Rants and Raves

Be afraid.

The powers that be (aka ACGME) have decided that physicians in training are working too many hours at a stretch.  Let me frame this rant with a little history.

Back in the time of giants, there were no work hour rules for residents.  100+ hour weeks for months on end was the life of an intern.  It makes sense that perhaps in those times patient safety may have been compromised.  Several years ago, regulations were enacted that limit residents to an 80-hour work week and shifts of no longer than 30 hours at a time, with a recommendation for a period of 5 hours in those shifts for sleep.

What did this do, you ask, to patient safety, resident education, and the quality of healthcare in general?  We have no idea. 

Hand-offs between doctors have time and again been shown to be fraught with difficulty.  Invariably, the oncoming or “cross-covering” MD knows very little about the patient and is there really to put out fires and keep patients alive until the primary team is back at work.  The covering doc cannot talk to families, coordinate care, watch for med errors, review imaging and lab results, or care for patients as well as the primary MD because they simply do not know the patient as well or have the time (as they are often covering other teams’ patients as well).   The sign out process itself is, in many cases, alarming – snippets of information (mostly demographics) are rapidly provided.  Much like a game of telephone, by the time info is passed more than once it is grossly distorted.  Studies have shown that oncoming doctors retain almost none of the info they are given in the signout process.

There are new regulations coming soon to a training hospital near you.  Now, interns will be limited to 16 hour shifts (don’t worry, the rest of us can still work 30 hours).   This will necessitate even more frequent hand-offs between the least experienced members of your health-care team, doctors right out of medical school.  Not to mention the adverse outcome on education – when I look back over last year, the times I learned the most were those overnights in the ICU with really sick patients.  I never felt a patient was unsafe because of my fatigue (my program has built in naps and night-float, both of which help prevent debilitating fatigue), and I had other residents do procedures if I was post-call and tired.   I had plenty of supervision (both senior resident and attending level) and think it was the safest way for me to get as much experience as possible.   There is absolutely no substitute to spending hours at a patient’s bedside, prescribing and then adjusting treatments and seeing the evolution of their illness as well as the impact of your actions.  This is how doctors learn the difference between sick and not sick.  This is how doctors learn both the science and the art of medicine.  This is how doctors learn the skills required to save your life.

I see the intent of the regulations, but I wish they had asked for our input.  I think taking away valuable experience for physicians in training and increasing the number of dangerous hand-offs is not the way to go.  There is no evidence that working shorter shifts will lead to better patient outcomes.  On the contrary, there is some evidence to show that there isn’t much of a difference in outcomes below a certain number of hours (see the July 26 Journal of Surgery article online about surgical outcomes).

I’ve yet to see the details of how this will change my individual schedule for the next 2 years, but it seems the upper level residents will be working more hours than planned, increasing our fatigue.  After all, the same amount of work must still be done – but now with less people.  It seems this regulation is all but finalized, and my program unveiled their initial plan for how it will work for us.  It is a fragmented plan that does not offer continuity of care for patients or job satisfaction for residents.  And it looks like I get to work a lot more 80 hour weeks…