USA Today published a point-counterpoint on resident work hours today. The article that stimulated their point is one of the most deeply flawed studies on this subject that I could imagine – Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures

We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3–3.7) and 7.5 (95% CI, 7.2–7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4–22) and 7.0 (95% CI, 4.3–11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality.

So the basis of this “study” is web based self reporting. The number of biases here are too numerous to count. Yet the study is published and thus USA Today calls for decreased residency work hours. What do they know or understand about graduate medical education? What do they know about being on call? What do they know about being a physician and having to work long hours?

Sleep-deprivation studies fail to wake up teaching hospitals

The bigger barrier to reform is cost. Cutting residents’ hours to meet ACGME guidelines would require either more doctors or less care. But it would save lives and avoid expensive malpractice lawsuits. Concerns about continuity of care also have some merit. Vital information can fall through cracks when a physician hands off a patient to a colleague.

The executive director of the ACGME understands and does an excellent job explaining training – More hours, better doctors

Stories can reveal the truth: A thoracic surgeon meets with the family of a little boy whose life-threatening congenital heart lesion has just been corrected after a long and difficult operation. Though the lesion is corrected, the child remains critically ill, not yet out of the woods from the surgery.

The family members hover over the recovery room bed, somewhat relieved and yet still terrified and tearful as they query the doctor: “You’re not going home now, are you?” One truth: A tired physician who has just spent several hours getting to know the particulars of separating a patient from his disease might offer more than an equally competent, well-rested stranger.

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Upon graduation from medical school, students have an M.D. but lack the practical skills needed to practice independently; they are not yet licensed to practice. They spend three to seven years in educational programs (residencies) in which they care for patients under the supervision of other more experienced physicians — senior residents and ultimately the patient’s attending physician.

There is no steeper learning curve in medicine than residency. The dramatic difference in competence between interns and chief residents involves a journey in which learners discover both clinical wisdom and themselves. They learn to apply rules and values in particular cases; they learn how to deliver good patient care.

ACGME regulates resident duty hours. We have done much and have more to do. As we refine our requirements, we will be guided by rules but also by values. Fidelity to both is the key to good patient care. Our task is to discern and obey the truth, the deep truth.

The USA Today writers assume that interns make decisions in a vacuum. When they spend the night in the hospital, I am there the next morning at 7 a.m. to see all the patients. We carefully discuss the patient (history, physical, lab data and radiologic studies) and then go interview and examine the patient. The interns (and residents and students) learn much through this process. The intern has a resident supervising them at night. An ER physician has seen the patient prior to admission.

Interns make mistakes. So do residents. So do I and all other attending physicians. My anecdotes (just as valid as the anecdotal reporting in the PLOS study) tell me that interns make very few serious mistakes when on call.

Should they nap – absolutely. I have always encourage grabbing some sleep if at all possible.

Interns and residents must have the opportunity to see many sick patients. You cannot learn medicine from a textbook. Textbooks do not give you the context of illness. You must hear the patient relate their story. You must examine the patient during the acuity of illness and then hours later as they start to respond to therapy. You must listen to the attending physician repeat the history – noting the nuance used to flesh out the story.

Sometimes during training we all are tired. Sometimes as a physician we must see patients when we are tired.

The writers for USA Today mean well. They write enthusiastically about that which they really cannot understand. Their naivety is obvious to all engaged in graduate medical education.

The great majority of physicians understand the lessons that we learned in the dark hours before the dawn. Being on call, while tiring, is often invigorating. Interns and residents make a huge positive contribution to their patient’s health, and in so doing also learn much to help the next patient they see.

Related posts:

1. Duty hours, patient safety and resident education
2. More thoughts on work hours
3. Work hours – the problems of bureaucracy
4. How should we balance learning with work hours?
5. More on resident work hours

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