Disclaimer: This draft is rather informal. Proper citations to follow.

If you ask me my stance on 24-hour duties, I’m still undecided. My mind changes every so often as my experiences as a junior intern or clinical clerk in the Philippine General Hospital over the past year are quite varied. It can be bearable but sometimes fatigue kicks in somewhere midway and you’re on the brink of giving up. The stress is dependent on multiple factors: the size of the workforce, the demands and timing of the tasks, time for eating and sleeping, and many others.

Although one may argue that the hospital is generally understaffed, I think it all depends on how the workload is shared. Interns and clerks in our institution are more or less treated equally. Whenever one would encounter difficulty, you have the option to refer and another would help without hesitation. The flaw I think is in the expectation that the whole team should do the same thing throughout the whole shift. This is rather inefficient as some tasks are easily done by one individual. Like the tactics in war, pick who will fight your battles. You don’t exhaust all your resources.

The body is used to particular activities at certain times of the day. As a clerk, you are more often the worker during the unholy graveyard hours. The tasks are more or less the same however since the circadian rhythm is disrupted, one often feels tired. Think jet lag. This was the system in my first post of clerkship. Although I could rest early in the evening, it felt so unnatural to do so then and I would instead use the time for dinner or maybe read. Another stressor in this case would be an imminent endorsement at 7:00 AM where you are expected to have prepared well enough for an admission which may have come at 4:00 AM, this while completing the usual workload for the night. What worries me other than the risk for medical errors is if altered sleep cycles have an effect on the health of medical professionals. I hypothesize an association between a hormonal imbalance (ACTH stimulation-steroid secretion that is dependent on the circadian rhythm) and the occurrence of lifestyle diseases.

What type of tasks are expected of us? In our case, we are messengers, clerical workers, phlebotomists, nurses, transporters, bantays (the Filipino equivalent of a watcher or caregiver). The list goes on. In short, we are magicians because we are expected to do everything and make things happen. Kidding aside and not that I’m complaining but it seems a tad too much for especially for unpaid workers. This is the compromise for education.

With tasks so dauntingly requiring, there has to be some source of energy if not an opportunity to recharge, yes? Oftentimes, you miss out on meals and rest. Somewhere in the 24 hours, you attempt to fit these activities in if at all possible. The usual response of the body as a defense mechanism is to forget the hunger or tiredness and let the adrenaline rush take over until you burn out. It isn’t uncommon to hear of people collapsing because of hypoglycemia. Hypoglycemia can affect mental function. This also does not bode well with glucose-insulin levels in the body. Which again leads me to my point on medical errors and the risk of acquiring lifestyle diseases. Fatigue is bothersome. Exhaustion is deadly.

The 24-hour duty can be a misnomer. It can be the minimum amount of time you have to be in the hospital. It can go on for as long as 36 hours. Think it’s bad? I think the residents actually have it worse. The upside to this relatively prolonged working time (compared to other health workers) is learning is somehow maximized and there is some semblance of continuity of care. Although I think even with shorter shifts, if there are proper endorsements one can ensure continuity of care. Also, some departments are kind enough to enforce a mandatory rest period in between or even a post-duty status.

Research has yet to conclude on “how long is too long?”. What was once evidence to support limited work hours has been debunked in recent years. Even if mortality rates haven’t changed much over the past decade in institutions that have implemented a maximum, other factors haven’t been properly considered. Medication error remains to be a gray area. There may be unreported cases even with the mask of anonymity. Also, by the time these errors are detected, something will have been done to address it and it doesn’t go on record. But maybe the question isn’t about duration. Fatigue is significant but relative. The measures have to be reassessed. This issue has yet to be resolved.

Interesting links:
1. Doctors make mistakes. Can we talk about that?
2. Residents make more errors on shorter shifts.
3. Should Your Doctor Be Napping on the Job