Respectful Insolence

I’ve been meaning to write about this topic for quite a while but never really found a reason to. Indeed, this one’s been floating around in the back of my mind for a long time. Perhaps one reason is that it’s hard for a surgeon to write about this topic without coming off sounding like an old fart, a curmudgeon, unhappy about change and thinking that a system that was good enough for me must sure as hell be good enough for the current generation of residents. In fact, even after seeing an article that normally would have spurred me to write about this topic more than two weeks ago, I stored it in my folder of bloggable links and forgot about it. But sitting in front of my computer last night, I thought back to my residency and how different it was compared to residency now.

The article appeared in Salon.com a couple of weeks ago and was entitled Halt the Surgery–It’s Time for My Nap: The downside of requiring young doctors to get more sleep:

Much to the delight of harried young doctors everywhere, an expert panel recently agreed that medical residents aren’t getting enough sleep. Citing evidence that fatigue leads to more medical errors, the Institute of Medicine said last week that doctors in training should not work more than 16 hours without taking a five-hour nap. Though it carries no binding authority, the recommendation of the IOM’s report supplements an earlier rule, passed by the Accreditation Council for Graduate Medical Education in 2003, that limited residents to 30-hour shifts and no more than 80 hours of work each week. Surgical residents may someday soon have to prepare themselves to halt an operation and announce that it’s nap time.


Here’s where it’s time for the old curmudgeon to reminisce about how, back in my day, we used to complain about every other night call because we’d miss half the cases, how we’d show up at 4 AM to pre-round on our patients and like it, and how we’d walk miles to work through the snow every morning uphill both ways. Back when I did my surgery residency, there were no work hour restrictions. None. Work was over when the work was done, and not before. In general, in my residency program, call averaged every third night. True, for some rotations, mainly at the VA Hospital in our program, call was every fourth night, while for other rotations, such as cardiothoracic surgery and trauma, it was every other night. It was not uncommon for me to average 100 to 110 hours a week in the hospital.

There were also rotations, mainly senior rotations, where I did not take call from in the hospital. However, that does not mean I didn’t take call. What it meant was that I was on call every night from home, 24 hours a day, 7 days a week. Rotations where this happened included Transplant and Pediatric Surgery. That might sound better than the other rotations, but in fact it wasn’t. In actuality, I tended to spend more time in the hospital during those rotations. These rotations, I now realize in retrospect, were also the most like being an attending surgeon than the rotations when I was on call on specific nights. Worst of all was one period of time when we were short of senior residents and I got to experience the worst of both worlds. I ended up not only taking general surgery call every third night but being on call for Transplant on the other nights. On more than one occasion, post call I had to go out on an organ donation run. Indeed, I remember one week in particular where I estimate that I probably didn’t get more than four or five hours of sleep total over the course of several days.

Now let me make it clear right now: I’m not romanticizing my experience. At the time I was going through that week with virtually no sleep, I hated it. At the time I was spending 100 to 110 hours a week in the hospital, I hated it. During those rotations where I was on call every other night, I hated it. I may have loved the surgery and medicine, but I hated what it took to learn surgery. There were more than one occasion when I serious–and I do mean seriously–thought of walking into my chairman’s office and quitting. There were times when I feared for my marriage, and there were more than one times when I feared for my health and sanity. At times, I became cranky and irritable (even more so than demonstrated on this blog) to the point where I occasionally behaved in ways that now embarrass me to think back upon them. But I persevered.

Before I get to the topic of work hour limitations, though, let me point out that there were a few positives. First, I learned things about myself that I had never suspected before, the most important of which was that I could endure and tolerate far more than I ever would have dreamt possible. Second, I did learn the importance of continuity of care by observing how disease progressed over time by direct, uninterrupted observation. Finally, I learned how to function under pressure and extreme fatigue. These are not bad things. But are they worth the downside? We may soon find out. Or, more specifically, we may soon find out whether the advocates of work hour restrictions are correct that, if a little work hour restriction is good, more must be better:

The American medical establishment has been slow to give up a hazing ritual that assigns grueling schedules to trainees, with supporters of the schedule arguing that the long hours prime young doctors for the rigors of medicine, expose them to many disease scenarios, and promote continuity of care for patients. Other nations have been quicker to jettison that system. New Zealand limits residents to 72 hours of work each week, while France caps the workweek at 52.5 hours. Danish residents work no more than 37 hours a week. (What a breeze!) Elsewhere in Europe, countries are slowly lowering the work hours of “junior doctors” to comply with the European Working Time Directive, which limits hours for all shift workers. By 2009, junior doctors will work no more than 48 hours a week.

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.

Let’s review the reasons commonly put forward for work hour restrictions. First and foremost, it is put forward as a means of reducing medical errors, a highly worthy goal. Certainly, there is evidence that fatigue makes the likelihood of errors higher. At the risk of being too anecdotal, these tend to be errors of omission rather than commission, as in preferring sleep to doing what needs to be done. Certainly operative performance decreases as well; as have many surgical residents before me, I have come very close to falling asleep during an operation, although, I will note, only when was holding retractors or not otherwise the primary or secondary surgeon in the procedure. The prototypical case used to further this viewpoint is that of Libby Zion, although a good argument could be made that it was inadequate staffing and supervision more than prolonged work hours, where junior residents took care of her with little or no attending input. The senior resident was never wakened when Zion deteriorated, and the attending was not notified.

But do work hour restrictions actually enhance patient safety and decrease the likelihood of medical errors? For all the confidence that its advocates present, the record is actually quite mixed. At best, it’s a wash. We have retrospective analyses full of confounding factors that suggest perhaps an improvement in patient outcomes, but the changes are small at best. Certainly there has been no large scale improvement in patient safety due to a decrease in fatigue-related medical errors attributable to the 80 hour work week. That much, at least, can be said with confidence.

The reason, very likely, is the law of unintended consequences. While it is quite possible that fatigue-related medical errors may have decreased, it is also quite possible that errors related to other factors, including systemic factors, may well have increased. The reason is that decreasing resident work hours by necessity harms continuity of care. Patients have to be “handed off” to different residents, and the shorter the work hours the more frequent the hand off. Another worry is how well the next generation of physicians will be trained, particularly in procedure-intensive specialties like surgery, where quantity counts; i.e., practice makes perfect. It will become more difficult for surgeons to achieve adequate training under then new system:

Proficiency in the operating room notoriously demands long hours, and one-third of orthopedic surgical residents were deprived of training in the operating theater because of shorter work hours, according to a 2002 survey by the British Orthopedic Association. “To become a competent surgeon in one fifth of the time once needed either requires genius, intensive practice, or lower standards. We are not geniuses,” wrote the authors of an article published in the British Medical Journal in 2004. “That many senior house officers arrive at posts halfway through their rotations without any real competence in operative skills as basic as suturing and tying knots is therefore unsurprising,” they noted.

As a counterpoint, there is evidence that the 80 hour work week doesn’t significantly decrease operative experience among general surgery residents. Of course, the 80 hour work week is only a 20-25% decrease from previous work loads. Will there continue to be no decrease in caseload if hours are decreased to 56, which indications suggest will eventually be the next step? Again, we can look to our European colleagues, who are further along in this process:

As European countries approach a 2009 deadline for fully implementing a 48-hour workweek for doctors, critics have renewed their arguments. In November, a study published jointly by the Royal College of Anaesthetists and the Royal College of Surgeons suggested that medical education in the United Kingdom would need an overhaul in order to maintain certain training standards while complying with reduced-hour rules. Testifying before the U.S. Institute of Medicine’s committee on residents’ work hours, Dr. Bernard Ribeiro, former president of the Royal College of Surgeons of England and an outspoken critic of shorter work hours, urged members to consider the implications of reducing residents’ hours: British residents today perform 25 percent fewer procedures than they did before the regulations began to take effect, he said.

