As I get near the completion of an intense 5-year orthopedic surgery residency program, I had an interesting interaction with our hospitals sub-committee specifically tasked to address duty hour and resident fatigue issues.
As they gave examples from other departments about changes made to their programs regarding duty hours, a clear-as-mud connection was continually made. They spoke of “improvements” made as the result of residents stepping up to serve as whistleblowers in identifying duty hour violations within various programs. I quickly chimed in to get clarification. They were assuming that increasing compliance with duty hour restrictions set forth by the Accreditation Council for Graduate Medical Education (ACGME) meant an improvement in the residency program that went beyond improved compliance. It made me reflect on the last five years of my residency training. I asked myself, “How many times have duty hour restrictions helped me?” The answer is many.
Being in the first year group where PGY-1 residents (also known as interns) were specifically restricted to 16-hour workdays resulted in my not having to cover grueling 24 hour-plus call in the trauma and burn intensive care units, the general surgery department, or any other off-service rotation that was of minimal interest to me. I spent, at least, part of every single day of my intern year home with my wife. I had time to help train our new golden retriever puppy. It was great. A much different intern experience than that documented in the medical training cult classics such as the House of God and Intern Blues.
In later years of my training, our weekend work schedule was changed where unless you were on call, you would just sign out your services inpatients to the call team and they would see your patients over the weekend. Now I also have most of my weekends to myself. Sweet.
Then I asked myself: “How many times have duty hour restrictions helped me become a better orthopedic surgeon?” That was a much more difficult question to answer. In fact, I could not think of one specific situation where being well-rested from having the mandatory 8 hours between work days or being happy that I didn’t have to work the weekend or handing off a patient that I took care of all night so that he was now someone else’s responsibility made me a better orthopedic surgeon. I am a happier orthopedic surgery resident, and with all the talk these days about physician burnout maybe that’s something. But that is not what the duty hour restriction is all about.
Time for a history lesson.
In 1984, a woman named Libby Zion presented to a New York teaching hospital emergency room. She was taking an antidepressant prescribed by her primary care doctor. She became agitated, was given a medication that was found out later to have a deadly interaction with the medication she was taking, resulting in her tragic demise. Her father, a prominent newspaper editor at the time, launched an investigation that became known as the Bell Commission. The conclusion was that residents who were working long hours and not directly supervised had been the cause of Libby Zion’s death. The interaction of the medications she was given was not widely known at the time, and the residents had been in contact with her primary care doctor about her treatment plan, which was customary at the time.
However, it was a very high-profile case that resulted in New York being the first state to enact work hour restrictions on residents. Other places followed, and it is now the standard for all American training programs. All under the assumption that restricting residents work hours results in safer patient care. I think the truth is something more like, “Residents who are appropriately supervised and not overly fatigued provide the best combination of safe patient care while continuing to gain valuable clinical experience.”
We have learned a few things since the ACGME instituted duty hour restrictions in 2003, and further restricted in 2011. Duty hour restrictions result in more patient handoffs and happier residents. Luckily the Flexibility in Duty Hour Restrictions for Surgical Trainees (FIRST) trial recently remonstrated that the frequent patient handoffs have not caused harm to patients, which was something feared by many of the opponents to duty hour restrictions.
So, as a resident who has enjoyed the benefits of the duty hour restrictions with no tangible evidence that a patient has been harmed and the overall feeling at the end of my training that my surgical education was adequate to be a safe, effective orthopedic surgeon, why am I so against the concept? The truth is, I’m not. Kind of. I’ll elaborate.
Medicine is a profession. Some, including my program director, refer to it as a calling. I think that this is mostly true. Many of us made the great sacrifices necessary to become physicians and surgeons because we feel that we have a responsibility to use the knowledge and skills we have acquired to help people. Therefore, it just doesn’t feel right when we are told that we can only help people for 16 hours then we have to go home. Or we can help people for 24 hours then spend the next 4 hours transitioning care to the next team, then we have to go home. Or we can help people, but you have to be out of the hospital for 8 hours before you can come back to continue helping people, but that’s if you worked 16 hours. If you worked 24 hours, you have to have 14 hours at home before you can come back to help people.
It actually sounds crazy when you think of it in that way. By forcing residents into working shifts, they may begin to watch the clock, waiting to pass off complex problems to the next person. I’ve seen it. Emergency room doctors don’t see patients that come in at the end of their shift and just wait to pass it off to the next shift, delaying patient care. An anesthesiologist prevents you from adding a case towards the end of the day because the day shift is leaving and the night shift can only run a fraction of the number of operating rooms, so you wait to do cases in the middle of the night. And even in orthopedics, a resident may be slow to work up a potentially operative case because they know they will be forced to go home and not get to do the case, so they just pass it off to the next guy. I’ve seen all these scenarios happen, and they are all the result of the new clockwatching culture being mandated by the ACGME.
So, what do I propose as the solution? Lighten up, ACGME! The FIRST trial made the case that increased patient handoffs don’t necessarily hurt surgical patients. That’s a win for you. It also suggested that when giving programs and residents the opportunity to stay late past the prescribed daily hour restrictions, residents were more satisfied with continuity of care and handoffs. And they all still managed to comply with the 80-hour week restriction.
Therefore, if a resident wants to work 35 hours one day so he can be a part of an educationally valuable case, let them. If an intern wants to work 20 hours one day so they can examine a patient one more time to get experience on how a compartment syndrome can evolve, let them. They will benefit from the experience, and their future patients will benefit from having a doctor who knows what will happen, because they were there to see it.
The hospital subcommittee that came to my program acknowledged that violations of the 80-hour rule were not the main problems that were faced. The majority of violations were related to the daily hour restrictions. Restrictions that the FIRST trial has suggested may be unnecessary. I fear that improvements will be sought after that focus more on compliance than the real improvements in patient safety, outcomes, and quality of education that we all seek. It is time to refocus our efforts and remember why we are all here in the first place.
The author is an anonymous orthopedic surgery resident.
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