situation. Doctors are ALWAYS going to be in short supply. Doctors take ages and a lot of money to make and maintain. It’s an investment that is paid back through reduced sick leave, mortality and disability. But the doctor is a direct cash black hole.

How do you stretch doctors? Either you poach them from third world nations with promises of cash which is a problematic practice but one that will always occur due to the high salaries of doctors in first world nations and standards of living. Added to which third world doctors are often heavily entrenched in practical medicine which produces a faster work ethic due to a relative surety born out seeing a lot of cases of diseases often considered rare in western society. Or you force your doctors to work longer hours.

The UK has one of the longest work hours for junior doctors in the EU. Often racking up to 60 hours a week. Which is not as bad as it can be. The USA’s hell year has often racked up nearly double those hours. I do around 60 hours a week normally out here. I believe in my internship I will end up doing close to 100. Sleep is for the weak.

The reason for that is the idea that if you can perform above average during sleep deprivation then you can do anything. You are pushed to the breaking point so that you know you can perform. It’s the same logic for why special forces train while sleep deprived. Yes, accidents can occur during this time period. You are more likely to fuck up. But how do you balance between the need to be pushed to the absolute limit of human endurance and the need for safety? You cannot train doctors without patients.

The new schedules are a good thing. A straight 16 hour shift is ridiculously gruelling (The SAS or Green Berets on a 16 hour exercise can sit down once in a while. I have had days where my 10 hour shifts were done standing up and missing meals) and the 8 hours guaranteed downtime is vital for some well needed shut eye.

However, I am not so lucky. My day as it is looks like this. Bed at midnight to 1:00 AM, wake up at 530 AM. Transit at 630 AM to be at the hospital by 7. I am posted from 7 till 5. I am usually back just before 6 and do this sometimes on saturdays too. In my internship year I will have to work overnights on this schedule (AKA from 7 AM to 7 AM) or be at the hospital for 24 hours…

Not really looking forward to that. But it’s what needs doing. So spare a thought for your local doc. It’s not easing being a hippocrat.

14 comments

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  1. 1
    pramod

    Doctors are ALWAYS going to be in short supply.

    What is the reason for this? Maybe I am missing something but I don’t see a fundamental reason why doctors should always be in short supply.

    Also, how does technology affect the situation? Don’t modern computers and the internet make it easier (i.e., more efficient) to be a competent doctor?

    /now putting on my conspiracy hat

    There’s a folk theory I’ve heard that says that the Institute of Chartered Accountants of India deliberately limits the number of qualified CAs to ensure that people who already are CAs make a lot of money. I wonder if there’s something similar happening with medicine.

  2. 2
    Avicenna

    Because doctors are always needed. You cannot afford to keep on tap as many doctors as you require since they are expensive to train. The few countries where there are too many doctors are places like Portugal but most western nations have enough doctors but want more because they want coverage. As you get more doctors you get more specialisation of doctors. So while in Africa you have “doctors” in the UK you have “cardiologists and infecious disease and internal medicine”.

    You basically improve care by division and specialisation in the west which creates localised shortages in different fields. And some fields will always have high turnovers such as Emergency Care and Pre-hospital Care.

    And in order to have an “excess” of doctors in india you would need roughly a thousand times more doctors. There is no physical way India can hit that target. It’s actually easier to just use contraception so the target value for doctors needed falls.

    Oh and in western society we have an aging population which includes doctors. A lot of our doctors are going to retire at the same time.

  3. 3
    Avicenna

    And by Africa I mean “in rural areas, not in urban africa”, I understand that the generalisation is dumb.

  4. 4
    lorn

    The shortage of doctors would be far less acute if the 30% of medical doctors who avoid medical practice, going mainly into business or research, didn’t.

  5. 5
    Avicenna

    Not everyone can practice. Even after all this work there is a fair chance that I may simply not be able to hack the medicine life. There is a chance I may completely hate it and decide to go hustle pool using my skills…

    Research is also vital to the field. It’s not the cause for the shortage since we really need medical research to be done…

    Someone has to do our clinical tests after all.

  6. 6
    Nepenthe

    But how do you balance between the need to be pushed to the absolute limit of human endurance and the need for safety?

    This is absurd. You are a doctor, not a Green Beret. Assuming that you don’t go into disaster relief, you are never going to be dropped behind enemy lines to see patients with hookworms for 30 hours straight in the pouring rain without food. There is no reason to push you to the absolute limit of human endurance except macho posturing.

    Sleep is not for the weak. Sleep is a requirement for proper human cognitive function. Bullshit like this is part of the reason medical malpractice and iatrogenic infections are so common.

