Shorter Hours for Doctors

I asked one of my friends who happens to be a doc about this a couple of years ago, and his paraphrased (because I'm working from memory here) response was thus:

Yeah, 36 hour shifts as an intern and resident were complete hell, but everything you do is overseen by a senior doc who hasn't spent the last 24 hours awake. Those senior docs still have days where they spend six hours on one patient, and then have to attend to at least another twenty. A fourteen hour day of non-stop intensity is not a big deal when you spent several years doing 36h shifts, napping when patient load permitted.

He actually commented that a lot of the younger docs he sees coming out of the programs where they've stopped doing the long shifts are having trouble maintaining stamina through a long day of high stress patients.

He hated it, but he's glad he went through it, seeing how well his colleagues (and he assumes himself) who did it compared to those who didn't.

The reason for the long shifts is quite simple: Continuity of care and observing the evolution of a disease process over a long period of time. Of interest, if you look closely at the case that started the move for hour restrictions, the Libby Zion case, you'll see that it was obviously poor supervision by senior residents and attending physicians that resulted in Zion's death.

In surgery, you are the doctor. Period. Often there is no one else to back you up when the shit hits the fan, and being on call used to be viewed as training to prepare you for that fact. I'm not going to say that I enjoyed working 100+ hours a week nearly every week or doing every other night call on some rotations. That would be a lie. I hated it. In fact, I almost quit as a third year resident because of what it was doing to me. But in the end, I knew how to take care of patients, a knowledge forged in long nights at the bedside of critically ill patients.

Although I tend to think that work hour restrictions for residents were probably needed and are probably on balance more of a good thing than bad, they are not without their significant downside. After only three or four years of the 80-hour work week, I already see in junior residents who have known no other system a disturbing new tendency towards a shift mentality and a willingness to pass off problem patients to the on call group. The sense of being "the doctor" is being eroded.

Here's another thing: There are no work hour restrictions for attendings, and some private practice attendings routinely work 80 hours a week and beyond. When these surgery residents get out and go into private practice, where they can't just leave when their shift is over, they will be in for a rude awakening the first time one of the patients they've operated on comes back late in the day with a complication. There will be no on call team to turf that patient to, and it's doubtful that their partners are going to want to deal with their complications.

Now if someone would propose work hour restrictions for attendings, that I might be able to get behind! Of course, Medicare and third party payers are doing everything they can to try to increase the work hours of attendings by cutting reimbursement, thus necessitating many private practice surgeons to do more and more cases just to stay even. At least in academia, for now, we are somewhat shielded from that.

It seems like we ought to be able to use some science to figure out what's really better for the patient.

As far as I know (and that's admittedly not much here), the only fact that is well established is that cognitive function decreases with lack of sleep.

Things we may not know include whether continuity of care actually results in better patient outcomes, or whether sleep deprivation in your early twenties actually prepares you, in any measurable way, for the same thing later on.

The long tedious shifts don't make it easier to deal with the long days from a physical standpoint, your body requires a certain amount of things like sleep, food, and water, or bad things happen.

What it prepares you for, and my paraphrase missed the point he made, is how not to screw up and kill someone when you're the on call doc and after working 12 hours, going home, getting two hours, and coming back in because your pager went off, and are thusly working under less than ideal conditions.

I'm highly skeptical of the "preparation for future long hours" claim-- at least, it's not clear to me that working truly ridiculous shifts for a few years is better preparation for working merely long shifts later than working merely long shifts right from the beginning would be. I spent a goodly number of long nights in the lab when I was a grad student and post-doc, and I don't think it's made me any happier about working really late as an assistant professor.

Most such claims have a whiff of "it was good enough for me, it's good enough for kids these days."

The "continuity of care" argument is a better one, and I don't have an immediate response for that. Like Eric Wallace, I'd be interested to see how much of a difference that really makes, though, and whether it outweighs the effect of really disastrous things being done by sleep-deprived residents.

Jamie's second comment snuck in while I was typing, btw. And now, I have to go to an annoying meeting, and can't respond to it...

I went to the University of Chicago for graduate school in astronomy and astrophysics. As part of that program, I took a lot of courses from the physics department. Physics at Chicago is big on graduate courses that require large time committments. (For those in the know, a weekly homework sets would be, say, twelve problems in Jackson.) My favorite quote the amount of work was, "this is nothing a 80 hour week can't handle."

When studying for my quals, I was shocked at how little I retained from the previous year. I had to relearn, or learn from scratch, a lot of material I was supposed to have covered. I also found the material much easier on a full night's rest.

