More on residency work hours

The comments on last Friday’s post are interesting. They remind me of conversations that I have had with many non-physicians. We who have done our residency have a different understanding of training than those who imagine what is must be like.

Physicians accept great responsibility for patient care. We examine, invade and make critical decisions. One cannot learn these skills from lectures or books.

Residents need training. While I do not know how to specify the proper amount of training, I do know that our current system works very well. We see “green” interns enter the program with varying knowledge bases, and little concept of the details of patient care. They know many facts, but rarely recognize the patterns of illness. They are less likely to “anticipate” bad outcomes.

Senior residents are so much better than interns that most interns cannot believe that they will grow to be senior residents. But every year they do.

We learn medicine in various ways. We learn from case discussions, which work best when we have evaluated the patient personally. We learn at the bedside from attendings, residents and our fellow interns. Before we can grow, we must have exposure to sick patients, whenever they arrive.

Medicine is not, and will never be, an 8-5 job. Patients get sick at night, on weekends and without schedules. Our learning requires that we see sick patients – when they are sick – not the next day.

The 24 hour shift seems cruel to outsiders, but you can find few physicians who believe it unnecessary. Often one can sleep (at least a little), but even when you cannot, patient care does not suffer. We have sufficient checks and balances to protect patients in teaching hospitals.

Interns have to make mistakes – and we have to catch them. One cannot learn without making errors, regardless of the task. The study I cited on Friday noted that no patient was harmed.

Being a physician is hard. We need to develop “instincts” during residency. Residency requires long hours and dedication. We are proud that our residents graduate with the skills to handle sick patients, regardless of our personal stress. We understand that patient care comes first.

The challenge in residency training is to balance the long hours with appropriate time off. We do need to limit working hours, but if we limit them too much, then I worry about education.

So comments aside, I stand by Friday’s rant. We have the challenge of balancing continuity with work hours – and the answers remain challenging. I doubt that anyone can design a study that truly evaluates these two issues.

So worry about fatigue and worry about the “hand-off”. Both could lead to errors if we are not vigilant. But please do not “water down” residency training. We have a great responsibility to fully train residents. That training does take long hours and many months.