    If you want to be hardcore and push yourself to the boundaries of human endurance, regardless of the effect on performance, go into computer programming, where your typo or spoonerism won’t kill anyone.

    Doctors are ALWAYS going to be in short supply.

    Perhaps the short supply of doctors has something to do with the absurdities of medical training (hours, admissions standards, curricula, etc.) and the limited number of slots in training.

    The reason for that is the idea that if you can perform above average during sleep deprivation then you can do anything.

    I don’t want my doctors to perform “above average”. I want them to be fucking excellent. When the difference between slightly above average and peak performance is the difference between health and death or permanent disability, there’s no excuse for pushing toward merely above average.

  7. 7
    Avicenna

    Er…

    I have put up such days… I have had days where a hundred people show up and need to be seen. You cannot really tell them to come back tomorrow. Otherwise you will have a 110 people to see tomorrow.

    Iatrogenic infection is due to the fact you are filthy as a human being. There is nothing you can do about commensal that normally lives on your skin. There is no way to sterilise a human without affecting them poorly. High fiving you right now is a literal bacteria soup!

    There are a lot of times when you are pushed for performance beyond normal human limits. In normal everyday medicine. My mum is a surgical oncologist. Sometimes she has days where she stands for 6 to 8 hours straight while concentrating down a endoscope. My dad doesn’t because he is a radiologist but during storms he has had to pull 20 hour shifts.

    And I must point out? That many hours on shift aren’t spent awake. You sleep in the hospital whenever you can.

    AND I will point out that I don’t live in a western nation. There is a massive shortage of doctors because the population rose faster than medical schools could be built. You would need close to a 100 times more doctors to make up the deficit here in India. So “Long Hours” are needed. Especially for general practice. We don’t have the luxury of not working. Well you do it’s just that people have to wait for you…

    I know doctors who work from 8 AM to 8 PM every day… It’s not a rarity so much as doctors grow up expecting that here.

  8. 8
    Corvus illustris

    The historian of science James Burke picked up an interesting thread in “modern, Western” medical practice: the origin of some of its traits in the medical corps of the Napoleonic armies. E.g., while 18th-c doctors might have philosophised with their patients, Napoleon’s doctors gave orders to their patients and staff–and physicians still do; certain other militarisms are obvious to us outside the profession. Now, um, the military puts soldiers on sentry duty overnight with no rest–and shoots them if they fall asleep (at least that used to happen). The parallel with the traditional treatment of resident physicians is striking (though the summum supplicium may go to the patient). Forcing recruits to work under fatigue doesn’t seem to be based either on necessity or on machismo.

  9. 9
    Ms Anne Thrope

    Ever heard of modafinil? I have been tempted, but never quite worked up the guts to try it.

    Check out the review: Modafinil and methylphenidate for neuroenhancement in healthy individuals:
    A systematic review. Repantis et al., 2010.

    Short story is it seems to provide cognitive enhancement in sleep deprived individuals.

  10. 10
    feedmybrain

    And you blog?

    Impressive!

  11. 11
    psocoptera

    #9 I have come across reports that modafinal and methylphenidate are widely abused in U.S. medical schools.

    Avicenna, I believe the American Medical Association has recommended limiting U.S. residents to 80 hours per week. Every time it comes up, it prompts whining from older physicians about how students won’t learn as much and quality of care will decrease because patients will be handed off more frequently, ect. I suspect the bigger problem is that they won’t have the same quantity of cheap labor if hours are decreased.

  12. 12
    Avicenna

    Acutally that is one of the problems. Hand offs are often the points where errors occur.

    Cheap Labour? Doctors are anything but cheap…

    You have to do 80 hours, but remember duty hours are at time and a half. Reducing hours saves money. One of the main reason why residents don’t want hours reduced is that their salaries are relatively low because they make up using the duty rosters and extra pay from that.

  13. 13
    Corvus illustris

    #9, #11: “I have come across reports that modafin[i]l and methylphenidate are widely abused in U.S. medical schools.”

    An MD of my acquaintance (I’m not a patient of this person) confirms that Provigil = modafinil is used, if not abused, by some MDs who are long out of med school and residency but–as this and other posts of Avicenna’s describe–work inhuman hours anyway.

  14. 14
    Corvus illustris

    #11: From Wikipedia:

    New York State Department of Health Code, Section 405, also known as the Libby Zion law, is a regulation that limits the amount of resident physicians’ work in New York State hospitals to roughly 80 hours per week.

    The AMA seems to propose extending this New York state statutory requirement to all states, possibly to preempt demands for an even more stringent standard.

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