Wednesday, May 29, 2013

ED MD wants residency hours capped at 40 per week

Blogging at his site "Adventures in Emergency Medicine," Dr. Sam Ko says resident work hours should be limited to 40 per week. Via Twitter, I warned him that I would rebut his assertion.

Without any data or references except a tangential one, he bases his opinion on four premises.

1. Residents will be happier and nicer to patients because they will be less stressed. There is no proof that this is so. In fact, a recent paper in JAMA Surgery says about one-third of interns who work a maximum of 16 hours per day "demonstrated weekly symptoms of emotional exhaustion (28%) or depersonalization (28%) or reported that their personal-professional balance was either “very poor” or “not great” (32%)." And "at the end of their intern year, 44% [of interns] said they did not believe that the work hours limits led to reduced fatigue." This is not a very resounding confirmation of the theory that reduced work hours leads to happier or better rested residents.

2. "But we did it so you have to do it to." Under this heading, Dr. Ko says, "We are busier than they were 20-30 years ago. Before they probably got more sleep and had less patients in the hospital."

With the exceptions of more paperwork and the burden of the electronic medical record, I'm not so sure residents are busier today, but if they are, what's making them busier is REDUCED WORK HOURS. This recent paper from JAMA Internal Medicine concluded the following: "Compared with a 2003-compliant model, two 2011 duty hour regulation–compliant models were associated with increased sleep duration during the on-call period and with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care." [Emphasis in bold added]

The supposition that there were fewer patients in the hospital 30 years ago is incorrect. When I was a resident over 30 years ago, cholecystectomy patients stayed in the hospital for 4 to 6 days. Even herniorrhaphies stayed 1 or 2 nights. Day surgery was in its infancy. Patients could be admitted for workups which are now done as outpatients. These people all needed H&Ps, had to be rounded on daily and notes had to be written. We had to draw routine and stat bloodwork and start IVs ourselves, we often transported patients to radiology and the OR. I could go on.

Dr. Ko is right about one thing. We did get more sleep when we were on call because we weren't cross-covering many patients that we didn't know very well. The abomination known as "night float" did not exist.

3. Residents won't get enough training. Dr. Ko dismisses this objection by pointing out that menial tasks should be delegated to others. But who are those others, and how will they be funded? In addition to the bolded portion of the sentence at the end of the paragraph above, here's another paper (of many such papers) documenting that many residents are already being poorly trained. And Dr. Ko wants to cut hours by half.

4. Less depression, anxiety and alcohol/drug abuse. He cites a statistic that 300-400 physicians commit suicide very year. That may be true, but there is no proof that decreasing work hours will alleviate that problem. Most papers on the subject seem to indicate that suicide is a problem of physicians who have completed training and are in practice. Did I mention that there are no work hours limits for doctors who are in practice?

Being a doctor is a stressful job. Sleep, or its lack, is not the only factor causing stress. Limiting resident training to 40 hours per week would be a catastrophe for residents, their education and most of all, their patients.


Anonymous said...

Im an attending in my third year of practice as a general surgeon in a rural community. You know what makes me depressed and anxious? Not knowing what to do with a sick patient or doubting my technical ability to do an operation.

I trained in the 80 hour work week. Imperfect, sure, but I left residency confident in my abilities and have never regretted the time I spent in residency, training under people with high standards and high expectations for me. Exhaustion is a real issue when people are working a lot of hours a week. Inadequate training is a bigger issue when you aren't working enough.

Skeptical Scalpel said...

Anon, that is a good comment. I will bet that you are working more than 40 hours per week in your practice.

ADS2015 said...

Maybe it's not ideal, but I bet if given the choice between 40 hr weeks and an extra year or two of residency or 80+ hour weeks and a shorter residency (and paying off those loans faster) most would choose the 80.

Anonymous said...

I'm starting my year as a veterinary intern at a large, we'll known, hospital and while I get that it's not the same ... We still don't have hour caps. I'm expecting 90 plus hour work weeks ... And chose this internship for that reason (there are certainly more cushy ones available) and will choose a residency likewise. It's one year of my life (four with residency) to learn how to be a competent doctor. I chose this profession and path and feel I owe it to my future patients to be the best I can possibly be. I wouldnt learn the most and be the best with 40 hour work weeks .... And my Future patients would suffer.
Lovely blog! I enjoy following!

Skeptical Scalpel said...

ADS2015, I agree with you. Most would choose the 80+ hour week.

Anon, You sound like you are going to be a very good vet. Thanks for following.

Anonymous said...

As an MS1 at the very start of my career, these attitudes and the resultant inadequate training remains one of my greatest fears. I understand the idea is "well-meaning", but these individuals are not going to be standing next to me at 3am when I am one day an attending and I have a complicated patient. I wonder who they expect me to call at that point. I have discussed the issue with multiple surgical attendings who express frustration at the "clock-watching" of many residents these days and comment that the residents simply don't handle tissue as well or operate as well in general as residents from years ago.

Furthermore, having come from a prior career where 36+ hour shifts were not uncommon, I cannot help but think of all the things I learned during those shifts that I would not have learned during the normal workday. My seniors at the time were able to sit down with me in the evening and walk me through various teachable points that they simply did not have time to discuss during the normal workday. I fear opportunities like that are becoming more and more scarce as they force more restrictive hours on residents.

Anyway, thank you for publishing an always interesting and well written blog.

Skeptical Scalpel said...

Anon, thanks for reading and your comments which are spot on. The value of those nighttime teaching sessions cannot be measured.

DD said...

Maybe I am 'old-fashioned' but I detect a lackluster work-ethic in the desire for a 40-hour work week. If Residents want to work 40 hours, they should pick a less intense line of work; maybe one where they punch a time clock. And-- if they cannot 'be nice' to patients, they have made an inappropriate career choice indeed.

Skeptical Scalpel said...

DD, spot on. I have said the same thing in previous posts. Under "Popular Posts" above right, click on the second one "Choosing a Medical Specialty Is Difficult."

Alva said...

This is cool!

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