From my point of view, there are two compelling arguments for work hour restrictions. The first is education. The purpose of residency is education, to train the next generation of physicians. Residents should not be considered cheap labor, which they all too often were in the past. Indeed, when I was a medical student, residents and medical students put in all the IVs and drew all the blood aside from one morning blood draw a day. Although all that practice did make me very, very good at putting in IVs by the time I finished medical school (a skill that served me well as an intern, in contrast to a lot of fresh interns these days who seem unable even to put an IV), it was scut work, pure and simple. There was virtually no educational value after I achieved a certain level of proficiency and, from my perspective, using us to put in IVs was exploitation of medical students and surgery residents as cheap labor, pure and simple. Indeed, the article cites a report that shows just how much it would cost to replace this cheap labor:

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.

And:

In 2003, when the Accreditation Council for Graduate Medical Education ruled that residents could work no more than 80 hours a week, hospitals were forced to hire additional nurses, technicians, and senior doctors to pick up the residents’ slack. Last week, the IOM committee said its recommendations could cost $1.7 billion a year. The committee justified the expense by saying medication errors and the cost of treating drug-related injuries in hospitals add up to more than $3.5 billion a year.

I have yet to see one whit of evidence that work hour restrictions have decreased medication errors by anywhere near that amount–or, that they have decreased medications errors measurably at all. In this area of the debate, faith all too often wins out over science. However, from an educational perspective, work hour restrictions do appear to allow residents to spend more time studying, thus resulting in improvements in the American Board of Surgery In-Training Examinations taken every year by residents.

The second argument for resident work hour restrictions is simple humanity. Thinking back on my residency, there are times when I marvel that I made it through it all. It was brutal. Even now, nearly 13 years after I finished residency, the tincture of time has not led me to look back with misplaced romanticism on just how brutal it was.

There is one thing that’s completely clear, however, and that’s that, if we keep decreasing resident work hours, the structure of residencies will have to change. They will have to become longer, particularly in residencies that demand a lot of procedural skill. Indeed, the move to decrease resident work hours is conflicting directly with another movement in medical education to document patient care experience, such as operative cases, patients admitted, patients with different conditions and diseases cared for, and the like. More importantly, the ideology–and yes, it is an ideology; the science supporting reducing work hours much further than what they’ve been reduced to is shockingly thin, particularly the claim that doing so will decrease medication and medical errors–requires flexibility. As the article points out, the “one size fits all” approach completely ignores differences between the specialties and could actually end up hindering medical education in some areas:

We all want our doctors to be well-rested, but the IOM’s effort to ease the burden on overworked residents saddles some doctors with recommendations that could hinder their education. Across-the-board guidelines lump together doctors with vastly different skills, sleep needs, and career goals. More flexibility would keep the United States from facing the doctor shortages and training deficiencies seen by other countries. By allowing individual programs to tailor work hours to meet the needs of their residents, the rules could accommodate aspiring physicians for whom shorter shifts are sufficient as well as those surgery residents who may benefit from logging extra hours in the operating room

We are now in the middle of the sixth full year of resident work hour restrictions, and thus have now had sufficient time to see the first couple of classes of surgeons who have trained solely under the new system, as well as more than that for specialties that require less training. There has been a sea change in how general surgery residencies operate, if you’ll excuse the term. Despite that, it’s surprising how little hard evidence there is to support their efficacy. Education and humanity may argue for such restrictions, not to mention a need to make medicine a more family-friendly specialty in order to make it possible for women in particular to be physicians and have children, but the long-ballyhooed and extravagantly promised reductions in medical errors predicted to result from resident work hour restrictions have yet to materialize. Color me cynical when I predict that they probably never will, because of the complexity of the systemic factors that influence rates of medical errors and, of course, to the law of unintended consequences, including increased handoffs and the takeover of these functions by less trained and less motivated workers. Very likely, though, as Kevin MD and DB have mentioned, the next unintended consequence of these work hour restrictions will be the increase in the length of residencies.

I’m wondering how physicians in training will like that. It’s already an amazingly long commitment to become a surgeon, for instance, even more so to become a surgical specialist. At the old hardest of the hard core surgical residencies at Duke, they used to joke about a “decade with Dave” (meaning Dr. David Sabiston, a giant of surgery), who would keep residents until he thought they were good surgeons. Few could tolerate training that long, but it may well become the norm for surgeons. One thing’s for sure, though. We’re about to see just how much society values providing shorter work hours for physicians, because it’s going to cost a whole lot of money to replace that labor and and to extend the number of years most physicians will need to train before they can practice.

Comments

  1. #1 Lora
    December 29, 2008

    “The reason is that decreasing resident work hours by necessity harms continuity of care. Patients have to be “handed off” to different residents, and the shorter the work hours the more frequent the hand off.”

    This part seems to imply that longer work hours are being used to make up for deficiencies in workload management. Hand-offs of work in other disciplines are often tightly managed, almost ritualized to ensure continuity; when this hand-off is not ritualized and tightly controlled–and there are several ways of doing that–that is where you see continuity break down, in every field, not just in medicine. What matters is that the ritual happens and that there is accountability, rather than what type of ritual. It’s a management and communications problem, not a work ethic problem. And typically when I’ve seen “well, (low person on totem pole) needs to work harder!” it’s always been by someone in charge looking to evade accountability.

    Just sayin’. As soon as you transfer the same issue of mistakes, training and quality to any other field, suddenly it looks a bit different.

  2. #2 DLC
    December 29, 2008

    Some good thoughts, Orac.
    It seems to be a difficult situation. In most other jobs you would be quite right to insist on limiting your work week to 50 hours. However, so much of medicine seems to be time-based — you’re either in a hurry to get something done or have to sit and wait for the case to develop. And certainly, having one doctor who’s been in on the case from the beginning seems to have an advantage. I’m afraid this one’s above my pay-grade.

  3. #3 Diane
    December 29, 2008

    Thanks for this. I would have never thought that there was any good in those crazy long resident hours. It’ll be interesting to see what develops.

  4. #4 rrt
    December 29, 2008

    Um…I assume the news article’s crack about halting surgeries for naps is misleading…right?

    Right?!

  5. #5 budbud's mom
    December 29, 2008

    An interesting take on a raging controversy. I am a reader of your blog who came to it from the autism side, but am myself a neonatologist by trade (doctor in an NICU for you non-medical types) and I agree with all the points above. Do I think that every other night on call, which amounted to 36 hours on, 12 off if that was safe and humane? not at all. But to suggest that it is feasible to essentially half the training hours of residents is unreasonable. I finished my training with the only rule being every 4th night in house on average,and home after 28 hours. Was it bad, certainly sometimes, tired, yes but i do agree that you ‘learn’ to work through it and don’t think its unreasonable, and in fact, by choice i still work 24 hour shifts. We are seeing the downside already, residents who finish paediatrics without having ever seen some procedures and don’t get enough training. work hours must be shortened enough to be safe and humane, and allow residents to have slept enough to learn. as for the continuity issue, i agree with the systems approach, nurses have handed off for a long time, have a system and seem to have overcome that issue. perhaps we can learn from them. I have rambled, perhaps because I have been up for quite some time :) I would hate to see more errors due to poorly trained physicians and do agree that the length of training will soon have to increase and that individual programs should have the freedom to decide.

  6. #6 David C. Brayton
    December 29, 2008

    Would anyone get in a plane if the pilot had been awake for thirty hours? I know I wouldn’t.

    And I don’t want a doctor repairing my burst aneurysm if she has been awake for thirty hours.

