The restrictions on resident work-hours arguably most impacts the field of surgery.
I understand that fatigue increases the risk of medical errors, but in this excellent post, Jeffrey Parks notes some benefits of being immersed in the hospital. Something is lost as doctors are scuttled out of the hospital when the 81st hour starts.
Dr. Parks notes that “there’s more to being a doctor/surgeon than just learning how to fix a hernia or run a code. There’s a mindset that has to take hold . . . one’s immersion into the totality of hospital life as a trainee leaves a lifelong mark.”
He then draws parallels to other fields: “Imagine the military without basic training. Football without two a days in the July heat. Medical school without the grueling second year of no sunlight and 10 hour library sessions. A lot of guys can throw a nice tight spiral on the practice field, but that’s not what makes a great quarterback. It’s the guy who can make the clutch throws late in the game when he’s exhausted, banged up, and all the pressure is on his shoulders.”
As I’ve mentioned before, I certainly don’t want tired doctors operating on patients. But a vital part of physician training is lost when hours are capped. Lengthening the course of residency by a year or two seems to be the only reasonable compromise.
Related posts:
- Surgeons don’t receive enough training when resident work-hours are capped
- How work-hour restrictions harms resident surgeon training
- Restricting resident work hours forces doctors to lie, and other unintended consequences of the 80-hour work week
- The steep price of restricting resident work-hours
- Restricting resident work hours leads to a shortage of surgeons
- Resident work hours: An alternative view
- Poll: Is further reducing resident work hours worth the cost?
{ 14 comments… read them below or add one }
Lengthen their residency and pay them less. Where do I get to sign up for that one.
I agree with the soldier analogy (not so much with the one of the football player as they do not have human lives on their hands), but I like to compare doctor better with airline pilots instead. They also have a great big responsibility, with human lives depending on them, they need training, schemes, checklists, continuing education and approval from committees based on regular evaluations, and any error during flight is recorded and analyzed until they make sure it won´t happen again… and BTW, they should not be allowed to fly more than a limited time of hours (i.e., if they are exhausted) as commented in this post ( http://www.consumertraveler.com/today/tired-pilots ) . It is difficult to prove that adequate rest and limit hours of pilots saves lives, but this is because the outcome is very rare (accidents). The same applies in the health professions?
Lol @Jenga!
The solution lies in abandoning medical school and signing up for nurse practitioner surgery school
You won’t have any problem with tired doctors. You’ll have refreshed NPs ready to tackle the surgery of the day.
You people are baffling. Your job is to help patients not act out some weird ritual of professional bonding and initiation.
Some evidence says that shorter works hours hurt patients.
You speculate that shorter hours makes less competent doctors, but you cite no evidence.
You argue for shorter hours.
I think you are either illogical or care more for the mystique of your profession than patients.
OOPS. I meants “Some evidence says LONGER work hours hurt patients.”
This topic is one that will always generate emotion more than it ever will bring about debate based on facts. Dr. Parks proved this in his Oct 7, 2009 post In Defense of Scut. But as I pointed out in my comment on his blog, it serves no purpose to argue that scut is good or bad. Quite frankly, it is no longer tolerable and it is our mission as educators to find a better and more efficient means to create doctors better than ourselves.
The American College of Surgeons is keenly aware of the challenges that lie ahead in surgical education and its leadership is engaged in looking for improved models by which we will build our future surgical profession (I have no direct ties with the ACS, and I am only speaking from peripheral observation.).
I will leave you with my life experiences concerning scut and such. First, I began my adult career in the Army, as an enlisted soldier, serving as a cavalry scout. My basic training was during the summer in Fort Knox, KY. I might simply tell you that many of my drill sergeants were reportedly dismissed for trainee abuse after my training was over. I later met many soldiers that graduated from basic and AIT who did not go through the same rigors that I experienced. To my amazement, they turned out to be great soldiers. Our military continues to find better ways to train our soldiers without the abuse that I experienced. We continue to field the best fighting force in the world.
I also went through surgical training that included every other night call. The program was technically pyramidal (more categorical residents entered than were graduated). Neither of these truths remain. Yet, the graduates from that program continue to be excellent.
Finally, the current residents that I train have none of the scut missions that I had. However, I absolutely am sure that many of them will be much better surgeons than I will ever be, because we are absolutely focused and committed to their education.
