Why Are Doctors Still Working 30-hour Shifts Despite The Known Risks to Patients?

Hidden behind the perceived glamour of a noble job, high salaries and acknowledged as society’s creme de la creme, lies a brutal system that pushes doctors to their physical, mental and emotional limits with 30-hour shifts.

One year ago, I was frantically looking for ways to help my doctor husband, who was on the verge of burnout. He had been working non-stop, with 7 on-call (30 hour+ shifts) duties a month, with hardly any weekends free. I could tell that he was reaching his mental and emotional limit. He would come back listless, and swing suddenly to the extreme, obsessing about whether he could have done things faster in order to save more patients. He was attached to the Surgery Department as a House Officer (HO), and it was there that he experienced a patient dying in his care. He became afraid to leave the hospital, frantically checking the stats on all his patients, and his sleep was always troubled. He would clench his teeth in the middle of the night, wake up screaming, and at 5.30AM, he would trudge out to the hospital again, with barely 5 hours of sleep a day. This nightmare continued until he rotated out of the department. However, the nightmares and perpetual exhaustion never ended.

All this while, I felt helpless as a wife. I did everything I could in my power to relieve him of “work” outside of work. I took charge of all our finances, bills, family obligations (organising the birthday gifts etc.), housework, cooking etc. and was resigned to going to the hospital alone for most of my gynae check-ups when I was pregnant. When he was free, I would leave him to sleep for as much as he needed, and pretty much functioned as a single lady with two mouths to feed. Thankfully, he became slightly better with coping with the demands of his work, but the nightmares still exist today.

The History of 30-hour Shifts

I would very much like to believe that 30-hour shifts have a good reason for existing in the medical profession. It seems that it began with the lack of manpower, but continued to exist based on the following beliefs:

1. It allows “a seamless continuity of care” (Accreditation Council for Graduate Medical Education (ACGME))
2. Novice doctors “learns best by following a case in the critical 36 hours after a patient is first admitted” (Asch, 2015)
3. Handing-off to other doctors “affect patient safety” (Asch, 2015)
4. Rostering becomes “needlessly difficult” if things were to change.

Known Risks to Patients When Doctors Are Subjected to Such Grueling Hours

Before diving into examining the validity of the claims above, there have been many groundbreaking, sad and needless accidents that have happened due to the 30-hour shifts. In 1984, a college student, Libby Zion, died under the care of residents who were on such a shift. They were sleep-deprived, and did not realise that the anti-depressants she took would cause an adverse reaction with the medicine that they gave to her. This landmark case pushed a new regulation in the US in 1989, called the Libby Zion Law. Under this law, doctors are not allowed to work more than 80 hours a week, or for more than 24 consecutive hours at a time.

Although there was no other case like Libby Zion’s, how reasonable is it to expect doctors to perform their best when they are sleep-deprived (let alone food-deprived, toilet-break deprived etc.)? No human can work for more than 24 hours straight, and to demand that of a doctor who has the highest responsibility to care for and save patients with complex health issues, is frankly as hopeful as we are about pigs flying on their own one day.

Cases of Doctors Being Harmed In The Process

Apart from the known risk to patients, there have been countless cases of doctors who have been affected by this demanding schedule. In 2019, a 23-year old medical resident, Lauran Connelly, died at the wheel. She had worked for “ten consecutive days totalling 91-and-a-half hours, and for another stretch of 12 consecutive days totalling 107-and-a-half hours”.

A similar case happened nearer to home. In 2017, a 33-year old Malaysian doctor died due to an accident after her 33-hour shift. A few months before, another 27-year old doctor, Dr. Afifah, was “worn out after a long shift…lost control of her car and crashed into a tree, resulting in fatal injuries to her chest and brain.”

Depression and Burnout

Some may argue that the cases above are the worst-case scenarios. Most doctors survive and are doing well today. However, is this really true?

Studies have shown that doctors and healthcare workers face the highest risk of burn-out, and it can also lead to further mental health issues such as depression. In Singapore, a study by the Singapore Medical Journal found that “the burnout rate among junior doctors in Singapore was higher than that in the United States. They also had lower levels of empathy.”

