First, let me contrast two letters. The first is published in today’s AMA news.

Resident work hour limits are compromising patient safety

Regarding “Resident hour limits may hit attendings” (AMNews, July 7): Of course attendings will be working longer hours to perform the work that residents no longer do. PA or nurse physician extenders cannot fill the role of upper-level supervision and experienced medical judgment that is now missing with diminished senior and chief resident clinical participation.

After a full year’s experience with the 80-hour limit to surgical residents’ week, I can confirm that if I don’t perform the work residents can’t complete, no one else does — with the consequence that patient safety is directly compromised. Concrete examples include my need to perform even the most primary data collection regarding vital signs, intake and output records, verifying medications administered and primarily reviewing x-ray findings at morning rounds, since residents no longer have the time to perform pre-rounds.

While I have always reviewed this information, now I frequently have to collect it too, spending the time to track down the wandering nursing records, med lists, etc. And if I don’t directly enforce a meticulous review of the medication changes and interventions performed by the evening-covering housestaff, they may be otherwise transparent to the “day” crew.

Communication of all these little details is rarely completed during “signout” when “call” residents are under pressure to leave promptly.

Lacking the time to examine patients, resident failures to recognize serious postoperative wound infections or to perform adequate wound care have also worsened substantially. How can a housestaff team be expected to determine whether cellulitis is improving or worsening if the same individual does not examine the patient on consecutive days?

My morning rounds now routinely last 30% to 50% longer than in previous years, forcing me to schedule fewer patients in clinic or the operating room.

Even minor calls from the evening “cross cover” resident (who often has no idea about the patient’s disease process or hospital course) require my fullest attention (even if I have been deeply asleep) to avoid serious errors, since there is little chance that the physician at the other end of the phone is knowledgeable about the specific patient details.

But most disturbing of all is that when I recognize an error made by a resident, the opportunity for me to constructively educate the trainee is absent since he or she has gone home and is strictly instructed to turn off the beeper.

It remains unclear how this lack of follow-through can be consistent with the high level of care to which patients are entitled. Worst of all, if residents perceive the message that it is appropriate to walk away from patient responsibilities as the alarm sounds, this is the way they also will behave as attendings!

–Amy L. Friedman, MD, New Haven, Conn.

Read this letter carefully, for the author makes several strong points, but also exposes her hospital and residency program as not attacking these issues creatively. As our program has thought through these rules, we started with principles. We want to maximize continuity of care by a team. We understood that physicians deserved days off (this has been standard in internal medicine programs for several years). Thus, we (the attending, resident and interns) had to work as a team. As a team we make rounds daily, first discussing all the patients, then visiting every patient. These visits and discussions make clear to the entire team what the important issues are that the patient is facing. We work through decision making as a team (obviously I have the final say). We view abnormal physical findings together.

I would argue that this system maximizes both education and patient care. Only when I can challenge the housestaff’s decision making can they work through a process to improve. Only when we go to the bedside and examine a patient or interview a patient can we be certain that we are all on the same page. We need a common understanding of the patient and his/her problems.

Using these principles, we are able to function very well under the new guidelines. When one intern is off, the other intern knows the patients. When the resident is off, I know the patients and can round with the interns satisfactorily. (Come to think, I am the only one who rounds every day – but then I do sleep in my own bed every night).

Contrast this letter (from my comments section).

I’m pleased that you like the new changes. I wish that every hospital would be able to follow suit. Where my girlfriend serves her residency there has been very little change. Despite the new rules she has yet to serve a call shift that is less than 36 hours. The hospital has made no changes except to hand out a memo to the attendings about getting the residents home sooner.

Personally, I think call should be abolished. I understand the whole continuity of health care “issue”, but I think the real issue is money.

At my girlfriends hospital some patients are admitted by hospitalists, who work 8-10 hour shifts and pass the patient to the next shift. And some are admitted by residents who are working 36 hours. I’m sorry, but I don’t see the difference. Are the patients being admitted by the hospitalists somehow receiving worse care? I find that very hard to believe. For example, my girlfriend had to administer an LP after not having slept for 28 hours. Hmmm – that seemed sort of needlessly risky. I wonder if the patient knew? You want tort reform? Maybe the medical profession should put its house in order first.

Why are the residents pulling 36 hour shifts? why 30? why 24? why 18? why not 8!!!?

The residents work massively long work weeks, and yet are paid on the basis of a 40 hour work week. As if. There is a specific exemption in the labor wage and hour overtime regulation for them. Lucky them.

The whole system has evolved simply because residents are over a barrel – they don’t have full licensure (which they need), they don’t have a union to protect them, and thus they are the only exploitable labor force that the hospital has.

I’m glad that you like the new ACGME rules, but, personally, I don’t think they went far enough. And don’t be surprised if congress doesn’t agree with me on this issue. The new “limits” are pathetic. A 30 hour shift and an 80 hour work week don’t sound like “limits” to most folk, that sounds like injustice.

Chris

Well, Chris, I disagree with your premise. The workweek is in fact related to education. As one goes through training, one needs to see enough patients to understand the broad spectrum of ones specialty. Evaluating new patients does require enough time to think and observe. I have always assumed that there is an optimal time for being on call.

In the old days, many attendings complained about every other night call. With every other night call, you miss half the cases!

Now our challenge is to make certain that the housestaff see enough patients so that they are adequately prepared for practice (or further training). No amount of reading and studying substitutes for interviewing patients and caring for them.

I believe the 80 hour work week actually is reasonable doing this stage of training. I would not want to go to a physician who had insufficient clinical experience.

On the other hand, your girlfriend’s residency program and hospital may well get into trouble. We have gone to great lengths to adhere to the guidelines. Many of our residents would like to abolish the guidelines. They remain concerned about continuity of care. Passing off care is hazardous. Housestaff will tell you that you never know a patient as well when you do not do the initial evaulation.

The hospitalist example sounds good, but probably fails on two counts. At most teaching programs, the sicker patients go to the housestaff – because they provide better night coverage. Second, the hospitalists are already trained. They can pass patients off a bit better because of their previous housestaff training.

As I have written previously, this year represents a year of adjustment for housestaff and training programs. We must find new methods of teaching while providing high quality care. Our program is reviewing our systems regularly, and we are prepared to continue to tweak the system until both education and patient care remain excellent. I only hope that all other programs are taking the same attitude.

Related posts:

1. Duty hours, patient safety and resident education
2. Duty hours – no easy answers (h/t @FutureDocs)
3. Work hours – the problems of bureaucracy
4. Resident Work Hours
5. The AMA proposal on resident work hours

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