Adapting to work hour restrictions

Movin’ meat writes Work Hour Restrictions and challenges me to critique his analysis.

Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed. Flexibility is fine, but accountability should also be demanded.

I would also take issue with Dr Bob’s comment that this "training system that has served our profession well for many years." I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide. They are terribly concerning. I would not lay all of this at the feet of residency, but I would say that the abusive (I’m sorry, "rigorous") environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients. Nobody is well-served by the current system.

I love being challenged.  Perhaps intellectual challenge is the greatest reward for blogging.

Let me define flexibility.  I have worked with interns and residents who I know cheated on their work hours.  The program and this attending reminded them of the work hour requirements.  Yet they sometimes stay too late and violate the strict rules.  They do comply with the intent of the rules.

Should you punish the program?  Should you forcibly make them leave the hospital?

I love these things about the new rules:

• 80 hour work week
• average 1 day off each week
• efforts to avoid sleep deprivation

While I believe my training benefited from over night call, I can see a logic for avoiding this tradition.  At the family practice program where I am regional campus dean, we are going to a strict night float system July 1.  In this system, we are restricting residents to 14 hour shifts.  We do have a challenge.  We still owe the night shift physicians education and we owe the patients good care.

We will start with the night float residents working from 7:30 p.m. and leaving at 9:30 a.m.  From 7:30 a.m. to 9:30 a.m. we will have "overlap" rounds. During those rounds the night float residents will present their new patients and their old patients.  The other resident on the team will participate and know the plans – handling day time cross coverage.  The family medicine program has designed a system in which the night float admitters keep patient care responsibility for those patients that they admit.

We hope it works well.  We hope that we can provide adequate education and supervision.  This new system does put new stress on the attending physicians and that does concern me a bit.

We are trying to limit handoffs.  One problem with most work hour plans is that they do not balance handoffs as a risk factor for poor patient care.

Where we need flexibility is on the precise leaving time.  I can imagine situations in which a resident wants to stay an extra half hour for good reason.  Do we push them out the door?

I am also concerned that too many programs have not considered that one needs adequate patient exposure to expand knowledge and attain wisdom.  I do not want to go back to the old days; I only want the new days to be designed to produce the best possible physicians.