To his credit, Dr. Thomas J. Nasca, chief executive of the Accreditation Council for Graduate Medical Education, is aware of the many problems in trying to limit work hours for physicians in training.
This topic has been frequently discussed on this blog, but some points bear repeating.
The first are the ethical quandaries that the cap often places on residents. In one example, a doctor wanted to spend time with a dying child she had been caring for during the past 10 to 12 days. “This resident stayed, but there was an unintended consequence,” says Dr. Nasca. “She could tell the truth about breaking the hours rule, and thus jeopardize herself and the residency program. Or she could lie. What could be worse than a training system that encourages doctors to lie because they want to be with their patient? This is the last thing we should be doing, but we’ve done it.”
Next, the mistakes that occur due to more frequent patient hand-offs perhaps negate the improvements in patient safety resulting better rested residents. It’s difficult to know for sure, as I’m not aware of any data showing that capping work-hours improves patient outcomes in the first place.
One point I do agree with, is the “hazing” aspect of grueling training. That should never justify the long hours that doctors in training put in. However, further reducing the amount of hours a resident is able to work does a disservice to both the doctor and the patient.
In the real world, where there are no caps to pamper newly minted attendings, do patients want a physician who’s used to punching out at the clock, or worse, lack the experience necessary to perform a complicated procedure?
The answer is no. But hey, at least they were well rested during residency.
Related posts:
- The consequences of limiting resident work-hours
- The steep price of restricting resident work-hours
- Restricting resident work hours leads to a shortage of surgeons
- How work-hour restrictions harms resident surgeon training
- Old-school doctors on resident work-hour restrictions
- Resident work hour restrictions
- Doctors lose a part of their training when resident work-hours are capped
{ 6 comments }
Residents aren’t the only ones who have to lie. At my medical school, students supposedly have work-hour restrictions, too. I pulled 85 hours/week during my first month on surgery and later told the clerkship director that I was within the specified time frame.
I think the focus should be on working smarter, not longer. I believe you can get 120/wk training in 80/wk using time wisely and eliminating busy work. This requires rethinking the daily progress note in many institutions, streamlining rounds, VALUABLE education time, a cohesive and easy to access medical record, and for goodness sake just go home if your work is complete and you are being covered. Maybe instead of capping resident hours and hiring more staff to take care of patients, residents could be freed up to take care of those patients with some inspired reorganizing of the system in a shorter amount of time. Accomplish that, take a away the hours cap, and then no one has to feel guilty about taking part in a meaningful patient experience as described above.
As a medical student, I was faced with the “lie or cause an awful lot of trouble” quandary in my very first clinical rotation. I went along with the lie choice for a week or so, and then rebelled and went with the “let the chips fall where they may approach” . . . with support from a couple of other students who were in the same pickle. We were threatened with dire consequences that never occurred, patient care was improved, and I don’t think that any of us ever regreted it.
Now, more than 20 years later, seeing what ethical depths some have descended to, who just started with the little “necessary” lies, I am more glad than ever that we made the right choice.
A system which “forces” people to lie in order to function is a system which is founded on a lie and should be stressed to the point of bending or breaking by someone with the courage to tell the truth. The “necessary lie” is the process by which systems become and foster evil and the truth the means by which that descent is prevented.
Medicine is supposed to be a profession of gentlemen. Let’s keep it that way.
The ineffeciency you speak of stems from government regulation/mandates and cover your a$$ documentation against lawyers. If you can find away to get rid of them, then more will be done.
As for hour documentation, my hospital has badge swipe in systems for the employees, but yet they have a whole seperate other program for the residents which is self reported. People don’t want to know the truth. If they did, the residents would swipe in, too. Every one knows that in residency you are supposed to lie. That’s why the new idea of dropping down to a 56 hour cap is rediculous. We can’t even cap at 80 hours.
The restrictions on time are courtesy ACGME, not the government. Hospitals and programs comply with the policy because of studies demonstrating increased mistakes when residents are tired, so if they don't go along they are exposed legally. To that extent, restrictions on student time are absurd, because students have no LEGAL clinical responsibilites ie writing orders. The rule extends to clinical duties; it does not dictate where you are on your own time. If I want to check out my clinical duties and stay with a patient's family that's my business, I just can't perform any clinical functions. The biggest problem with these policies is that they have led to more hand-offs, and I can see from our M&Ms that many sentinel events start there. The other problem everyone has failed to mention is that the policy leads to fewer residents on service at a time, covering far more patients; and that is the other cause of sentinel events I see. Don't get me wrong, I like being out of the hospital and spending time with my family. But when I'm at the hospital I cover way more patients than my attendings did when they were residents, and that is what makes me most uncomfortable. With so many patients it is easy to have 3 or 4 unstable at once, and we don't have the support in house to cover that. The extra work also makes teaching team greatly diminished; we don't talk about the disease process in every patient, we just have to pick 1 or 2 interesting ones and hammer through the others superficially. The older attendings tell us it wasn't always thus; they used to have 6-8 total patients on rounds and would discuss the pathophysiologic process in all of them extensively. We treat many more patients, but the teaching is much more superficial. Example: fewer patients covered in the unit (2-4 as opposed to 6-10) but much more detailed teaching.
Anon 9:16
You make me think back and open my eyes to an aspect of this I had not previously considered. It isn’t just, or I think even primarily the detailed teaching on rounds that make the internship and residency. It is the detailed teaching by patients. We worked very very long hours as interns, but not all of it running around to attend dozens of patients. I spent more than a few nights spending several hours at the bedside of one unstable patient. I learned a lot about clinical processes as well as the emotional process of dying sitting for hours at the bedside of a single patient titrating morphine and lasix (always in the wee hours).
With a larger service, I would not have that experience which is the core of my clinical instincts today.
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