Resident Work Hour Restrictions: My Solution

I trained back in the dark ages, befitting a dinosaur, when there were no restrictions on the hours worked by resident physicians in training. One of my most difficult memories is the post-call Monday after finding out at 7:00 am that my mother had died. Not only was I not allowed to leave early, but I remember hating my director by 4:30 as he made me stay and discuss the pathophysiology of heart failure with the medical students.

Not so in the modern era. There has been plenty of discussion by Dr. Centor and others about the pitfalls of blanket adoptions of limitations on trainees work hours, specifically the contention that any reduction in errors from fatigue is more than offset by errors from handoffs. Shift-worker mentality seems to be creeping into medicine as well, with new graduates stunned at the realities of actual practice work hours. Still, the greatest failing of the concept of limited hours in training is the lack of actual evidence that it affords any benefit either to patient care or physician education.

I have a better idea.

Medical training is a process. You don't go in on Day One expected to know and do everything perfectly. You also don't immediately have full responsibility for patient care (even though it may feel that way). As you learn, your skills improve. With experience, you gradually take on more responsibility both for patient care and for your own education. By the end of training, most physicians are functioning fairly independently, although in retrospect most of us are acutely aware of how green we still were.

One dirty little secret about residency training that I have not seen addressed elsewhere is that although long hours without sleep are indeed stressful, the major source of anxiety in residency -- and therefore of stress -- comes from the uncertainty of knowing what you are doing. As your training progresses and your confidence grows, you are capable of performing better at any given level of fatigue. By the time I was a third-year resident, I realized that (even though I no longer had to do it) in-house night call wouldn't be as big a deal as it was the first year. I'd be tired, sure; but knowing more about what I was supposed to do went a long way toward alleviating the stress. By the time I started practice, of course, I was on call for myself 24/7. If I was up in the middle of the night admitting a 6-week-old febrile infant, I still had a full appointment book the next day, and I had to be ready for that. Or, as Dr. Bob put it:

Would I rather have [a fully trained trauma surgeon] at 2 am - tired but experienced, or a general surgeon without specific trauma training.

Here's my suggestion for both forced humanity in medical training, coupled with the necessary rigor to produce competent physicians:

Taper work hour restrictions down as residents progress through the training program.

I have no problem with 16 hour shifts, post-call days off and night float in the first year. Lose the post-call restrictions second year, say, and then gradually increase the allowable hours per week so that by the final year of training there are no limits. The moment they graduate, those physicians are no longer going to be subject to the protections afforded by all those cushy regulations. Just as residency is a huge step forward over medical school in training for practice, becoming an attending is just as big a step. We do our trainees a disservice by failing to prepare them for the reality that not every baby comes in less than 16 hours, not every operation is finished by 5:00 pm, and patients crash regardless of how much sleep you got the night before.