Residency Work-Hour Reform: Is this progress?

Thanks to Dr. Happy, I found MedSchoolHell's mention of an upcoming IOM proposal to reduce resident work-hours from 80 to 56 hours per week.

I have mixed feelings about the proposal. On one hand, when the original movement to reduce resident work-hours was proposed, I was all for the change. 

At that time, there were essentially no controls over how many hours a resident could work. Under a classic q3 call schedule (overnight call every third night), a resident could easily be expected to work 105 hours per week, if not more. A sample schedule might look like this:

• Mon: Round for 12 hours on inpatient service
• Tue: Round for 12 hours on inpatient service
• Wed: Round for 12 hours, in-house call all night until...
• Thu: ...the following day, then resume rounding for 12 hours
• Fri: Round for 12 hours on inpatient service
• Sat: Round for 12 hours on inpatient service
• Sun: Round for 12 hours, in-house call all night until...
• Mon: ...the start of another week

This is a grueling schedule for anyone, and all of us who have trained under such a system will remember what a few months of this kind of schedule does to our spirits. In medical school I used to cry in the car on the way home from a long day of rounding, and not know why. I remember feeling numbed by fatigue, although I never achieved a state of indifference toward human suffering that I've heard results in some training programs.

So I was in favor of work-hour reform to 80 hours per week, which sounds like a lot of hours but breaks down to a schedule like this:

• Monday: Round for 12 hours on inpatient service. Night float takes call.
• Tuesday: Same
• Wednesday: Same
• Thursday: Same
• Friday: Round for 12 hours on inpatient service. In-house call until...
• Saturday: ...when you round for 6 hours on inpatient service, then sign out
• Sunday: Round for 12 hours on inpatient service. Night float takes call.

This is how we scheduled our days during my residency. (It actually adds up to a 90-hour work week, but the work-hour regulations are based on an average number of hours worked per week, over a four-week period, so on those weeks when a resident actually gets a weekend off, they would only work 60 hours and this would offset the long week outlined above.)

The 80-hour work week is hard work but at least gives residents several evenings off during the week to feel almost like normal people. Certainly, this kind of schedule would not be sustainable for a lifetime but at least it eliminated the 36-hour shifts the old q3 call schedule involved.

Now, I have no idea how the new guidelines arrived at a 56-hour work week, but I suspect it is based on 4 eight-hour days and one 24-hour call day. For example:

• Mon: Round for 8 hours
• Tue: Round for 8 hours
• Wed: Round for 8 hours
• Thu: Round for 8 hours
• Fri: Round for 8 hours, take call until the following morning
• Sat: Off after call
• Sun: Off

It looks like a good schedule, doesn't it? The problem is that I don't believe it is possible for a hospital to staff such a schedule unless they have three shifts of housestaff for each inpatient service (surgery, medicine, pediatrics). For example:

• A shift: Rounds 7am-3pm
• B shift: Rounds/admits 3pm-11pm
• C shift: Admits/cross-covers 11pm-7am

Now, assuming most services require at least two housestaff to be present during the day, and one at night, you'd have to be able to staff five housestaff per rotation per service every calendar day. Effectively, you'd have to increase the size of every residency by 33-50% in order to meet these staffing needs. You would also have to lengthen the duration of a residency in order to make up for the shortfall in total inpatient hours--apparently extending the duration of residency training is part of the assumptions underlying the 80- to 56-hour reduction.  (Hm, that's where you might get a few more residents to staff the three-shift scenario.)

The other problem is that the three-shift system requires three sign-outs every day, instead of one under the old systems. Sign-out refers to the process of communication between the incoming and outgoing medical teams. Information on every patient on the team's service is distilled and relayed between day and night teams, usually by some combination of computer database and in-person report. Any time information is transferred from one agent to another is a highly vulnerable point in any system. Miscommunications occur and errors sneak into the system; physician sign-out is no exception. The prospect of tripling the opportunity for communication error in a three-shift resident work-hour scenario is truly terrifying.

Finally, I agree with old-school physicians when they argue that keeping long hours during residency imposes rigor and discipline on a profession which does not close shop at 5pm. I am not in favor of returning to 36-hour shifts, but I believe the middle-ground solution of 80 hours per week balances out the humanizing influence of time off against the reality of life in medicine. That reality sometimes involves making grim decisions at 2 o'clock in the morning, when you haven't slept in 20 hours. It is true that the decision made at 2am might not be as well thought-out as the same decision made at 10am the next day, but that's why I routinely sit down at a computer and look things up when I'm forced to make these 2am decisions. Doing so makes me discipline my weary thought process. However, if I had not gotten accustomed to making wee-small-hour decisions during my residency, I don't think I would be able to make them now.

Don't get me wrong:  I want to protect residents' work-hours.  We all benefit from having doctors who are well-rested.  But I also want to protect the rigor of our profession.  Nobody goes into medicine to have a 4-hour work day.  Ask any working physician; we regularly put in 10-12 hour days and some of us are still on call all night.  Preparation for working long hours, and making tough decisions during those hours, must begin during residency.

Comments

[allergist]

I totally agree with what you've post here.Its true that lots of hospital don't have good napping facilities.

-Kaylee

[Theresa]

I'm not surprised. A 56-hour workweek isn't feasible unless you prolong residency durations, and nobody wants to spend 4 years in internal medicine, etc. Thanks for stopping by.

I'm a proponent of naps. Unfortunately, a lot of hospitals don't have good napping facilities (like mine)...

[Chris]

That Medschoolhell post was interesting. I looked into it, too. It actually DOESN'T look like 56 hours is coming. Instead, there's at least one person who wants to mandate naps.

I wrote about it here.

http://www.cleveland.com/medical/index.ssf/2008/05/residents_expecting_to_work_fe.html

[Theresa]

LOL! Couldn't have said it better myself! Sounds like the kind of lecture I used to give to interns when I was Chief Resident....

[Mark's Tails]

Rural Doc I wholeheartedly agree so my little rant below is not directed at you.

Seriously!? you are a physician for crying out loud, you do not have a nine to five job unless your in Dermatology or an Allergist, I can say that because I am an Allergist. My colleagues whom I did Pulmonary/CCM training with worked much harder and longer hours in private practice than they did during residency or fellowship. I have to wonder how this will effect the 'work ethic' of people coming out of training and going into practice.

"I'm sorry Ms. Peel but the doctor is no longer in the hospital to take care of your crushing substernal chestpain, he will be back at 9am tomorrow morning."

I'm not saying we need to maintain the whole 'rite of passage' thing but 56 hours? Personally I would rather be cared for by a tired doctor who has the ability and character to balance his/her life for the 3-5 years it takes to go through a residency working 80 or more hours a week than the well-rested, can't stay for rounds because my times up, sissy pants that may be coming down the pike.

Ummm, I'll stop there, Thanks.