    Sleep and performance go hand in hand. There are dozens and dozens of studies showing that those without sleep don’t learn or perform as well.

    Extrapolating those studies to overall medical errors may introduce lots of other confounding variables.

    But given the strength of the sleep/performance studies, there is no way I would ever let anyone without sufficient rest perform non-emergent surgery on me.

  7. #7 Ivan
    December 29, 2008

    I think Lora’s point about handoffs is very important here. To add to it, the fact is that right now patient records are mostly handwritten makes handing off more difficult. Especially if its the handwriting of some physician who hasn’t slept in 48 hours.

    There is no doubt that we need to overhaul just about every part of the health care system and this is just one part of it.

    Orac has made some very interesting points and I am surprised to learn that there isn’t much evidence that the shorter work hours makes a difference in patient care. There is clear evidence that working those long hours makes you stupider, at least while you are working them.

    Have there been any studies which looked at the reduction in deaths due to sleep deprived doctors driving as part of the calculation?

    I do think Orac is right that we need to look at the different specialties individually, but my guess is that that will mean that some specialties or general residencies can work substantially less hours, depriving hospitals of their overly cheap grunt work. I don’t think that extending residencies would be such a problem if residents were better compensated and had actual lives instead of spending 100 hours a week in the hospital.

    I don’t think this is a problem limited to health care. In many of the sciences, you are asked to work really long hours for low pay until you get your degree. Then you can work really long hours for slightly more pay. But in general, we should move away from the paradigm of slave labor for many years then holy grail and try to make these long term training careers more palatable. I know this would help lower the attrition rate from people dropping out or never starting in the first place.

    sorry for the rambling comment.

  8. #8 Rockin Morroccan
    December 29, 2008

    What? You mean a job requiring pinpoint accuracy and extreme focus should not be done after 36 straight wakeful hours?

    Who knew?

  9. #9 Dangerous Bacon
    December 29, 2008

    Orac notes that there is limited evidence on whether better-rested trainee physicians make fewer mistakes. The contention that current limitations on work hours are resulting in more poorly-trained physicians seems to be based on nothing more than anecdotes.

    I am also unaware that “handing off” cases to another physician has been proven to result in poorer quality care. There are numerous severely ill patients who are in the hospital for days and weeks at a time. It’s routine for numerous physicians and other caregivers to be involved in those patients’ care, and impossible for anyone to be at their bedside 24 hours a day for continuity. Good communication between caregivers is what’s essential.

    As a physician and sometime patient, I also don’t want anyone fogged out by lack of sleep to be making critical decisions about my treatment or performing procedures. Patients are the #1 consideration, training for physicians and cost come later, convenience for attendings somewhere near the bottom of the priority scale.

    As to the quote in Orac’s piece about lengthy work hours being a “hazing ritual” for residents, unfortunately I think there are elements of this – certainly some of the resentment I see from older physicians about shortening of resident work hours has this overtone (although possibly more of it comes from the perception that less cheap labor will be available and the senior doc will have to do more work).

    Maybe some residencies will have to be reworked and even lengthened to permit more rest for residents. Perhaps some proposed restrictions go overboard. Our goal should be to base decisions on the best evidence possiible and to consider the patient’s welfare as the top priority.

  10. #10 Beach Bum
    December 29, 2008

    This is one of the most balanced summary of this discussion I have seen. Thank you!

  11. #11 Dr Benway
    December 29, 2008

    The sign-out, no matter how ritualized, can be a problem with diagnostic dillema cases who do unpredictable things in the middle of the night. It’s hard to convey context – conversations with family, specialists, all the what-ifs considered.

    Anecdote regarding work hours:

    I picked an every 4th night call internship affiliated with my med school. But it didn’t fill during the match so it became an every 3rd with some months of every 2nd.

    We worked out a night float system to avoid the every 2nd. The person on night float covered all patients in the hospital from 5:00 pm until 8:00 am. New admits went to the on-call R2 & R1.

    Night float for a week is better than every 2nd for a week because working post-call sucks. As night float, I could get home and sleep from about 10-3:00ish. Ah, soft pillow…

    But night float for a month is much worse than every 2nd. The chronic sleep deprivation slowly messes with your head.

    I vividly remember the moment I cracked. It was around 7:00 am. I lay down hoping for a coupla z’s before signout at 7:30. Then I got beeped to the ER. I started crying. I faced the ER attending with tears all over my face. I said, “Why won’t you let me sleep?!! I just need a little fucking sleep!!” Patients waiting to be seen must have freaked.

    Thankfully I had a reputation as a hard-working level headed intern unlikely to snap under pressure. So I wasn’t reprimanded. Instead the float rotation was changed to include one day off per week.

    I learned more during that internship than any other year of my life. Watching the arc of illness, from initial presentation until discharge or death, is the best teacher. Yet that requires episodes of overwork and sleepless vigilance.

    I’m not sure how to balance the need for an immersive experience with tne need for rest. I note that days off make a big difference. One can handle greater call frequency with periodic days off.

  12. #12 Dangerous Bacon
    December 29, 2008

    “Watching the arc of illness, from initial presentation until discharge or death, is the best teacher.”

    This sounds great – but how applicable is it to everyday practice in a hospital setting?

    Acording to the link below, in one recent year the average length of hospital stay (for all diagnoses) was 4.8 days.

    http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5427a6.htm

    In the golden years of extremely long workweeks, hospital stays were much longer (7.4 days on average, as recently as 1980). Who was around and conscious for over a week to follow the patient’s entire hospital course?

    Who works nearly five days straight without sleep to see patients through from admission to discharge (or death)?

    How many complex cases are resolved within a call shift to afford maximal teaching moments?

    What are the benefits to the patient from having a sleepy resident around for this teachable moments?

    And while this has been only marginally alluded to, what are the consequences for both physician and other hospital staff of having the sleep-deprived blow up at peers and other hospital staff? What are the long-term personality changes that may ensue?

  13. #13 Orac
    December 29, 2008

    In the golden years of extremely long workweeks, hospital stays were much longer (7.4 days on average, as recently as 1980). Who was around and conscious for over a week to follow the patient’s entire hospital course

    Actually, quite a few.

    Back when I was a medical student, there was almost no cross coverage. It was every other night call, but the intern and resident in house took care of patients that they knew because the patients were on their service. Even earlier, there were “hard core” surgery programs with rotations (usually ICU rotations) where they did literally live at the hospital for a month. They walked in on the first of the month and did not walk out until the last day of the month.

  14. #14 Orac
    December 29, 2008

    Um…I assume the news article’s crack about halting surgeries for naps is misleading…right?

    Wrong.

    Friends of mine tell me that there are European countries where, if a surgery runs past the surgeon’s designated quitting time,” another surgeon comes in and finishes the case. I don’t know if he’s exaggerating or not, but clearly a shift mentality is what medicine is moving towards, at least for residents. Too bad they don’t cap attending hours at 56.

  15. #15 rlbates
    December 29, 2008

    Very nice, balanced look at a difficult issue.

  16. #16 Dr Benway
    December 29, 2008

    Dangerous Bacon

    Who was around and conscious for over a week to follow the patient’s entire hospital course?You don’t have to watch a patient’s course continuously, like you watch a movie. You just need to catch the meaningful bits.

    A patient’s response to treatment can be appreciated during scheduled morning rounds. But other useful teaching moments include:

    - the presentation in the ER just prior to admission
    - any sudden decline resulting in death or ICU transfer

  17. #17 Max Kennerly
    December 29, 2008

    A fair article (I say that as a trial lawyer inclined to support restrictions), but I think you’ve missed one other possibility: the shortening of medical school.