Maybe, somehow, medicine is different. Maybe the process of observation and decision uses different cognitive functions than the abstract problem solving that one does in physics. However, I think that weeding process is suppose to select people who are committed. Learning is secondary, what is really important is that future doctors, or physicists, show that they are willing to deprive themselves of basic needs in order to pursue their education and accreditation.

Chad, I don't want to seem snippy about this, but comparing long nights in the research lab to medical call is apples and oranges. A large part of the labor when on call at night involves high stress situations - the adrenaline is flowing, your heart is pounding. Sure, there are periods of tedium, too, but being busy is the norm. I believe the residents of my generation were the better for it in many ways, especially in acquiring the confidence to feel you could really function independently as a physician. Sadly, it was trying to stay awake the following day that proved most difficult.

What it prepares you for, and my paraphrase missed the point he made, is how not to screw up and kill someone when you're the on call doc and after working 12 hours, going home, getting two hours, and coming back in because your pager went off, and are thusly working under less than ideal conditions.

This is another excellent point. Part of being a doctor is learning to be able to avoid screwing up under less than ideal circumstances, whether it be lack of sleep, lack of food, the chaos of a busy emergency room, whatever. I think that the old way probably went too far into sheer abuse, but the new way seems to be producing a "shift" mentality. A shift mentality works in emergency medicine and anasthesia and some other specialties, because such specialties lend themselves to shift-style work, but it doesn't work so well in general surgery and most other surgical specialties.

I also agree with drb that Chad is comparing apples and oranges. There's a huge difference between being on call at night and just working late in the lab. I've done both a lot, including many late night stints in the lab at both the graduate student and postdoc level, as well as late nights doing grants at the assistant (and now associate) professor level. When you're in the lab late, you can stop, stretch your legs, get food, get coffee, etc., any time you want. There's pressure (wanting to get useful results), but if you screw up the only thing that will happen is that your experiment will be ruined or your grant or paper will suck and need more revision. If you're on call and screw up, a patient can be harmed or die. If you're a surgeon who's started an operation, it's highly unlikely that another surgeon will be available to come in and finish the operation if it takes much longer than anticipated or if it is an emergency case started in the evening or middle of the night. The surgeon has to be able to suck it up and finish the operation correectly. No one else is going to do it, and he can't just stop and take a long break or a nap in the middle of it. This is in contrast to most nonsurgical specialties.

Most such claims have a whiff of "it was good enough for me, it's good enough for kids these days."

Yes and no. Some are clearly what you say; some are genuine expressions of concern.

I always look askance at surgeons who say that the only thing wrong with being on call every other night is that you miss half the cases or at doctors who claim they liked being on call and the long hours. Most of the time, they're full of it, looking back at the past with rose colored glasses and exclaiming how they had to walk uphill five miles to school every day--and five miles uphill back. I'm quite up front when I say that I absolutely hated the long hours to the point where I almost gave up surgery in the third clinical year of my residency. I even went so far as to meet with the Chairman of Pathology at my medical school about becoming a pathology resident.

On the other hand, although I leave open the possibility that my take what I'm seeing is influenced by confirmation bias, I can't help but notice that the junior residents, who've all known nothing other than the 80-hour work week, have more of a "shift mentality" and seem less interested in continuity of care, of following the patients through all phases of the disease. In any case, on balance, the workweek restrictions are probably more good than bad, although the literature is mixed on whether they result in fewer medical errors on the part of residents. The rules' main problem is that their implementation can be very rigid and unflexible. The RRC mandates an average of one day off a week and an average 80 hour workweek over a four week period, which is reasonable. This allows some flexibility. However, some states mandate the workhour restrictions by the day and the week, which is much harder to implement.

Chad, I don't want to seem snippy about this, but comparing long nights in the research lab to medical call is apples and oranges. A large part of the labor when on call at night involves high stress situations - the adrenaline is flowing, your heart is pounding.

Actually, it's comparing anecdotes to fish stories. Is there a profession out there that doesn't decry the changing methods of instruction after a ten or twenty year gap?

I'd like to see some actual clinical studies comparing success rates of groups from the same age and experience cohort, but trained by different methods, before I buy the idea that medicine is a profession which uniquely requires and benefits from practices that would be just about illegal in any other profession.

The Wikipedia article on medical residency refers to a 2004 study which apparently found that (quoting from the abstract) "Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit."

One question that occurs to me is how universal this situtation of long hours for medical interns is. Does it work this way in, e.g., Japan, the UK, France, or Sweden? Is there any evidence that different internship practices affect patient care? (Unfortunately, the Wikipedia article only discusses the US system.)