Dr. Tony alerted me to the uninformed discussion occuring at Asymmetrical Information. He has written a nice short commentary – Long hours in residency

I will address two issues discussed at Asymmetrical Information – duty hours, and medical school class size.

DUTY HOURS

This past Sunday, not yet being aware of the discussion about work hours, one of my golfing buddies commented on duty hours. I always find this issue interesting but frustrating to discuss. I know no physicians who believe that long hours hurt their education. Many who are unfamiliar with medical training have misconceptions about the hours.

While being on call as a student or resident involves long shifts (typically still 24 hour shifts), the experience is not entirely unpleasant. Being on call on a hospital rotation generally is a group activity. There is a team aspect (a resident, 1 or 2 interns, 1 or 2 students) sharing the workload. The team has periods during which they are very busy, and other periods during which they socialize or discuss patients.

Why did the 24 hour shift evolve? While I admit to speculation here, I believe it continues because we cannot schedule significant illness. During our training we must see an adequate volume and variety of illness. Seeing the patient as they first present represents and important part of our education.

When we make rounds the next morning (and I arrive at the hospital at 7 a.m. with fresh bagels for the team), we have the opportunity to rehash the previous day’s events. The opportunity to “replay” the previous 24 hours allows me to examine the trainees thought processes – and critique them. We go to each bedside, talking to the patient and once again examining the patients. Generally the team does an excellent job. Often I agree with all their decision making. Some patients appear different when the sun rises and the attending enters the room. Sometimes I make a major difference in patient care. I always make a difference in the team’s thought processes. Sometimes only the resident understands the why of the decision making. During rounds we make certain that everyone understands.

Could this work as well doing shift work? It is possible, but we all have problems with shift work in medicine. Our job involves caring for the patients – independent of the clock. We should finish our tasks prior to “handing off” to a covering physician (remember the covering physician has his/her own patients which occupy most of their attention).

As we decrease work hours, we must lose some continuity. Patients expect continuity. Physicians know that continuity matters.

Our schedules during training imprint important attitudes about patients. Patients do come first, as they should.

Being on call is tiring yet often exhilirating.

Many commentors worry about tired physicians making major errors after working 24 hours. That is where training and supervision make a difference. Sleep deprivation has 2 major effects – free floating anger and sleepiness. Sleep deprived residents respond nicely to adrenaline. When crisis occur, adrenaline overrides sleep deprivation. Driving rarely stimulates adrenaline.

We have made great strides in humanizing training. As we make decisions about training, we must always balance providing enough exposure to illness with enough free time. Current guidelines limit the work week to 80 hours and specify 1 full day away from the hospital each week (averaged over 4 weeks). These guidelines have markedly improved resident’s quality of life.

While guidelines make sense, each resident wants to use common sense in applying them. Sometimes we should work longer hours. We can err by rushing to leave the hospital, and these errors of omission will likely cause more harm than the rare errors of commission which occur because the resident is tired.

CLASS SIZE

I know of no thoughtful academic leaders who believe we are training enough physicians. Nor do I see any indication that the AMA has tried to limit class size.

Increasing class size takes money and enough patients. Training a medical student is expensive, and additional students have high resource requirements. We need sufficient lecture room size; we need sufficient laboratory space; and we need sufficient patient exposure.

The federal government has discourage increases in class size. They also have limited graduate medical education (residency) slots. We could train more residents in our internal medicine program, but Medicare (which pays for most of our training these days) will not pay for increases in numbers of trainees. Many subspecialties which should increase trainee size have been constrained by federal policy.

As I blogged several days ago – No doctor glut – Oops! we will probably see an increase in both medical schools and class size over the next decade – and this is a good thing.

I hope this rather long discussion receives careful consideration from Jane Galt and her readers! I will link to this on her site. Here are her 2 entries dealing with these issues – More on medical residents and Arguments that don’t quite make the case you think. Once again – thanks to Dr. Tony for alerting me to these discussions!