    I have yet to meet a medical student who felt that the initial purely scholastic component of medical school required two years, and, indeed, the existence of combined undergraduate/medical programs in shorter time frames suggests that multiple improvements could be made to reduce the first two years of medical school into 18 months or a single year, depending on prior experience.

    In such a scenario, you would either have a longer clinical experience or a longer residency, either of which would permit physicians to finish the school & residency within the same amount of time as they do now.

  18. #18 Dr Benway
    December 29, 2008

    Oh I screwed up the blockquote thingie. I’m not post call, but I am viremic.

  19. #19 Orac
    December 29, 2008

    A fair article (I say that as a trial lawyer inclined to support restrictions), but I think you’ve missed one other possibility: the shortening of medical school.

    I have yet to meet a medical student who felt that the initial purely scholastic component of medical school required two years, and, indeed, the existence of combined undergraduate/medical programs in shorter time frames suggests that multiple improvements could be made to reduce the first two years of medical school into 18 months or a single year, depending on prior experience.

    Who are these medical students? I’ve never met a medical student who felt that two years was enough to grasp the initial purely scholastic component of medical schools, and I went to medical school and have been dealing with medical students as a resident and attending for over 20 years now. True, they often chafe at being kept from seeing patients earlier, but the way around that is not to shorten the two year preclinical component, but to add more patient-centric teaching earlier.

  20. #20 Escher
    December 29, 2008

    How did you manage to walk uphill both ways?

  21. #21 Dawn
    December 29, 2008

    Orac – what about U of M’s Interflex program? That was 6 years to MD instead of 8 years. Since I left Michigan (the state) shortly after graduating college, I didn’t keep in touch with any of my friends who were in the program. Do you know any ‘Flexies and how they felt the program was? (I don’t even know if the program still exists).

  22. #22 Max Kennerly
    December 29, 2008

    Who are these medical students? I’ve never met a medical student who felt that two years was enough to grasp the initial purely scholastic component of medical schools, and I went to medical school and have been dealing with medical students as a resident and attending for over 20 years now. True, they often chafe at being kept from seeing patients earlier, but the way around that is not to shorten the two year preclinical component, but to add more patient-centric teaching earlier.

    That’s part of my point: the second year fails to reinforce information the way that patient-centric teaching and clinical care does. The scholastic introduction is necessary, but after that you have recurring cycles of information collection & dumping, with little to show for it upon entering clinical settings. There’s little-to-no retention of the specifics, the most that’s left is a vague familiarity with multiple subjects, the type of learning best reinforced in a practical setting. As such, you end up with students bored and unable to progress at the end of both the second year and the fourth year — better to shorten the process, make it more efficient, and aim more towards learning and less towards grade stratification.

    Frankly, most of these problems would have been resolved through resident antitrust actions, actions halted by specific Congressional exemption, but that’s a discussion left for another day.

  23. #23 James Gaulte
    December 29, 2008

    A fair and balanced analysis.My blogging attempts to suggest there may be some down side and unclear benefits to resident hour restrictions were met in part by vigorous denunciations and accusations of me wanting to return to the good old days.The continuing push to limit hours further can be carried too far and at some point residency programs will have to be lengthened if we want the surgery residents to learn how to operate and when to operate.

  24. #24 Interrobang
    December 29, 2008

    I can certainly see the point of capping hours for doctors. Commercial pilots in my jurisdiction are limited to a maximum of 90h a month of on-duty time, and any number of reports in the occupational health and safety fields (in which I spent two years) show that swing shifts and long working hours (like 12-hour shifts) increase the likelihood of occupational incidents by up to 50%.

    Even if the doctors in question aren’t making medical errors due to overwork and lack of sleep, chances are good they’re more likely to suffer occupational injuries or illness.

  25. #25 rrt
    December 29, 2008

    Thanks for the reply, Orac, and: Eeek. The idea of surgeons regularly changing over during surgeries just for the sake of a schedule at least sounds scary to me. Worse than the risks of fatigue I dunno. I could imagine situations where it might make sense, though I’m no surgeon or MD. Interesting post!

  26. #26 PalMD
    December 29, 2008

    Orac, you really summed up my thoughts on this issue, except with the addition of data.

    In internal medicine, I’m really struggling with this. I really do thing hand-offs and shift work inevitably degrade patient care, but by how much and if it’s worth the trade off is s good question. In IM, you really learn the care of the sick patients that represent today’s hospital census by repetition, volume, and continuity.

    I teach in our program but don’t administer it, so I’m not a direct part of the decision making as far as how to restructure things, but i can’t see how we can train internists with shorter hours without adding a year or two to the training.

    One of the complications to this is not just the cost to the helathcare system, but the cost to individual doctors:

    Already, we’re down to 2% of med students choosing primary care, and much of this is for financial reasons. If we extend the relatively low-paid training years, and don’t reduce the cost of medical school, you can expect us to have the worlds best pediatric neurosurgeons, but no pediatricians to refer to them.

  27. #27 Dangerous Bacon
    December 29, 2008

    “Even earlier, there were “hard core” surgery programs with rotations (usually ICU rotations) where they did literally live at the hospital for a month. They walked in on the first of the month and did not walk out until the last day of the month.”

    No sleep for a month, following patients non-stop (or miraculously attaining a sentient state for the many critical moments of care)? That _is_ hard core.

    We have softened up considerably from the days of our ancestors. Or at least we could conclude that if there was more than anecdote to go on.

    Has anyone ever proposed that attending (senior) physicians help out by assuming a little more work, so that residents can get more sleep and/or do less scutwork, permitting more important skills to be taught? How did that go over? :)

  28. #28 Dr Benway
    December 29, 2008

    When I was in training, we never talked about hours. We talked about call frequency. Among residence doing the same call schedule, the hours might vary. Some efficient people always seemed to finish early. Some routinely stayed late.

    Like self-employed people, doctors generally don’t think in terms of shifts or hours.

    When you work the clock, you don’t pick up a few items from Staples on your way in to the office. Instead you fill out a requisition and wait for your employer to provide the supplies. If a customer is inconvenienced, you shrug and say, “I know, I filled out a requisition weeks ago.”

  29. #29 Orac
    December 29, 2008

    Uh, yes, that’s exactly what’s happening. What do you think was happening?

    That’s also exactly part of the problem. Attending surgeons don’t have work hour limitations and don’t get to go home when their time is up. But they are responsible for patient care, and if residents can’t do it because of work hour limitations, then attending surgeons have to. Yes, attending surgeons have been taking up a fair amount of the slack. However, many of them were already working ridiculous hours before the work hour restrictions were imposed. There wasn’t a lot of room for them to do more then, and they’ve done it. It is unlikely that they will be able to “take up the slack” for further work hour restrictions in the future.

  30. #30 Orac
    December 29, 2008

    When I was in training, we never talked about hours. We talked about call frequency.

    Yep, that’s what we did too. We referred to it as q2, q3 or q4 call.

  31. #31 tim
    December 29, 2008

    Nice review of the problem. I too did residency in the “dark ages” with frequent on call nights. Only comment I can make reference another comment above: if I had to choose a surgeon to fix my aneurysm at 2AM, I would prefer someone who has a lot of experience repairing aneurysms while sleep deprived.

    The ONLY benefit I see of working long hours with some sleep deprivation is that is trains you to understand the difficulty of making decisions and working while sleep deprived. As a physician, you NEED this ability, because the next stroke will not happen at 9AM, they always seem to call at 9PM or later.

    tim

  32. #32 SC, OM
    December 29, 2008

    Finally, I learned how to function under pressure and extreme fatigue.

    I’ve long been skeptical of the claim that people can learn how to function under extreme fatigue. Is there research showing that this happens?

