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 reducing work hours leads to happier or more rested residents.
2. “But we did it so you have to do it too.” Under this heading, Dr. Ko says, “We are busier than they were 20 to 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 more than 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 on an outpatient basis. 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, and 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 to 400 physicians commit suicide every 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 hour limits for doctors who are in practice?
Being a doctor is a stressful job. Lack of sleep 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.
Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 6,300 followers on Twitter.