The debate over how many hours an intern can work misses the point

I still don’t know how I did it.  I don’t know how I got through life as a lower-level neurosurgery resident.  I vividly remember the horrific call nights and weekends.  There are certain sensations you get when you have gone weeks without more than two or three hours of sleep at a time.  It wasn’t the foggy thoughts that bothered me most, or continually feeling cold, or even when I eventually lost the ability to feel human emotions.  It was the perpetual feeling of sand in my eyes.  It’s a scratchy, irritating reminder of just how awful your life has become.  I remember feeling drunk from lack of sleep, struggling just to get home without passing out only to stumble through the door, hit the couch and have my pager erupt in a cacophony loud enough to wake the dead (which I nearly was).

“Doctor, you ordered IV medications on this new patient …”

“Yes?”

“Well, he doesn’t have an IV.”

“OK, can you place one?”

“I need an order for that.”

“Will you take a verbal order?”

“I’m sorry, I can’t.”

My old home computer and basic cable Internet takes me, on average, six minutes to start up, log in to the hospital server, then log in to the hospital electronic medical record (EMR) and place that order.  A nurse is a licensed medical professional, yet our hospital forbids that nurse from placing an IV without an explicit order from a physician.  Not only that, our hospital forbids the nurse from taking a verbal order for it.  The likely overworked nurse is not being negligent, lazy or malignant.  The nurse simply exists in an institution that has placed the ultimate workload on the residents.  I try to nap afterwards but the cycle continues, never allowing me to reach stage 4 sleep.  “Can you put an order in for Tylenol?”  “Can you re-order the restraints?” “The patient’s pain medications expired.”  “Do you REALLY need that MRI you ordered?”  The sand is still in my eyes …

The ACGME (Accreditation Council for Graduate Medical Education, the governing body for medical residencies) originally placed limits on resident work hours in 2003 as a patient safety initiative.  These limits are 80-hours per week and no more than 28 straight hours.  Then, in 2010, the ACGME further restricted hours on interns, limiting them to 16 hours straight. However, after much research has failed to show a positive effect on patient safety or resident well-being, the ACGME decided to go back to the way things were before 2010.  This has led to much uproar.  However, what the loudest opponents of the proposed rule change have failed to mention, is that the ACGME is actually getting more stringent with its work hour limits, not less.  Despite the experiences I described above, I was able to log my hours honestly without ever receiving a violation.

In its 2017-2018 update, along with allowing interns to work the same hours as all other residents, the ACGME also focuses on resident well-being.  The term “duty hours” has been replaced by “clinical and educational work hours.”  This includes all in-house time spent on patient care and education as well as any “at-home” time spent on patient care.  The inclusion of time spent on patient care from home is new, and represents a much more restrictive limit.

Many programs rely on home-call to avoid going over the 80-hour weekly limit.  Generally, smaller subspecialty programs that cover multiple hospitals simply don’t have the manpower to dedicate a resident to in-house call.  A survey showed that over 90 percent of plastic surgery residents believed their program could not function without home-call.  The same percentage also stated they preferred it to in-house call.  Our program, one of two neurosurgery programs in the city, covers two hospitals with nine total residents.  In-house call is simply not possible with our manpower.

However, the ACGME knows that most residents have home-call experiences like the ones I experienced as a lower level resident.  Home-call does not mean restful call.  Another study showed that ENT residents received, on average, 7 calls a night.  In researching data at our institution and just looking at one of the two hospitals we cover, our neurosurgery service receives ten calls per day outside of normal working hours.  In addition, the study found that 78 percent of their calls were non-urgent.  We didn’t look at urgency (although a vast majority of our calls could have waited until morning as well), but found that 10 percent of our calls were simply because of inefficiencies built into the hospital system, such as not allowing a nurse to place an IV without an order.

Additionally, the ACGME update forbids institutions from relying on residents to perform non-physician tasks.  Residents, a cheap source of labor, often play the role of scheduler, patient transport, social worker, lab technician and so on.  Hospitals receive money from Medicare and Medicaid to teach residents, so from a hospital standpoint, this represents very inexpensive manpower.  I remember calculating out my hourly wage as a second-year resident — barely over $9 per hour.  Replacing resident hours with a midlevel provider (nurse practitioner or physician assistant) would cost these institutions substantially more.

However, The ACGME thinks hospitals should make those capital investments.  They are advocating for improving residents’ quality of work hours, not just decreasing the quantity.  Midlevel providers have been shown to increase residents reaching educational goals and improved resident well-being.  A simple solution such as the addition of scribes to help with documentation not only increases clinician satisfaction, but it makes patients happier and actually increases patients seen per hour and the amount billable per patient for the hospital.

I agree that no physician should work 30 straight hours.  However, that is not always feasible.  Patient care comes first and foremost.  If I need to be up all night to take care of a sick patient with a brain hemorrhage, I’m fine with that.  My residency training has prepared me for it.  However, if I’m up all night getting phone calls about fixing an order in our EMR, reconciling the MAR when it was already done or driving in to sign a form that could wait until morning, I’m not OK with that.  The ACGME is not OK with that either.  After we graduate, there will be no governing body ensuring we get adequate sleep between phone calls.

The ultimate goal of the ACGME and the academic medical community shouldn’t be to keep residents from working an arbitrary number of hours in a row.  It should be to optimally educate the next generation of physicians in patient care, responsibility, and dedication without burning out those same individuals.  In order to do so, the work environment needs to allow residents to focus on patient care and education, not treat them as a source of cheap labor.  Institutional guidelines need to be implemented to minimize resident interruptions when they are on call.  Physician extenders need to be hired to take the burden of non-physician work off residents.

The debate over how many hours an intern can work misses the point.  Residents and nurses are the front-line employees at any teaching hospital.  Nurses don’t want to bug a resident for an IV order any more than a resident wants to be obligated to put that order in.  This is just one example of a gross inefficiency in the system.  Inefficiencies like this would not be tolerated in any private industry.  Residents and nurses should have clear and constant channels of communication between administration and clinical informatics (the group that programs the ubiquitous electronic medical record).  This will help identify the root causes to problems and decrease inefficiencies.   This will not only lead to increased resident wellness, but also improve overall patient care.  This is the ultimate goal of our profession.

Raymond Oliver is a neurosurgeon.

Image credit: Shutterstock.com

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