While scut may indeed have had many merits, it does not mean that there isn’t a better way to train surgeons. It is our responsibility to find a better way. It will not mean lengthening the training. I suspect that the college will change the training such that surgeons follow more specialized pathways. It may mean that there will be fewer “general” surgeons. But it appears that this is already the case.
JFS
Very impressive Dr. Sucher! This is the type of thinking that we need much more of. Luckily, some programs are starting to tackle this approach
Thanks for the insightful comments.
The key to the discussion is what is meant by scut and the definition of the word “is.”
I had the privilege to work in several academic hospitals as a trainee. In one such hospital, the residents did doctor work. We took histories, did exams, got collateral information, talked to families, interpreted tests, did procedures etc. We worked a bit over the work hours, but that was against the believable stipulations of the administration. We loved our job and what we were doing. We learned a lot and were appreciated. In return we appreciated doing the work and if we need a break, we got it.
Another academic center I worked at used the residents as slave labor in order to keep from paying for appropriate ancillary services such as nursing, receptionists, clerks, phlebotomy, etc. We spent most of our time (>50%) doing non-doctor-scut like calling outside facilities to get records that were “forgotten” on transfer, scheduling scans (ACGME violation), placing NGTs, pulling lines, drawing blood, etc. Teaching was minimal because there wasn’t time. Learning was non-existent because there wasn’t time.
As an internist, I learned so much at the first institution and very little at the second. I would venture that the same would be similar for surgery residents. If that 80 hours is spent in the OR, I bet the learning time would be adequate. At the first institution I mentioned, I rotated as an M3 and the R1s were in the OR from day 1 doing several surgeries a day. At the second institution I mentioned, the R1s hardly ever see the OR.
80 hours is a lot of time. What the residents are actually allowed to do during that time will have a huge impact as to if it is “enough” in order for them to become good physicians. I would guess that in well run institutions that see their mission as training good physicians, it will be more than adequate, while those that see residents as cheap labor will go on lamenting that the work hours are limiting good education.
As a former Army combat engineer (Ft. L, MO), I agree with JFS re: military training.
Nuclear fire: Nicely put.
I think the limit should be different for different fields. I do agree that surgeons need the 80+ hrs to be competent, but other non-procedure fields do not need the 80 hours of work. I don’t mind if the surgery residents are paid more, since their life style is harder.
A medicine resident does not learn anything more by admitting 50 vs 100 patients with a particular illness.
Thanks.
What does a surgeon learn in the 51st lap chole that is much more complex and requires longer work hours than in internist learns in the 50th case of rapid afib?
Honest question since the complications of disease management is what requires long hours of training. Are the complications of a lap chole somehow more complicated educationally than the complications of say sepsis or CHF or pneumonia or acute renal failure?
When a surgical complication fails medically, the surgeon calls the medical doctors. When a medical complication fails surgically, the medical doctor calls a surgeon.
So what is the basis for the requirement for longer work hours for a surgeon?
Dr. Parks hits the mark in his post “In defense of Scut”, he writes: “there’s more to being a doctor/surgeon than just learning how to fix a hernia or run a code. There’s a mindset that has to take hold. Call it indoctrination if you like but it’s a process that attempts to transform a self-satisfied, smug, well-educated medical student (I certainly fell into that category) into the sort of selfless, compassionate, dedicated, thorough, and mindful physician that we all deserve”. The hospital was the crucible of transformation Dr. Parks writes about in his blog. In all the eloquent comments above in defense of capped hours I can not find any mention of a realistic substitute for hospital hours”. Extended residencies? Narrower scope? Madness born of the feminization of medicine.
Dr. Parks and Dr. Christophil are the epitome of our inefficient medical system. You were born into a system of inefficiencies, you are now breeding it, and now you want to continue with the same inefficient ways.
The mindset you speak of is not developed through workload. Compassion is a quality that some have and some don’t. It certainly is not cultivated through scut work.
Working hard is a must, but we have to learn to become more efficient teachers.
@ m. blackmer
- you write “Working hard is a must, but we have to learn to become more efficient teachers”. Your platitudes are hollow. How would you make teaching more efficient?
-Interesting that you focus on compassion-a feminine trait- which is but one of the qualities gained through hospital immersion. You make my case for me. Medicine has been feminized.