Despite these well-known cases happening all over the world, little has been done to make meaningful changes to the schedules of our doctors. In fact, they merely try to fix the symptoms by sending doctors for courses on how to show empathy. What good does this do? Patients will know it when empathy is performed rather than genuinely expressed.

Belief #1 Debunked: 30-hour shifts allows a seamless continuity of care

The only seamless thing that happens is that the doctor is seamlessly tired. Let’s be real. Patients admitted to the hospital do not usually get discharged within 30 hours. Patients also do not need nor expect their doctor to be perpetually available to them and be at their bedside every single minute. A dear friend of mine was in the ICU for a month due to an autoimmune disease, and instead of feeling more assured that his primary care doctor was attending to him for a full 30 hours, he wondered if the doctor is okay and had enough rest. We know that no one is able to function at their best without any sleep. A seamless continuity of care can be only achieved when:

1. Doctors in the team are well-briefed on the patient. This is where accurate note-taking and history-taking comes in.
2. Nurses and doctors work together and communication channels are clear and transparent.

These two things do not require any doctor or nurse to work godless hours, please.

Belief #2 Debunked: “Novice doctors learn best in the first 36 hours of a case”

This is almost as good as asserting that all students learn best in the first 36 hours of studying a subject. Do you hear how ridiculous this sounds? If I tell you as an educator, that you as a parent should keep your child awake for the first 36 hours after learning a new math concept and constantly drilling him/her with practices, conversations and extended learning activities, what would your reaction be?

Scientific studies have already shown the effects of a lack of sleep on the brain. Apart from affecting a person’s mood, sleep-deprivation has shown to impair memory and decision-making. If we want novice doctors to learn fast and learn well, we do not want their memory impaired, right?

Belief #3 Debunked: “Handing off affects patients safety”

Please refer back to known-risks to patients section. Also, this statement stinks heavily of a lack of belief in the professionalism of colleagues in the medical fraternity. If it takes such a grueling 4–5 years of medical studies, day-long examinations and straight A grades, how much more perfect and prepared do we expect doctors of the next rotation to be to care for their patients?

Belief #4: “Rostering becomes needlessly difficult”

This is something that really boggles my mind. How can rostering of doctors be more difficult compared to my ex-Vice-Principal’s perpetual job of figuring out timetables for 62 classes with 14 different subject combinations, 108 school teachers and not enough classrooms in school?! I agree it is difficult, but to call it “needlessly” betrays the administrator’s laziness and a brazen lack of care for doctors AND patients. Rostering doctors properly ensuring they have adequate rest, and taking care of them first will translate to better care for patients.

Want Better Healthcare Systems? Fix This First.

If we want better patient care and healthcare systems, all countries should seriously consider looking more carefully into doctor’s schedules and such ungodly working hours. If such a system continues, I don’t see why we are complaining that there are not enough doctors, and that doctors quickly leave to the private sector when their bonds are finished in the public hospitals. Who would want to continue staying in an institution that is so highly demanding of their physical, mental and emotional health, especially when the institution does not care for them as people?

These are some things that governments and hospital administrations can explore:

1. Studying the rosters of doctors carefully and understanding why they are rostered as such. By the way, despite the regulations, somehow my husband still works 13-days consecutively without a break?
2. Understand how novice doctors are trained in the hospitals. I have also known of one too many House Officers (HO) who eventually leave the profession with a huge debt, or take long No-Pay Leave, because they sink into depression and are not able to cope. They cannot even practice as locums after that because they do not have full licenses. We need to examine how House Officers are being trained and mentored, so that we can retain them in the hospitals and train them to be the doctors we need them to be.
3. Explore a rotation system. Instead of working doctors for 30-hours, can we model after the Emergency Department doctors who work for 8–10 hour shifts? It is intense work, but they are alert and have enough rest to recover from the intensity thereafter.

Final Thoughts

We need to advocate for better care of our healthcare workers, especially after the Covid-19 pandemic where many risked their lives to save others. Better care doesn’t just come from increasing salaries. We need to look at the systems and welfare put in place currently. When we care for our healthcare workers, they will be at their optimum level to care for us.