Since the beginning of this blog I have written about resident work hours.  We continue to see a solution imposed on a problem that not all observers view as a problem.  Pauline Chen does address this issue once again – On Young Doctors and Long Workdays.

Handoffs are when most errors occur, and most of the potential reductions of error based on fatigue have been replaced by an escalation of errors related to handoffs.

Another unintended consequence has been placing residents in certain ethical quandaries. One resident told me about caring for a child who was dying. She had taken care of this child for 10 or 12 days and was on call when it became clear that the child was going to die in the next few hours. But this resident was supposed to go home; her hours limit was up.

What is better for the patient and that family — to have a new doctor who didn’t know them preside over those very difficult circumstances, or someone they knew and trusted? This resident stayed, but there was an unintended consequence. She could tell the truth about breaking the hours rule, and thus jeopardize herself and the residency program. Or she could lie.

What could be worse than a training system that encourages doctors to lie because they want to be with their patient? This is the last thing we should be doing, but we’ve done it.

We do have a responsibility to make housestaff training humane.  We also have a responsibility to produce well trained physicians who have high patient commitment.  I believe that our strict rules (you must leave after 24+6 regardless of the situation) are so obviously absurd that most interns and residents cheat periodically.  To their credit, these residents put patient care above the rules.

How do we adequately train physicians to have clinical instincts if they do not have enough patient care exposure?  As we decrease work hours, we actually do decrease the probability that our residents we mature enough during training.

The problem that I have in all these discussions is the rigidity of the rules.  Rules that work in one situation might not work as well in other situations.

In the blog which accompanies this column, some support these rules while others critique them.  Supporters fail to accept the handoff issue, while critics do not endorse the tired physician problem.  Both are wrong.

We really need a different group to evaluate this "problem."  We need clinical educators and senior residents to attack this problem on the basis of values.  The problem with the debate thus far is that we have rules imposed which may disregard educational principles.  The rules do make education much more difficult. 

How can we rise above hysteria and tradition to find the proper balance?  How can we insure that our residents become the physicians that our patients deserve?

Being a physician is difficult.  It requires knowledge, decision making ability, compassion, and commitment.  Sometimes it requires long hours.  We should aim for better working conditions, but we should beware of the rigidity of our current rules.

Related posts:

1. Reform residency but intelligently
2. Adapting to work hour restrictions
3. More thoughts on work hours
4. Duty hours, patient safety and resident education
5. In which at least 2 commenters miss my point

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