  33. #33 SC
    December 29, 2008

    Er, sorry about the “, OM.” Forgot I was away from home.
    :)

  34. #34 Dangerous Bacon
    December 29, 2008

    “I’ve long been skeptical of the claim that people can learn how to function under extreme fatigue. Is there research showing that this happens?”

    I’ve never seen any in relation to medical care. I suspect that the belief that one is “functioning (competently) under extreme fatigue” has something in common with people who drink and believe they are performing motor tasks just fine, but by objective standards are doing poorly.

    I don’t doubt that some attendings somewhere have on occasion done extra tasks to make up for inadequate resident coverage, whether or not this is due to restrictions on hours. Whether this is commonplace, and how much “slack” is picked up by other personnel (i.e. nurses and med students), or not at all, is another question, and one doubtfully confirmed by verifiable evidence as opposed to anecdote.

  35. #35 Dr. Val
    December 29, 2008

    There sure is a lot of scut work in residency training. If that could be reduced with IT efficiencies (and some additional midlevel staff) I do think that the same practical experience could be gained even with dramatically shorter work hours. If I had an hour of sleep for every time I had to rewrite discharge prescriptions… or walk down to the lab to beg for test results… or redraw blood work for “insufficient volume of sample”… or page the pharmacy to inquire as to where my patients’ medications were… I’d have been a better doctor to my patients.

    On the flip side though: residents are often in their 20′s and early 30′s – the time of life when extra hours made available for sleep are used for other endeavors (not that I would know – heh). I knew one surgical resident who was so angry about his lack of social life that he would actually go without sleep just to be with friends. He had some pretty scary things to say about short-fused, sleep deprived surgeons in the OR. Anecdotal, yes – concerning, yesiree.

    I agree that hand offs are a major problem and introduce more errors when they’re more frequent. My personal observation is that the source of many of the “dropped balls” was poor resident documentation. They tended to try to hold everything in their memories and pass on some chicken scratch with check boxes to the next team – Call me crazy, but I do think that IT could help with this. However, it still requires effort on the part of those documenting each patient need/status update (more ?scut?) but there’s gotta be a way to make thorough hand offs easier to document and transfer to others.

    No easy answers here.

  36. #36 budbud's mom
    December 29, 2008

    reading over the responses you know, they all really boil down to the same thing, a week with no sleep is bad, 40 hours a week is really unreasonable for training and scheduling and continuity and just learning.

    the problem as i see it is the push that if say, limiting a shift to 24h is good, then 16h is better, and heck! why not 8? for me its not the length of shift, but the amount of time between those shifts really, call frequency, which is really where this all started.

    though, if we applied ‘evidence based medicine’ to medicine it might not give us practical answers, but the art of medicine, and interpreting the evidence in the context it is being applied is what we need here.

    i wouldnt choose a surgeon who had been up for 36h, but i would choose one who had been up for 20, and had experience to do the procedure.

    also, i totally agree with minimizing scutwork, lets have residents working less hours but more quality.

    my most sleep deprived week to date has been when i was attending staff, with no restrictions and on call, so it is not always reasonable for attendings to pick up the slack, again should be applied individually where necessary and where reasonable

  37. #37 Comrade PhysioProf
    December 29, 2008

    Nice post, dude. Two things to add:

    (1) Chuck Czseisler (sp) from Harvard has done some very convincing studies that demonstrate severe breakdowns in decisionmaking caused by sleep deprivation/circadian disruption.

    (2) The biggest incentive for residents and attendings to be worked absurd hours is the financial one experienced by their employers, who bill for resident and attending work by the procedure, but pay residents and attendings an annual salary. Do the math.

  38. #38 Dr Benway
    December 30, 2008

    Salary? Most hospital attendings are not salaried. They get whatever Medicare pays.

    Off topic rant re: IT and saving time.

    I set up a MySQL based EMR system for this RTF I visit as a temporary measure until the place bought the big million dollar system.

    Well, the shiny EMR has been on the horion for over five years. The facility continues to grudgingly use my system. But whenever I press for more consistency, I’m reminded of the new EMR about to roll out in “six months.”

    I never wanted to be the software dude.

    Yes, centralized info makes sense. It’s a joy to ask a question, like, “Is Mr. X truly less aggressive this month?” or “When did the bedwetting start…after the Risperdal increase?” and have the answers at my fingertips.

    But getting people on board with electronic records is rough. Nurses, direct care staff, support staff, are stretched thin. People are worried ‘cuz their paperwork is behind and there were three new admits and the state is coming and…

    My fellow physicians appreciate the benefit of an EMR, but are happier hand writing orders. I don’t blame them. Click click click dropdown scroll –computer orders are time consuming, particularly if you’d like to generate MARs from the orders. A Depakote taper might be three handwritten lines. But those three lines can translate into 12 separate orders on a MAR (and thus the FDA blackbox re: Depakote and suicidal ideation).

    The hype around EMRs has hurt DIY doctor geeks like me. For the EMR world is wonderous beyond compare. It’s nothing like the crappy Dell box Windows XP thing of today wot forgets how to print ‘n such. No, the EMR is a revolution. It will make taking a pulse a thousand times easier and more fun. But you’ll need a hundred hours of training before you can even think about it.

    When I talk to people about centralizing info, they say, “but why create a system now when we’re gonna get a new system later?” Yes, why clutter our heads with information management thoughts today when tomorrow Jesus will arrive with His Mighty EMR in hand?

    The prices of the EMRs on the market are simply insane. I assume vendors are raping while they can. They know the big secret will eventually get out: tables are basically tables.

    A committee of computer illiterate bureaucrats are developing guidelines that will force us all to buy “certified” software real soon.

    Ok, I’m febrile. Sorry. What I mean is: the ‘puter is good. But it won’t save us time.

  39. #39 raiseya
    December 30, 2008

    | I’ve long been skeptical of the claim that people can learn how to function under extreme fatigue. Is there research showing that this happens?

    Yes…it’s called Navy Seal Training. It has a very high washout percentage, similar to what I see being described in this thread.

  40. #40 M
    December 30, 2008

    My UK medical school has us on the wards from Semester 2 of first year, (alongside lectures) and it’s certainly not unique in this. We start being assessed on clinical tasks from first year as well. I have a suspicion that in the UK only Oxbridge keep their students away from patients for as long as two years.

    I do worry that some of the statements about what doctors can/could do on sleep deprivation is the sort of ‘superman’ bullshit in medicine that leads to alcoholism and burnout. Systemic problems with the EWTD need to be addressed (for example I know at the moment a lot of Consultants are pulling extra hours to cover for juniors with reduced hours). However, if someone is not not safe to drive, how can they be safe to do procedures on a patient? We’re told repeatedly in our lectures of how dangerous medicine is, and how we should be learning lessons from the (far safer) airline industry. No airline would be so crassly stupid as to put a sleep deprived pilot in charge of a plane.

  41. #41 Imhotep
    December 30, 2008

    I agree with the comment from raiseya! When the task is broken down and made “reflexive”, then the training has been a success.

    As far as stopping surgery to take a nap, well sadly, the answer is yes. I have seen a number of residents leave the O.R. because their 80 hours are up! Really. It is very disturbing to see “physician’s in training” fail to realize that there is another human being under the drape relying on you skill, experitise and desire to heal them.

    The common word here is “shift worker mentality”. I am not a SHIFT WORKER, I am a SURGEON!

    Great Blog Orac and thanks for letting me post! I hope to be a regular around here.

  42. #42 Lora
    December 30, 2008

    Dr. Benway:

    What about a handwriting capture system that translates handwritten notes into (more or less) typed records and then moves the information to a central database? We already have such software for electronic lab notebooking, and I know a couple of the local universities have such a system for TAs to post class notes. Hell, my vet even uses a similar system with tablets in every exam room–all you have to do is write on the thing. Even with pretty bad handwriting (such as professors visiting from overseas and forgetting to make notes in English), you can still tell what it’s supposed to say.

