IOM Calls for Further Resident Work-hours Restrictions

Anyone who has read my blog has read many rants and whines about residency and fellowship training.

This month, the Institute of Medicine released a report on Resident Duty Hours: Enhancing Sleep, Supervision and Safety basically stating that more revisions to medical resident’s workloads are needed. Apparently, the last revisions in 2003 which did drastically cut down on resident work-hours have not done enough to prevent fatigue on the job that lead to medical errors.

Hmmm! Let’s review. Start from understanding that prior to 2002, residents in the US routinely worked 100 – 120 or more hours per week, and were on call every other night (q2).

The 2003 ACGME rules now in effect:
1. Maximum hours of work per week not to exceed 80 hours per week averaged over a month

1. Maximum length of a shift not to exceed 30 hours (24 hours of admitting patients, 6 hours of other activities such as attending lectures, rounding, seeing patients in clinic, etc)
2. Maximum call schedule of q3, every third night, on average
3. Minimum time off between shifts of 10 hours
4. Mandatory time off duty of 4 days/month, ie. 1 day/wk averaged over a month
5. Internal moonlighting hours fall under 80 hour work-week

IOM’s suggestions:
Keep everything else, except –

1. Maximum length of shift not to exceed 16 hours; however can have a 30 hour shift if there’s a 5-hour protected time for sleep. (I would like to see that happen! Imagine physically being in the hospital and the nurse not paging you. sarcasm)
2. Maximum call schedule of q3, every third night, without averaging
3. Minimum time off between shifts: 10 hours after day shift, 12 hours after night shift, 14 hours after 30 hour shift
4. Maximum frequency of night shifts of four nights in a row, with 2 nights off (hmm, that would dramatically change night-float as I know it)
5. Mandatory time off duty of 5 days off per month; 1 day off per week no averaging, and one 48 hour period off per month. (Oh, my goodness, that would get rid of black weekends and ensure a golden weekend for everyone each month! Having a full weekend off makes all the difference)
6. Both internal and external moonlighting fall under work-hours

I am a product of the 2003 work hours. I have complained of the many insane hours I have had to work. So I should be pleased by IOM’s suggestions, right? But I can’t help but think that further reductions in the hours residents work would decrease our competency in providing patient care. A part of me says the most logical thing to do is to cut down the work-hours to something reasonable (ie. not 80 hour weeks) and increase length of time to complete residency.

However, a lot of us have already spent many years delaying emotional and financial gratification. Most of us will be well in our 30s before we are done with our training assuming we took no breaks along the way. A bigger part of me would be overwhelmed by the thought of prolonged medical training. Another year, or two, or three of loans in deferment, of barely there stipends, of deferred contributions to retirement plans, and of going to my parents for handouts? I don’t think I could handle it.

But, you can’t work less hours and expect to learn all there is to learn. You can’t just punch in and out like everyone else and say “Well it’s 5 pm! Got to run” and leave your work for someone else to complete. Or can you? Is my mentality wrong?

When I was a resident, we would work side by side with PAs (physician assistants) on the cardiac service who would routinely come up to us at quarter to five to sign out the troponin that was pending on the patient with chest pain, or the chest x-ray for a central line just placed, or a page from the ER still waiting to be answered.

The PAs could not understand why the resident would get upset at the signed out work. My generation of medical residents still believe that we should make sure that the troponin was normal, check that chest x-ray and pull the line back as necessary, or field the ER call before signing out our patients, even if that meant spending an extra 30-45 minutes in the hospital. Completeness. Follow-through. Understand the pathophysiology of your patient’s illness from beginning to end. Evaluate the effects of actions taken and of decisions you have made. So, is this mentality old-school?

I’m not afraid to say it. I marvel at the physical examination and history taking skills of the older physicians because we don’t get time to spend with patients like that. Nope, it’s paperwork here, paperwork there, consult this, consult that, and get an interventionist to do the procedure. CYA medicine! I receive sign-out or consults from current interns and residents and wonder if anyone actually knows what’s going on with their patient. Signout is atrocious and sometimes very painful to hear. Everybody “is just covering”.  One should always check the patient, get a history, and review the data oneself, true, but today, you truly cannot rely on an intern or resident’s synopsis as a backbone when you go in to see a patient. And patients just l-o-v-e i-t when you as the 20th doctor they are seeing ask them for history. Sorry patients!

Day-float, night-float, clinic coverage, emergency back-up and other assignments abound at residency programs throughout the US just to try to comply with the 2003 ACGME work rules. I doubt most programs are actually in compliance. My residency program was actually humane and yet there were many times somebody violated the work-hour rules. Hush hush! Just covering. Ownership. There is none today. And we are going to be the future leaders in medicine? Will we really be equipped when the time comes?