Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, June 09, 2009

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.

17 Comments:

At Tue Jun 09, 03:16:00 PM, Blogger HugeMD said...

Sounds reasonable, Dino. Cuz it is worse when you get out in most cases. Quite frankly, I got sick (literally) of being up multiple nights a week all night and then going to work the next day every day and bailed on primary care, so I'm doing urgent care full-time. I think it's too bad we can't make it possible for people to make a living doing primary care without almost killing themselves, but that's another topic... However, if I hadn't been used to working 36-40 hours straight every 3rd-4th night in residency, I wouldn't have lasted as long as I did.

 
At Tue Jun 09, 06:51:00 PM, Blogger Resident Anesthesiologist Guy (RAG) said...

Been advocating for a real look at WH ridiculousness for a couple yrs now. Many residents think I'm nuts, but I see the problems hand-offs cause regularly.

 
At Tue Jun 09, 09:32:00 PM, Anonymous Anonymous said...

Well, your plan sounds reasonable. But that jerk still should have let you go home.

 
At Wed Jun 10, 04:22:00 AM, Blogger Dragonfly said...

Good post. People not having unrealistic expectations re the commitments they can have during training is important as well...so many people seem to feel betrayed because they can't balance medicine with other fulltime pursuits.

 
At Wed Jun 10, 05:41:00 AM, Anonymous Anonymous said...

Gotta disagree. It WAS the sleep deprivation that did me in and made me sick and made me want to leave medicine...or at least head to a cushy field.

 
At Wed Jun 10, 08:46:00 AM, Anonymous craig said...

The problem is that residents only want 9 to 5 jobs and so far are finding them. That's because we dinosaurs are still willing to suck it up. When we go, all hell is going to break loose.

 
At Wed Jun 10, 11:56:00 AM, Blogger புருனோ Bruno said...

I don't know where you are practising, but I disagree on certain points.

Here in India there the situation of residents are much worse.

They are forced to work even for 48 hours continously

And I am really amused by this point

//The moment they graduate, those physicians are no longer going to be subject to the protections afforded by all those cushy regulations.//

How

After I graduate, if I have done 5 emergency surgeries yesterday and another patient comes, I can ask him to go to another surgeon

Where as that luxury is not given to be as a resident

There lies the difference

 
At Wed Jun 10, 11:59:00 AM, Blogger புருனோ Bruno said...

By the way, A Neurology resident treats about 20 patients as inpatient. In addition he treats 50 patients as Out patients every day.

If he is on Duty, he has to attend 30 to 40 calls

And you expect him to again fulfill justice to the 50 outpatients he treats the next day ????

 
At Wed Jun 10, 12:48:00 PM, Blogger #1 Dinosaur said...

@Bruno: Dude! I'm talking about the good ole US of A here. No commentary intended on conditions in other countries.

 
At Wed Jun 10, 05:38:00 PM, Anonymous Anonymous said...

I think you're ignoring the fact that new graduates aren't doing both primary care and hospital based practice. In fact almost no one is doing primary care for obvious reasons. Everyone I know graduating from Peds/IM programs is going to and finding work as a hospitalist. In some cases they are signing on with large groups are becoming the designated hospitalist for the group while the other members of the practice handle the primary care aspect.

In this respect medicine is changing. Whether for the better who can say?

 
At Thu Jun 11, 02:02:00 PM, Anonymous Anonymous said...

ok, I am not a dinosaur. I've only been out for 3 years. And, I chose rural practice - FP/OB - so I am definitely not in a 9 to 5 job. My hours are relentless.

I agree with many of your points. I am glad that I had a year of internship before the work hour restrictions began. I learned so much in that year - despite sleep deprivation. But, I have to say that 3rd year being easier work hours wise) allowed me a little break before beginning practice, where, just like as an intern, you are stressed due to the fact that you just don't feel like you know what you are doing! But, maybe that would have been alleviated by an intense 3rd year? Not sure, but I agree the WH restriction needs to be re-evaluated!

 
At Fri Jun 12, 02:20:00 PM, Blogger The Happy Hospitalist said...

In the real world, everyone admits to hospitalists or hires PAs to do their 3 am consults for them.

 
At Mon Jun 15, 03:22:00 AM, Anonymous Anonymous said...

#1 Dino, your idea should be considered as it would work better than the WHR going on now. I agree with your thoughts here wholeheartedly especially because your suggestions would seemingly continue to help eliminate the person who doesn't have the fortitude for practicing "real world medicine" vs. shift worker medicine.

Plus I agree with Craig 100% Kudos gents!

 
At Mon Jun 15, 11:24:00 PM, Blogger Frank Drackman said...

You're a "Dinosaur" bragging about howmany hours you worked as a resident...and you took NO inhouse call as a Senior Resident??? Heck, I did ANESTHESIA and we did more than that...
OK we did get to go home at 8am our post-call days...
NO in house call???

Frank

 
At Mon Jun 22, 12:28:00 AM, Anonymous Anonymous said...

You didn't take call as a third year resident and you are whining about today's residents...Sheesh. Pot meet kettle.

 
At Tue Jun 23, 09:37:00 PM, Anonymous red rabbit said...

Work hour restrictions for residents are the official party line. I am on my second 60 hour shift in 3 weeks, plus a 72-ish hour one, not to mention two trips to the mother ship (3 hours drive away) and weekly visits to the smaller hub (an hour away) all as part of my programme. Oh and plus the 9-5 clinic stuff. I've gotten one post-call day.

This is not a complaint, it's a choice. How am I supposed to get sufficient experience in a smaller centre if I don't do this?

I am in this for myself and for my current and future patients.

 
At Tue Apr 20, 10:38:00 PM, Anonymous Anonymous said...

I suppose when primordial dinosaurs saw their way of life unraveling into extinction they as well evinced such soft arguments to forestall the inevitable. The fact is we live in a different time. The perceived benefits of physician life no longer financially, nor necessarily from a fulfillment stand-point, exceed that of family and social life. And with the malpractice running wild, the same patient you pressed on for in that 40th hour may in turn draw legal suit. The times, the times, they are a changing. A broken system has come to a head and needs its dis-repaired model replaced by a more relevant one. (A resident perspective)

 

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