    I know you’re not the computer guy, but I’m sure the EMR writers can create an “autopopulate” function for MARs. That’s so easy even I can do it.

    I absolutely hear you on the issue of simply not having adequate staffing in general and computers not being the solution to everything, but seriously…with the sheer amount of data and paperwork to manage, it’s unbefuckinglievable to me that they haven’t been implemented long ago.

  43. #43 D. C. Sessions
    December 30, 2008

    I’ve long been skeptical of the claim that people can learn how to function under extreme fatigue. Is there research showing that this happens?

    The US Army has done quite a bit (no need for IRBs!) The Army has a tradition going back at least for centuries of “training” troops and their officers to function under severe sleep deprivation, and in the last few decades they decided to quantify it all. I mean, we know that there has to be some limit to our ability to tough it out on sheer manliness and all that, so where is it?

    Oops. Turns out it doesn’t work. All of that, “I drive better when drunk” stuff is, indeed, your inability to tell that you just ran two stop signs and are heading against traffic on the Interstate. Likewise sleep deprivation: you suck just as badly, but with practice you get accustomed to sucking.

    Sort of like Kruger and Dunning’s work on competence and awareness.

    And, no, I don’t have cites. This is from recollection of secondary sources several years ago, but they shouldn’t be too hard to find in the literature.

    Now, of course it’s arguable that physicians aren’t subject to the same limitations as long-distance truckers, airplane pilots, etc. It’s arguable that they have some undocumented immunity from these kind of physiological limitations. Perhaps we should just continue to assume so in the absence of any actual science on the subject.

  44. #44 Tsu Dho Nimh
    December 30, 2008

    I have seen a number of residents leave the O.R. because their 80 hours are up!

    Why did they start a 6-hour procedure with only an hour left until they turned into a pumpkin?

    It was SOP when I was a medical technologist to minimize hand-offs on lengthy lab tests by doing a sanity check on the length of time a test took to do versus the time left on that shift. Whenever possible, we would let the tech with an 8-hour shift ahead of him/her start the 6-hour lab test.

    A Depakote taper might be three handwritten lines. But those three lines can translate into 12 separate orders on a MAR

    Uh … it’s a well-known process control function for ramping concentrations up or down.

    Start at time A, and reduce the incoming variable (the drug) to YYY dose in N time units. Computer figures out the steps, adjusts for pill size (rounds to a reasonable dose and schedule for the drug, based on previously entered parameters) and spits out the orders. Doc checks orders and verifies them.

    Doc would only have to enter the final dose desired and the desired number of days to taper up or down. Computer would do a sanity check based on ramping slope.

  45. #45 Dr Benway
    December 30, 2008

    Hi Tsu Dho Nimh,

    Letting the computer do more of the work is a great idea. This requires an accurate, continually updated set of formularies for each insurer (each state Medicaid has its own evolving quirks, such as pill size and count limits per month). Then there are the patient quirks – e.g., must be Depakote Sprinkles 125 mg, ‘cuz patient can’t swallow the big Depakotes. He won’t take extra pills in the a.m. ‘cuz they upset his stomach. Oh, and no dose changes while the patient is on a home visit next week.

    I’m all for automation. But the coding work and maintenance time associated with automation can seem hardly worth it when you have to tweak the output fairly frequently.

    Little policies change and mess up my system. Examples:
    - Nurses used to break pills in half. Then someone decided that this was “dispensing” and outside their scope of practice.
    - Maine decided not to pay for Seroquel 25mg, although it will pay for 100mg (not an insane policy since Seroquel 25mg=Benadryl 50mg-ish).

    I really, really hate when family members want a patient on some alt.med supplement protocol. Much of that nonsense doesn’t fit neatly into brand/generic/ingredient /NDC/category/indication/strength fields.

  46. #46 Dr Benway
    December 30, 2008

    Hi Lora,

    Yes, handwritting and voice recognition for data entry would help. But generally I want drop-downs. You can’t query data nested in English sentences.

    It’s commonly believed that EMRs will save doctors and nurses all sorts of time. This is untrue. EMRs only save time when logging very routine events – e.g., flu shots. Otherwise they eat your time. Trust me on this. Oh rats, you’re all skeptics…

    If data entry is such a pain, why am I pro-EMR? Because EMRs make it possible to ask questions.

    Cool stuff I can ask my EMR:
    - How many people we got on lithium right now?
    - How many started but had to stop?
    - How many had to go on Synthroid?
    - Who’s got a seizure disorder?
    - Who’s allergic to peanuts?

    When a patient isn’t doing well and people aren’t sure why, being able to ask questions that can be answered with a few mouse clicks is wonderful. Before, I had to rely upon the verbal accounts of direct care staff, which often carried the whiff of made-up bullshit. But how could I know?

    Hehehe. Now I know. And now I can prove that what people think they saw, what they think they remember, what seemed to happen after what, is wrong. And thus, my love of the EMR.

    Sadly, what’s important to me is not necessarily important to others. Most staff suffer the burden of data input without any obvious payoff. Hence their lack of enthusiasm for an EMR roll out.

  47. #47 Lora
    December 30, 2008

    “You can’t query data nested in English sentences.”

    Sure you can! It’s a string matching problem. Just like searching for specific domains in genetic sequences, just like the “find” function in (ugh ugh ugh) M$ Word.

  48. #48 lylebot
    December 30, 2008

    I’ve seen the kind of writing I do after being up for just 20 hours—the next day, I am appalled at how bad it is. I see the kind of work students do when they pull all-nighters—it’s not good. Unfortunately many of my colleagues and students persist in believing that staying up all night to write a paper or study for an exam is some kind of badge of honor or indicative of one’s commitment or something, when in reality it just begets crap work that has to be redone the next day.

    I simply can’t believe that the potential benefit of continuous care could outweigh both the risk of error and the inefficiency of having to re-do things, unless medical care is not at all mentally challenging. Yes, it’s an empirical question, but it strikes me as over-reaching: I’m reminded of the resistance to Ignaz Semmelweis and his hand-washing theory.

  49. #49 Dr Benway
    December 30, 2008

    Yes, you can find a string nested in a paragraph. But that’s of limited value.

    Image you’ve got a set of progress notes for Mr. X. You want to graph his blood pressure over the last year. You could search for “blood pressure” to pull up relevant sentences. You probably ought to search for “bp”, “SBP”, “DBP”, and even “***/**”. That last one will give you more than you want.

    Next you’ve got to translate the relevant text into numbers. You’ve also got to associate each numeric value with the date it was recorded, for your x-axis.

    Does the computer make this task any easier than simply looking at paper progress notes and writing down the blood pressures? I’m not so sure.

    Now imagine that you’d like to graph everyone’s blood pressure pre and post some drug trial. Starting with prose paragraphs… oy. If you’re not getting paid you’ll likely say, “Screw it; don’t need to know that badly.”

    But if the bp goes into two boxes labled “SBP” and “DBP,” associated with integer fields from a table that includes a column for patient_id and date recorded, queries across time and across groups of patients are a snap.

    In sum: tabular data totally pwns prose.

  50. #50 Dr Benway
    December 30, 2008

    I totally agree with everyone that sleep deprivation is bad. But limiting hours isn’t necessarily the solution.

    More hours can mean more sleep. In fact, living at the hospital for a month might provide the most sleep, since time spent commuting, doing laundry, dishes, etc., can be spent sleeping.

