Strict work hours are not the right solution

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Category : Medical Rants

Lisa Rosenbaum has described the problem well – WHY DOESN’T MEDICAL CARE GET BETTER WHEN DOCTORS REST MORE?

We have a classic conundrum in medical training. We want our trained doctors to care deeply for their patients and to have superb bedside manner, to have excellent diagnostic skills, and generally to put patient care as the highest priority.

But we hamper education and tell our trainees that we must put their sleep as a higher priority than patient care.

We do need to have reasonable work hours, but we have become a bit too draconian in the prescription of work hours.  Most residents that I know want to provide the best care for their patients.  They often “cheat” on the work hours to achieve that.

Some residency programs demand that residents leave at an appointed time.  What does that teach about professionalism?

Some residency programs have creatively designed their new work hours to limit hand-offs and still meet the “requirements”.

Residents do not seem to sleep more when given the work hours adjustments. They seem to learn less about the natural history of disease.

I am in favor of work hour restrictions, but would prefer that residents have more flexibility.  I would prefer that we put patient care first over strict resident work hours.

Whenever you create strict rules you have inevitable unintended consequences.  The rush to make rules without studying the implication of those rules flies in the face of our evidence based profession.

Residents need sleep and they need to become excellent physicians.  We need a bit more flexibility to achieve both goals.  We can do it, but not if rules are rigid.

Comments (2)

Simple arithmetic:

More and sicker patients divided by (same number of residents x reduced number of hours worked) = recipe for disaster.

Work rules are a reaction to a situation that has come to the attention of the public or those involved. First we need to remember that all of us on this blog, no matter what our field, would not consider abusing an employee. My experience is that we cannot imagine what goes on in some situations because we do not have the capacity to think in that manner.

This was brought home to me with the recent death of an intern in a financial office. Some boss should have seen the ever deteriorating situation and send this young man home.

Like wise I am sure that Bob monitors the work and personal life of those he is responsible for and is willing to move them from a front line position to a learning position and even send them home for a rest if he felt they, or their patients, were in danger.

Compare this to the stories of house staff being treated as fodder for the enterprise, nothing more than cheap labor. Add in the concept that doctors teach the way they are taught and we have this never ending cycle of abuse.

This extends beyond the walls of the hospital. While at church one day a young man was being introduced as a doctor, hearing the minister’s wife was a doctor he asked what type and she replied, she had a PhD in nursing. With a great deal of disgust he stated; Oh you a nurse.

The problem is she had just returned from a Baltic country where she had arranged to have installed, along with training and supplies, an imaging system, the only one in the country. This system had been discarded by an American hospital for financial reasons.

Abuse may take many forms and once immersed in that environment it becomes very difficult to distance yourself from the behaviors you have been taught.

Steve Lucas

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