Comments on: More on resident work hours

By: Thomas J. Westgard

Thomas J. Westgard — Thu, 21 Aug 2003 18:29:10 +0000

As an attorney, I’m aghast that anyone would seriously defend the idea that medical professionals, or anyone else, should work while sleep deprived, if it is at all avoidable. Tired people make mistakes; all medical evidence does is to add detail to what we already know from personal experience. If doctors need extensive experience with patients, it makes more sense to extend the time of residency, not make them work while impaired. The 36-hour schedule in particular should be abolished in light of the evidence of 24- or 25-hour circadian rhythms in humans. It’s also disturbing to see this scientifically-testable hypothesis promoted without support, by people who should know better. Is there a study that shows residents learning more or better by working when they are too tired to think straight? If you can’t point to a conclusive study with solid “lab technique,” long-term, double-blinded, with a control group, and replicated, then it’s going to be hard to be convincing when you say that tired people don’t make more mistakes than rested ones. Personally, I wouldn’t want to make that argument to a jury, just as I hope you don’t want to have to “explain” it to a patient’s family in the waiting room. Especially if it’s mine.

Thomas J. Westgard

By: Bard-Parker

Bard-Parker — Tue, 29 Jul 2003 12:53:51 +0000

I agree with C. Henry. A large part of the night duties of housestaff esp in large urban training centers has NOTHING to do with patient care. If you were to poll residents about what they do when they are not resting at night alot of time is spent transporting patients, inserting IV’s, drawing blood ect…
The hours limits would be more acceptable if the ACGME would issue a blanket statement forbidding moonlighting. Some residents are not using the extra time for rest or reading, as they are supposed to,but to increase their moonlighting hours.

By: Eric Rescorla

Eric Rescorla — Tue, 29 Jul 2003 06:43:24 +0000

The thing that seems to be getting forgotten here is that human performance declines VERY dramatically with lack of sleep. Doctors who haven’t slept in 30 hours are fooling themselves if they think thatthey can provide a standard of care equivalent to when they are rested. (See, for instance, http://www.mcu.usmc.mil/TbsNew/Pages/Officer%20Courses/Infantry%20Officer%20Course/Human%20Factors/Pages/page4.htm)
This doesn’t mean that you can’t work 80 hour weeks, but it does mean that you shouldn’t be accumulating much sleep debt. If you’re working 80 hrs a week you can’t be doing much else.

In general, I think it’s a very common human failing to overestimate the amount of control that one has. Thus, the errors that get made when one is not there are overestimated and the errors that one makes when tired are underestimated.

By: CHenry

CHenry — Tue, 29 Jul 2003 00:56:57 +0000

DB, I would agree more with you if hospitals didn’t so regularly abuse housestaff in their own pecuniary self-interest, namely in their refusal to employ adequate numbers of ancillary personnel and their use of house officers in their place. Do residents have to start all IVs? In many hospitals they are made to do so only because there isn’t adequate intravenous nursing staff (or any, in some cases). Sure, peripheral cutdown procedures and critical care IV access rightly belongs to residents, but that should not extend to non-critical, routine line care? What about phlebotomy? There is no reason residents should have to perform these routine draws, but in many places, this in mandatory. Sure, training in these skills in necessary, but that does not translate into a limitless entitlement of the institution to impose these duties on housestaff, at the expense of more worthwhile activity, including rest. As you know, the salaries of these housestaff are not ultimately paid by the institution, but by DHHS, with the interest in providing a future trained specialist workforce. So it seems a fraud on the government for these institutions–who by the way are being paid in grants much more than the total value of the salary and benefits package that their house officers are receiving–to divert the housestaff to duties that the hospital should rightly hire others to perform.

As for the hoary old saws of the only bad thing about port-and-starboard call is that you miss half the cases; most of those who spout these bromides are more than just few years out of training themselves, and many are looking through a foggy retrospectoscope. I have worked more than a few 100+ hour workweeks, and I know that you just don’t think as well when you are chronically sleepless. A little more honesty from my colleagues about this fact would be a refreshing change.

By: Bard-Parker

Bard-Parker — Mon, 28 Jul 2003 22:08:30 +0000

I have posted on the surgical aspect of work hour restriction here:
cut-to-cure.blogspot.com/2003_07_01_cut-to-cure_archive.html#105726723437933347
and here:
cut-to-cure.blogspot.com/2003_07_01_cut-to-cure_archive.html#105717302011464074
While I feel that the writer of the letter feels put out at having to work a little harder I think she makes some valid points:
The lack of “pre-round” time affects a surgical team much more than a medicine team. Often the upper level residents and attendings have to go to the OR starting at 0730 every day. Without adequate time there is alot of LGFD (looks good from door) rounds going on before operating. Is this how they will do it in private practice?
“Constructive education” is most effective when delivered promptly. Otherwise it loses the “constructive” element and becomes more beligerent.
I see only two solutions: 1. Hire more residents. or 2.Extend the length of training.