  51. #51 Russell
    December 30, 2008

    I have no doubt that there is good research that shows that people at the end of shifts, especially if it involves sleep deprivation, whether that means 8 hours from 2300-0700 or 28 hours, don’t perform as well. That said, it is a mistake to suggest a 1:1 relationship between medicine and airlines/long distance truckers, at least in most cases. The major difference is that those industrial jobs require constant vigilance in an often minimally stimulating environment. Effort is required to assert this kind of attention, which is not only mentally fatiguing but prone to increased error as it becomes more difficult to attend to that non-stimulating task. Anesthesiology (my specialty) is like this and is one reason why my community not only recommended limited work hours before the RRC did (no patient care after 24hrs) and why we take breaks during the day whenever possible (much as the surgeons scoff). It allows us to relax our focus and come back to the OR fresh and able to assert concentrated attention again. Many other specialties don’t have this sort of work environment. Either the situation is constantly changing (surgery progresses), or there are opportunities to regroup by chatting with a nurse, getting a cup of coffee, or simply by interacting with a new patient. Obviously this doesn’t replace sleep, but it does extend the amount of time one can function.

    One of the important aspects of military training mentioned (I’m a former military physician and I’ve worked occasionally with special forces personnel) is to learn to recognize the degradation in performance and learn to compensate for it. Of course performance declines under the conditions of prolonged military operations, but by exploring personal limits under controlled circumstances the dangers of this degradation can be mitigated.

    The voluntary work hour restrictions for anesthesiology work because they are voluntary, and because they are recognized throughout the specialty as valid. This allows us to extend our day when appropriate, for example when a case is particularly challenging or the patient’s condition is labile, a handover would result in an inappropriate learning curve while the new anesthesiologist got up to speed putting the patient at increased risk, and when our own fatigue does not present a greater risk than the handover. It requires practice and experience to evaluate these competing risks, experience that can only be safely gained by practicing it. The only safe way to practice it is to try it under supervision: residency.

  52. #52 Russell
    December 30, 2008

    One other thought: when people think of work as a shift with a definite end point they often begin to lose focus, get sloppy and become less productive as that end point approaches and their attention turns to clock watching and what to do after they get off. Not very many shift workers “sprint through the tape” at the end of the day.

  53. #53 trrll
    December 30, 2008

    Who are these medical students? I’ve never met a medical student who felt that two years was enough to grasp the initial purely scholastic component of medical schools, and I went to medical school and have been dealing with medical students as a resident and attending for over 20 years now. True, they often chafe at being kept from seeing patients earlier, but the way around that is not to shorten the two year preclinical component, but to add more patient-centric teaching earlier.

    Medical students are often impatient with the basic science part of the medical curriculum, and anxious to get to “real” medicine. Some see little point in learning basic principles unless they are dressed up as case studies. But I’ve also had students who have finished medical school tell me how valuable their basic science training has turned out to be.

    And I worry about the consequences of shorting students on basic science training. It is quite clear that physician ignorance of basic science can compromise patient care. We have, for example, Dr Jay Gordon supporting delaying or avoiding vaccinations based on the irrational fear that a minuscule trace of formaldehyde–a molecule normally present at relatively high levels in blood–can be a hazard to patients. And we have Dr Egnor displaying a shocking ignorance of basic benefit-risk principles in comparing the number of adverse events with active, effective treatments to that associated with “alternative” medicine.

  54. #54 Prometheus
    December 30, 2008

    Although I know this point has been made already, I wanted to emphasize the fact that the first (and often only) response to reduced resident work hours by most university hospitals (including the one at my university) has been for the attending physicians to work longer hours.

    This may seem only fair to some people, but I think that it is more dangerous to have the people who are at the top of the supervisory chain being more tired and getting less sleep than the people they supervise.

    It’s one thing to have the resident make a mistake in judgement that the attending can catch and correct – quite another when the attending physician makes that error (which the resident may or may not have the experience to detect and/or the courage to correct).

    In an ideal world, everybody in the hospital (including the patients) would get a restful night’s sleep every night. However, this world being demonstrably not ideal, we need to address a few real-world issues:

    [1] Are we – as a society – willing to pay what it will take to run the “medical system” without sleep deprivation – or even with a reduced amount of sleep deprivation?

    Given the current reluctance of “society” to pay for the current delivery of medical care, I would say the societal answer is “no”.

    In the end, the only way we will end the practice of doctors – in or out of training – working when they are tired is to educate and hire a lot more doctors. That won’t come cheap, since people who put in the amount of work to become good doctors aren’t going to settle for a GS7 salary.

    At a time when every politician is talking about “reining in medical costs” or “cutting medical costs”, I doubt they will be receptive to an idea that increases costs without “delivering” medical care to more people.

    [2] How can we compress an adequate amount of experience into a manageable residency duration? If we mandate that the residents’ hours be cut from the current 80 hours a week to 50 or 60, they will have to be in their residency longer to get the same amount of experience.

    Since medical care is generally getting more complex rather than less complex, even the non-surgical residents will need to put in more total time to learn enough to be functional on their own. Combining the increasing complexity with a reduction in hours-per-week leads inexorably to more years spent as a resident.

    Will pediatric residents and medical residents be willing to spend four or even five years learning their specialty? Especially when their “earning potential” is likely to fall rather than rise in the future, as “cost-cutting” measures are implemented? I think that we will see even more of a shift toward procedure-oriented specialties and away from the primary care specialies.

    All in all, I think that a reasonable limitation on resident hours is a good thing. I doubt that the last few hours of a thirty-six hour sleepless stretch contribute meaningfully to a resident’s medical knowledge base or their “character”. However, more of a “good thing” is not always better.

    As always, we need to be mindful of the unintended consequences of our best intentions.

    Prometheus

  55. #55 Lancelot Gobbo
    December 31, 2008

    Most of my career I have done one in two call. My first job (general surgery and urology) we did every Tuesday and Thursday on call and alternate three day weekends. That meant every other weekend I worked from Thursday 8AM to Monday 5PM – 81hrs straight. I had moments when I really didn’t care. Just like someone repeating abusive relationships, I have gone on doing stupid work hours. Now I am in the middle of nowhere, and am ‘on’ all the time. I have been away for one week in the last eight years. I wonder why I can recall seeing three physicians kill themselves in this and the surrounding communities since I came here? I was nearly the fourth a few years back, but I’m too stubborn. We do need to spend more time making our own lives worth living, and showing residents how to work sensibly is the humane thing to do. If it adds a year to residency so the experience gained is the same, so be it.

  56. #56 epador
    December 31, 2008

    DC Sessions is accurate. Russell is only partly right. There are mounds of documentation of the impairments of sleep deprivation, and the first thing to go is your ability to tell you are impaired. The only mitigation a good operator (whether surgeon or SOF) learns is when they need to power nap and when they need to throw in the towel. Doctors are human and suffer the same impairment others do. Spoken as a USAF SFS with gold-bordered CSAR and SOF experience.

    What this research does show is that you CAN stay up 24hrs, but you need at least 4- 6 hrs rest between cycles AND you can’t do this for long before requiring more regular 6-7 hour rest periods. Thus there is a rational way to work those 80 hour weeks, have prolonged patient contact, get the rest you need AND avoid performance impairment.

    Chronic sleep deprivation (weeks and more of less than 6 hours sleep) has significant performance and emotional impairment well documented. Look at any surgeon who trained in the 1960 to 1980 period (LOL).

    RE: compression of training: I trained to be an MD in five years post high school. We only lost one to suicide and only about 20% dropped out of the program before graduation. When I got out, and interviewed around the country, I had more than one program tell me to take an internship somewhere else and then reapply. They didn’t want a 22 year old intern. (I can’t figure out why they’d want someone stupid enough to volunteer for two years of internship). A significant number of my classmates are overachievers, nationally prominent if not internationally well known in their fields. (OK, so I’m one of the Black Sheep). Nonetheless, I doubt any of us felt the need to extend our training clinically. Many did specialty and subspecialty training, but no one that I know of volunteered (or considered volunteering) to do an extra year of Fellowship or Residency training.

