Avoiding the unintended consequences of the new work hours


Category : Medical Rants

This letter from residents appears in Academic Medicine – Unintended Consequences of Duty Hours Regulation

Prior to this year, 30-hour call shifts were the norm for many residents in our hospital and nationally. The rigor of these shifts taught us to maintain professionalism and compassion amidst life-and-death stakes. Overnight calls, despite the unavoidable fatigue, were training grounds for independent decision making and some of the most exhilarating times of residency. These shifts were often the best opportunities to watch the evolution of disease away from the pages of a textbook and to experience the transition from trainee to doctor under appropriate supervision. Most important, the extended hospital shifts were the time for residents and patients to bond—developing the critical doctor–patient relationship and designing a collaborative plan of care.

No amount of shift-design or fatigue-mitigation strategies can replace such important experiences—from a medical and humanistic standpoint. The decrease in daily continuity has whittled away the interactions on which the patient–doctor relationship depends. Electronic cross-cover lists have replaced personal interactions as residents’ primary source of information. On the whole, the changes have established a norm of perpetual patient transfers from one team to the next, with diminished opportunities for any one team to develop responsibility for a patient. As a result, we residents are losing “our” patients.

While I empathize with these residents, I will argue that we can provide excellent training.  Our family medicine residency in Huntsville, Alabama developed a call schedule that minimizes the negatives and maximizes the positives.  The key is responsibility.  All interns and residents work a maximum of 14 hour shifts.  When you admit a patient, you "own" that patient.  They emphasize continuity.  Hand-offs occur during rounds with the night and day residents rounding together first thing in the morning with the attending physician.

While I do believe that the old schedule made great physicians, perhaps we can still succeed, if we do design our call systems around principles rather than hours.  When we emphasize the patient and the physician patient relationship, then we may even do better.

But then everyone knows that I am a life long optimist.

Comments (2)

Your continued optimism is inspiring and always a breath of fresh air in the largely pessimistic current medical training climate. We need more like you to focus on finding solutions to improve residency training. Have you considered positioning yourself to help shape U.S. residency training (e.g., through the ACGME)  in addition to your work in one residency program?

A quarter century ago, following the media noise over the Zion case, my residents and I conducted studies of the effects of sleep deprivation associated with the every 2nd/3rd night call schedules then prevalent.  We found that there was no evidence of increased error or other adverse patient care effects from such schedules, and published the data in JAMA and in Surgery — look it up.  My view, then and today, is that motivation among residents and students is the main factor controlling responses to hard work and short term lack of sleep.  Unfortunately, I know of no objective method for measuring motivation.  But, clearly the hand-wringers who imposed the 80-hour mandate didn't test their hypothesis before imposing it.  Typical among educators, isn't it?  The 80 hour limit was plucked out of thin air by the Bell Commission because, in my view, it fit the agenda of Commission members.

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