Scenario 1: you arrive in the emergency room of your local academic teaching hospital at 5 am with what is most likely a case of appendicitis. After being seen by the emergency room physician and several ER nurses, you are shuttled off for a CT scan which reveals the suspected appendicitis. The surgical resident is called and comes to see you at the bedside in the ER. He/she walks into the room to great you, and you can’t help but wonder based on his/her appearance just how long the resident has been awake. By this point, it is now 6:30am, and this surgical resident, who will likely being assisting the surgery attending in removing your appendix, has been awake since 5am the day prior. You are taken to the operating room, your appendix is removed, and then you move off to recovery. The surgical resident finally leaves the hospital around 11 am.
Scenario 2: you are boarding a plane at 6:30am from Boston to San Francisco. Your pilot has been awake and flying since 6:30am the day prior. Boarding completed, the plane takes off on the long journey to San Francisco. 6 hours later, you land in San Francisco. The pilot finally goes home around 12:30pm.
If you’re sitting here thinking that both of these scenarios sound ludicrous, I’m here to tell you that while we would never imagine the second scenario happening – the first one is all too common. A recent article in the Wall Street Journal asks whether medical residents should be required to work shorter shifts, acknowledging the brutal work schedule that medical trainees are subjected to. Currently, residents in training are prohibited from working more than 320 hours in a four week period, which averages out to 80 hours a week. Residents may not work more than 24 hours consecutively but are allowed a 4 hour window for “completing patient care duties”. Residents are required to have 10 hours off in between shifts. First year residents (interns) are not allowed to work more than 16 hours in a row.
There are critics on both sides of this debate – as evidenced by the opposing viewpoints in the article. Some point to the fact that increased fatigue leads to increasing mistakes. And unlike many other professions, mistakes in medicine can be fatal. Additionally, since residents are responsible for reporting duty hours, inaccurate reporting in order to comply with regulations is believed to be rampant. On the other hand, many physicians who trained in an era of no work hour restrictions worry that residents are missing out on educational opportunities by having to “keep an eye on the clock”, potentially turning down learning experiences in order to follow the rules. They point out that the brutal work hours prepare residents for the days when they will be in charge. Furthermore, reduced work hours will lead to an increased number of “hand-offs” – moments where one resident hands over patient care responsibilities to the next resident taking over and potentially critical communication failures can occur.
This all begs the question – is there a “sweet spot”? Is there a point where enough education can be gained without compromising patient care and more importantly patient safety? The bottom line is that residents must gain enough experience to be able to safely care for patients, and that experience only comes from doing the work. However, how much work is too much? Think about the next time you board a plane…
It is against the law for nurses to work over 16 hours in a row. Fatigue leads to errors. How much learning can be gleaned if the learner is sleep deprived. It is also incredibly detrimental to his/her own health. Kind of ironic. Hours should be limited for the benefit of patient and practitioner!
Reblogged this on Students for Quality Health Care and commented:
are we improving patient quality and safety by reducing resident work hours or potentially eliminating learning opportunities to gain experience in providing safe and quality care?
I think a discussion of work hours is missing a really big issue. That issue is teamwork. The medical world has changed – hospitalists on shifts take care of huge numbers of patients. So, it’s not how long you work but how well the team functions. Unfortunately, current deans and administrators are not up to date on this paradigm shift. The discussion is how to operate as a team without individuals making errors due to fatigue. It is an error of incredible proportions for a physician to try to practice like they did back when “giants walked the wards”! Students and residents need training for effective teamwork and the training program should set the example. Physicians who can’t function in a team should switch to some specialty without patient care responsibilities — in my not so humble opinion!