    My internship was q 3 night and we were so happy to get to q4 night call as residents we moonlighted in the ER 2 nights a week. Do the math. I believe that completes the argument of the deterioration of judgement with sleep deprivation.

    Lastly, though triple board certified subspecialty trained, I’ve been doing Primary Care for a decade. I work in a remote rural area. In two years I have not seen a single candidate who is seriously considering a similar position who will consider hospital call. Their training leaves them either feeling unprepared, or feeling that its beneath their primary care commitment, to care for in-patients. Our tiny hospital can’t afford to hire a team of hospitalists to cover 24/7, and there in one year there are only going to be two internists to take ICU call, three FP’s to take hospital call. Three newly established urgent care clinics in our town of 10,000 are draining the cream off the top of the struggling remaining primary care practices. I can only guess that the softening up of medical training is at least partly responsible for this shift in attitude and commitment to health care and medicine.

  57. #57 Russell
    December 31, 2008

    Thanks, epador, for adding detail to the discussion and specifically for clarifying my comment. I absolutely do not mean to dispute the fact that sleep deprivation is dangerous, even a 24 hr (or less) sleepless stretch can be too long, and I am absolutely not on the side of “make ‘em work until they drop.” Clearly “time to sleep now” is the best compensation for sleep deprivation induced reduction in performance.

    Yet when that cannot happen, for whatever reason, we can still use other mechanisms to partially compensate: slowing down, having someone else double check work, etc. While the ability to tell you are impaired may be the first to go, knowing this and knowing when that begins to happen to you, personally, based on supervised experience can (not will) allow one to predict this and take corrective/mitigating action, like a nap or making the decision turning patient care over to a more rested colleague.

    Too often physicians, especially those trained before work hours (I bridged this transition) and in “hard core” specialties think turning over care is anathema and a sign of weakness, won’t turn over, and thereby put themselves and their patients at unnecessary risk. The thing to keep in mind, just like we should with all the other medical decisions we make, is that it is a risk/benefit calculation. It is possible, though extremely unlikely, that the benefit for our patients (and ourselves) of staying on a case outweighs the risks of doing so even when we are fatigued. My point is that this is a continuum and one that varies from person to person and time to time for the same person. A one size fits all, not open to variation or exception policy cannot take either a risk/benefit calculation or circumstantial variation into account and is bound to result in unintended negative consequences.

    Sadly, like with so many other issues of self management, physicians have done a poor job of self regulation and the result has been external regulation, often to the detriment of our profession and sometimes to our patients. Work hours regulation is, I fear, yet another example of the failure of our profession to police ourselves and yet another step along the road to medicine becoming just another job.

  58. #58 cm
    December 31, 2008

    Only if we start by saying “institutionalized sleep deprivation is not an option” can we hope to figure out work-arounds. Once that hard limit is in place, we can get creative. And I suspect it really ought to be in place: the brain just doesn’t work well enough without sufficient sleep.

    Creative work-arounds might include changes to how medical school is structured, good “dorm” facilities at hospitals, much more rigorous/standardized patient records (no handwritten records), ritualizing the hand-off procedures as the first commenter said, monitoring via web-cam from home, time-tracking software to manage resident sleep needs, etc.

    The point is, when you allow for “well, we could just make them not sleep much every week, that’ll solve it”, then that’s all you get. It’s the simple, brutal, un-clever, 20th century way, and I think it’s gotta go.

  59. #59 Sid Schwab
    December 31, 2008

    Older than Orac, where I trained the every other night rotations were the easy ones. We frequently worked 12/14 nights, getting only every other weekend off. As Chief Resident on trauma, I didn’t leave the hospital for 60 days straight. I don’t claim I’m better than anyone else; I’m not certain the work restrictions will turn out badly. But I do worry. What I learned, among other things, was devotion to patients. Throughout my career I made hospital rounds at least twice a day, often more. I made rounds every day, on or off, unless I was out of town.

    More and more I hear stories of the recently trained coming out with inadequate experience, needing careful mentoring (I’ve argued that mentoring is a good idea in the new era, and ought to be formalized by the ACS.) I hear of doctors with a “shift mentality,” expecting limited and clear-cut hours. Good, or bad? I burned out younger than I planned.

    It’s also a trend that surgeons finishing training are opting for subspecialty fellowships; there are reasons, and implications. Among the reasons: feeling inadequately experience from the reduced hours. Among the implications: fewer “general” surgeons, like me, who’d take care of varied problems. Hyperspecialization. Less access, more problems in such things as taking emergency call. The good news is a trend toward “hospitalists,” both medical and surgical. It means you won’t have good ol’ doc Jones seeing you when you’re hospitialized, and you may have a different doctor every day you’re in. But all of them will be skilled in hospital level illnesses.

    It’s gonna be interesting.

  60. #60 storkdok
    January 1, 2009

    I’m guessing Orac and I finished residency with a year of each other, and I remember the call, supposedly every third night, but some rotations every other night, meaning we went at least 36 hours, none of the next day off call for us. Only one rotation was every fourth night, in our fourth year, and that was the two months we wrote up our research as well as did the “light” infertility rotation.

    I remember in my second year being thrown into the surgical ICU with every other night call. I essentially left the hospital to sleep every other night for about 6 hours for the two months. I got “lucky” enough to do that rotation in the summer “trauma” months of July and August, in the suburbs of LA. I remember one night when we heard gunshots, looked out from the 9th floor, saw police in a shootout with gang members just outside of the ER, and started getting bodies shipped up to us to resuscitate, while in lockdown. I remember one neurosurgery attending who gasped when I called him at home about one of his very unstable patients that was having a crisis, after I explained I couldn’t get his Fellow, and that I was an (OMG!) OB/GYN resident. After the crisis passed, he came to me and tried to get me to change residencies, so I guess I didn’t do too badly. I must admit, life was definately exciting, and I sure felt like I was on the “cutting edge” of medicine.

    I think your post is excellent, brings up many points that need to be considered. Many others here, like Prometheus, bring up even more information to consider. Since I haven’t been in academic medicine since residency, I have no idea how the new rules have impacted the medical students and residents.

    All I can say is, I loved the steep learning curve of residency, I loved the knowledge, the critical thinking skills I learned, but it was very difficult, because of the call schedule, to get through. I and my husband had it easier, we were at the same hospital, and we actually got to see each other more than the other residents did their spouses, and we really understood the situation for each other and cut each other some slack when actually at home and were exhausted. We did actually skip sleep at times, to make a run to Vegas for the weekend, or go skiing, just to do something “normal”.

  61. #61 Joe
    January 2, 2009

    A solution to the number of hours vs. the number of years problem is to start medical training earlier. I admit I was horrified when I learned that Ohio has (had) a program that accepted high school students into an accelerated (2 year) undergrad program followed by med school. I thought high school was too early to make such a decision, and that the students would enter clinical routines at a tender age.

    Since then, I have learned that many countries, with good medical programs, accept high school students directly into med school. Indeed, the medical degree is considered on a par with a bachelors.

    Either way, one could get an extra 2 or 4 years of extra clinical experience while decreasing the hours per week. As for training people to work under duress (e.g., sleep deprivation) I did that myself (without special training). However, as a chemist, my errors went into the waste bucket.

  62. #62 Carlie
    January 4, 2009

    What about having more doctors on call at all times, so that the residents are responsible for patients throughout their stay, but have fewer patients in total so that the residents have more “down time” during that shift?