I “came of age” as one of the first generation of residents to be trained under the ACGME’s 80-hour workweek rules. For those of who haven’t been following, in 2002 the Accreditation Council for Graduate Medical Education (ACGME) recommended several changes to the work schedule of resident physicians. Among these were an 80 hour-per-week ceiling, at least one day out of every seven off, call frequency no more than every third night, and no more than 30 consecutive work hours at once (with the first three numbers averaged over a four week period). These changes were implemented around mid-2003, around the time I began my pediatrics training.
As a resident I recorded my work hours dutifully, worked hard to get my fellow residents out post-call, and participated in surveys that tried to measure things like hours of sleep, resident mood, and error rates. Changes had to be made to accommodate the new rules, of course, and adjustments were made continuously year after year. Just like any change, the transition period was difficult, and people grumbled here and there about the relative merits versus drawbacks, but I like to think that we managed to make it work out. I finished residency over two years ago, but the ongoing work hours debate still remains near and dear to my heart.
A little over a month ago, the Institute of Medicine (IOM) released a report recommending that the ACGME become more stringent with its work hour restrictions. Foremost, they take aim at the 30 consecutive hours shift limit, suggesting a protected 5 hour sleep period for any shift that runs longer than 16 hours. They also, among other things, suggest one 24 hour day off per week without averaging over 4 weeks, and one 48 hour period off per month.
I think most people outside of medicine would look at these suggestions and find them reasonable. I think most people might even blanch at the thought of medicine being practiced without these restrictions, or even with them. After all, how many of us work multiple successive 80 hour weeks? How many of us work a 30 hour shift every 4 days for months at a time?
Just as in 2003, however, there are voices of dissent in the medical community. Some voices are less sensible, some more. The less sensible ones exhort of their own training many years ago, when life was hard and men were men. They walked uphill both to and from the hospital through snow up to their necks. They hated having call every other night because they missed half the patients. They worked 110, 120 hours a week and asked for more. These are the really annoying voices, because if you get these people to put away the rose colored glasses and truthfully say what they thought about that time, you find out that they hated it. It ruined health, it ruined relationships, it messed with your head. But still, for some quirk of human nature, they seem to want every other doctor in training to go through what they want through. We have a word for that; it’s called hazing.
The more sensible voices talk of things like reduced training time, especially in procedure-intensive specialties like surgery. They also note the added burden upon attending physicians, the need to hire more residents, and the associated financial restrictions. And they also fear the loss of care continuity and the need for additional patient handoffs that restricted work hours would entail. These concerns are legitimate and very real, but I would argue that they’re not enough to outweigh the health, safety, and other benefits of reasonable work hour restrictions. In any event, all of these conflicting pressures should not be left to converge upon residents, who are relatively helpless in the whole brouhaha. The demands are nothing short of superhuman – do more work, sleep more, learn more, and be better doctors, all in less time. Rather, the multiplicity of pressures should force us to reexamine all parts of the residency system and revamp where necessary.
There are no magic pills here, but I think there are several things that are easy targets. First off, the idea of years of repetitive sleep deprivation being necessary for resident education is one that should be snuffed out. I’ll admit fully that there’s something to learning about your own limits, realizing that it’s possible to function – if poorly – on ridiculously low amounts of sleep. But how many times does someone have to do that before the lesson sinks in? You don’t get better at being bone-tired with practice any more than you get better at having the flu. It sucks just as much the last time as it did the first. And what good is training so hard at long-term sleep deprivation when you’re not likely to be in such a situation again? Attendings avoid working resident hours like the plague, and for good reason.
Long shifts do give the opportunity to learn about the course of illness as you watch a patient’s condition evolve over time. This experience can be unparalleled. But at the same time, this mostly applies only to certain rotations, namely those involved with critical care. I don’t think anyone would argue about sticking around longer when there’s learning to be had. Often, however, there isn’t a compelling educational reason to stick around, and residencies should be streamlined with this in mind. There’s a sheer physical limit to education, as well. How much do you actually learn during your 29th hour on service?
Secondly, residents should not be viewed merely as cheap labor. By this I refer to the tendency of many residency programs to give the residents the jobs of phlebotomist and IV starter in addition to physician-in-training. Not to say that these skills aren’t essential for every doctor to learn, but once you get to – say – 100 blood draws or IV starts, it goes from learning opportunity to scut work that can suck up a surprisingly large amount of time.
Third is the need for improved, regimented patient sign out. I hear loud and clear the voices of those concerned about increased patient handoffs, necessitated by reduced physician work hours, being a potential source of error. We should of course avoid handoffs when practical, but I feel we’ve neglected the flip side of the coin, which is optimizing the handoff process. Handoffs/sign outs are often frenzied, hurried affairs accomplished with near-illegible notes scrawled on random sheets of paper and carried out by sleepy residents who are trying to tie their boots on so they catch the next bus, all while the pager continues to go off. Nurses have been doing this cleanly and thoroughly for years and years; there’s no good reason that doctors can’t do this, either. We must reevaluate the handoff process, identify weaknesses and potential sources of error, and act to stregthen the system rather than rely increasingly on flawed human minds already under stress. Increased adoption of computerized patient tracking systems can help immensely in this regard.
Resident work hours lies on a continuum, with inadequately trained, error-prone physicians on one end of the spectrum, and exhausted, bitter, error-prone physicians at the other end. There’s a happy medium to be found, but I would argue that we are still too much to the latter side. And in today’s world of physician shortages, there’s already enough disincentive to enter physician training. Adapting to the changing demands on residents may well require a complete overhaul of the resident education system, but I feel that the sheer importance of physician training requires that everything be put on the table.