Work hours and unintended consequences


Category : Medical Rants


Thanks to KevinMD for this link – Halt the Surgery—It’s Time for My Nap

Unfortunately, working less comes with a big price tag. Countries that have imposed shorter work hours for residents have faced steep staffing shortages as well as questions about the quality of their medical training.

New Zealand and Australia were two early adopters of shorter hours for residents, and their experiences should have warned other countries against the idea. In 1985, when New Zealand restricted residents to 72 hours of work per week, hospitals faced a sudden shortage and ended up hiring more senior doctors to fill the gap. Australia experienced a similar problem after physicians adopted a 1999 "National Code of Practice" designed to minimize the risks facing all shift workers who work extended hours. By 2004, physician shortages were common in Australia, and the state of New South Wales had 900 vacancies for residents and other doctors in training.

Other countries have seen similar snags. In Europe, where thousands of physicians were needed to fill vacancies created after residents scaled back their hours, hiring additional personnel cost an estimated 1.75 billion Euros. Exceeding the 48-hour-a-week allotment "is the rule rather than the exception" in Portugal, noted researchers in a 2004 British Medical Journal article. The United Kingdom needed an estimated 15,000 additional doctors to staff the National Health Service to comply with the Working Time Directive, which applied to junior doctors for the first time in 2000. In 2004, the BBC reported that the NHS was facing a "staffing crisis" brought on by shorter hours for residents.

We all know that every time Congress passes a bill, they create unintended consequences.  They fail to anticipate where the dominoes will fall.

I submit that the IOM and the ACGME have not considered the unintended consequences.  They are using a new treatment for a perceived disease without considering adverse effects. 

What bothers me is the total lack of understanding about the implications of changing a system that has actually worked.  I understand the desire to sleep.  I know that post-call residents are not as sharp as pre-call residents.  As an attending I have always adjusted rounds and overall patient management to work around their sleepiness. 

We need to examine the many permutations of the current 80 hour work week to understand what works and what does not work.  We need some cost-effectiveness calculations. 

A reader emailed me yesterday:

Twenty years ago, it was fair to say that residency was an apprenticeship.  You learned from the experience of your teachers.  Now that is only half true.  Now the volume of time that must be devoted to reading and learning new science is greater than ever.  And yet there is no corresponding increase in training time.  Working 30 hour shifts is great for experience.  But have you tried reading a "Clinical Implications" article from the NEJM at hour 31?  If you can do it, you are a better man than I.  Internal medicine cannot be taught in 3 years.  When you trained, it was possible.  It is not today.

But I could be wrong.  I’m very tired.

Let me address several issues.  I have never met an intern who felt that he/she read enough.  Internship is not about reading.  We have always had new science to learn, but putting new science into context requires knowing enough about patient care to have a framework.

I learned a lot of internal medicine during my residency.  I have learned much more since my residency.  You can never learn internal medicine, you only learn enough to start your path towards continuing improvement.

I remember learning that Larry Bird would work hard every summer to add new skills to his game – even after winning the NBA championship and the MVP award.  I have heard interviews with Tiger Woods in which he talks about working to get better.

Internal medicine (and every other specialty) changes steadily.  The great physicians are always improving. 

If we decrease work hours enough, then we should increase the duration of training.  We also must remember that such increases will cost someone money.

Today, when I work with senior internal medicine residents I am not worried about their training.  They are ready to work on their own.  They will grow and improve over time.

At 59-years-old, I feel that I am still improving as an internist.  I cannot explain all the newest science as it is published, but I learn what is important once it begins to impact patient care.  But I continue to improve at the bedside; I continue to improve as a diagnostician.

So please do not worry about not keeping up.  You will never be able to keep up.  But you can still become a great internist.

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