By: Greg Garcia

Greg Garcia — Mon, 28 Jul 2003 18:02:31 +0000

Some of the best and most respected attending physicians I had were those trained during the 50s and 60s. They worked longer than residents currently do, saw more patients (contrary to a letter writer here), and also received much less money. It is easy to gripe that training amounted to “slave labor,” but it was part of our training process and prepared us to be excellent clinicians and surgeons.

I don’t want to call the current crop of residents as cry-babies. They want to work less, get more money, and go home to sleep in their own beds. Fine, I don’t have any problem with those things. My only point is that those who taught us in the 60s and 70s never grumbled, spent as much time as they could refining themselves to be good physicians, and looked upon their intensive clinical exposure as something to enjoy and behold rather than to shun and bitch about.

“Fatigue” has become a convenient excuse to eschew our reponsbilities and to blame for our errors. A widly publicized case in NY City on a patient who died several years ago in one of the better known training hospitals has become a cause celebre to propagagate a movement that is causing more consternation than celebration.

By: db

db — Mon, 28 Jul 2003 17:47:35 +0000

Chris, I was an intern in 1975. I averaged 3 admissions every 3rd night - although I peaked at 6 occasionally. Length of stay was longer so my average census was greater than it is today.

Now most interns work every 4th or 5th night and get a maximum of 5 admissions (it is now legislated). The number of admissions is increased a bit, and the patients tend towards being sicker (although we had few ICU beds when I started and sicker patients came to the floor).

Comparing the workload between then and now is as difficult as comparing baseball players of the 50s with the current generation. Everything about medicine has changed. Internship is always hard, and I still believe always necessary.

When one is tired, manual skills are not seriously compromised. One gets angry easily, one may have difficulty concentrating, but procedures are actually fine.

I stand by my earlier opinion. I do think that our system works educationally. I am clearly biased, but I think patient care benefits from having housestaff in the hospital at night. If I am ever very sick, I would prefer a university hospital with housestaff around, than a community hospital. We have published data that suggest superior care in major teaching hospitals. Maybe having physicians there at night does lead to better care.

I would be reluctant to disband the system that has actually worked quite well over the past decades. We need to fine tune it, but not destroy it.

With regard to Brian's comment, we have increased our housestaff size by approximately 10%. This increase is enough to accomodate the necessary changes. Unfortunately, not all hospitals are as enlightened with respect to housestaff training as ours. That raises the question of who should pay for housestaff training - but that is probably a good subject for another rant.

By: Brian Tischener

Brian Tischener — Mon, 28 Jul 2003 17:27:25 +0000

There is one solution which would address the concerns of both letter writers:

Hire more staff.

-B

By: Chris Perkins

Chris Perkins — Mon, 28 Jul 2003 17:01:23 +0000

As you, yourself, have commented residents these days are seeing far more patients nowadays than residents used to 30 years ago. The patients they see are sicker, and the turnover is higher. If residents are seeing so many patients now then they shouldn’t have to work the long hours of yesteryear. There is plenty of room to cut back their work week to 50 hours and still see a reasonable number of patients.

I would be interested in seeing the numbers. How many patients did a typical medical resident see during the course of a four year residency in 1950? 1960? 1970? today? My guess is that the residents of today at busy hospitals are probably seeing two to three times the number of patients as their predecessors.

Your mention “Evaluating new patients does require enough time to think and observe”. But being run ragged every hour you serve in the hospital isn’t really conducive to this sort of proces. And neither is not sleeping during a 30 hour shift.

I can’t but help thinking that the residency system as it exists now, is not about education, it’s about cheap labor. Residents aren’t given the basic respect of being paid for each hour they work. They aren’t paid overtime. Their salaries are low. How is not paying them for their loyal work helping their “education” or “patient care”?

I don’t argue that passing off care may be hazardous, but non-teaching hospitals, hospitalists, and others manage to do this very well every day. I submit that long shifts with no sleep are far more dangerous to patient care than hand offs.

I understand that medicine isn’t a 9 to 5 job, and I honestly don’t ever expect it to be. But the gulf between what is reasonable and what we have now (even with the new ACGME rules) is stunning.

Chris

By: Anthony

Anthony — Mon, 28 Jul 2003 15:14:57 +0000

db I agree with you on your comments concerning the second letter.

Now, regarding the first letter, many physicians do not have residents or medical students to look up vitals or medication list. Frankly I have to do it myself.

The only comment I have about resident work hours is that overly exhausted residents fail to achieve good learning. I for one got the work completed to the satisfaction of my attendings but fail to learn important aspects of the care when I had been working to exhaustion. I think 80 hours a week is a good balance.