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Should Resident Work Hours Be Capped?

Author Information (click to view)

Skeptical Scalpel

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 6300 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

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 6300 followers on Twitter.

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Limiting resident training to 40 hours per week would be a catastrophe for residents, their education, and — most of all — their patients.

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.

13 Comments

  1. Why stop at 40 hours. Our medical students attend a maximum of 5 contact hours each day, that is only 20-25 hours a week. If an intern or resident is a student, then okay, we will limit his/her hours to 20 and they will pay for their training rather than be paid. When I started as an intern, I was paid $1200 per year, and was told that I should be happy, 10 years prior, I would have been expected to cover my own costs.
    I remember working as an intern and resident and averaging 10-15 admissions a day to the inpatient service. In the ED we saw over 100,000 visits a year. So there was no lack of clinical material. believe me those patients were no less sick than those we see today! There were many more patients with serious infectious diseases and I believe even more serious trauma patients, because of no automobile restraints.
    I don’t suggest returning to the every other day schedule that I was subjected to, but we have gone a bit too far

    Reply
    • Steven, thank you for commenting. You make some good points. I agree, we probably worked too much, but 40 hours? I think Jim’s comments above are worth reading.

      Reply
  2. At George Washington in D.C. The supervising Attending would take his interns and residents to the nurse’s station and introduced them to the nursing staff with the following instructions:
    “these are very experienced nurses, who know exactly what should be happening with the patients in this unit, and if they call you , at any time of the day or night, is because YOU need to do something, and you are well informed to check it out, then listen to their instructions, because most likely they have seen this case before and can help you.
    HOWEVER…if you choose not to listen to their call and concern, you will have to deal with me! And we all listened and thanked the nursing staff for saving our hides.
    If the new residents can only do 40 hr per week, then may have to extend their training time.

    Reply
  3. If the 47% of drones that live of those who work will put a 40 hours week doing anything positive, this would be a very different country.

    Reply
  4. Actually, I am OK capping hours at 40, as long as we can figure out a way to make disease keep “banker’s hours.” That would mean I could skip hospital rounds each morning (no 6:30am in the parking lot), read the paper and grab breakfast on the way in, know absolutely that no one with acute leukemia would dare bleed after 4:00pm, and schedule septic shock only during daylight. That means no weekends, no holidays and no working when I have a cold or on my wife’s birthday. We are talking about the practice of medicine, are we not, and not working at McDonald’s? jcs

    Reply
    • Jim, great comments. I am putting you down as agreeing with me.

      Reply
  5. I understand the concern of prolonged hours possibly resulting in mental fog sometimes. But these young doctors today are, most times, pathetic and don’t have a clue of what it means to be an attentive physician.

    When I trained–mostly at Grady Memorial Hospital in Atlanta (the uber-busy county hospital), and at the other Emory affiliated hospitals–I pulled 115+ hours a week, easy. There is MUCH to be said, and learned, by that type of hard work and dedication.

    I’ve been a patient lately due to having my car totaled by an SUV driver, and I am amazed and appalled at how things are done today. These kids just don’t even think anymore and nothing is to interfere with their off-time.

    One night, I actually needed to page my doctor about something; it was only ~9 PM, but not enough for me to go to the ER. The on-call doc returned my call at 5:30 AM…told me he was sleeping!!!!!!!!

    When I did peer review, I was astonished at the laziness of some docs, when the nurse was calling them REPEATEDLY, to not get up, go in to the hospital and check on that patient, even if it IS 4 AM and you’re almost off-call at 7 AM. One case was so tragic, I actually CRIED reviewing it.

    When HMOs came into our world, I said it was ‘the ‘raping’ of the medical profession. This limit to residents’ schedules is another major problem. They don’t understand that being an M.D. requires dedication, regardless the hour of day or night.

    Sorry to write so much, but…this makes me bonkers!
    @DrMelodyMcCloud

    Reply
    • Thanks for the heartfelt and enlightening comments. I do not think the experiences you had are unique. And I suspect they will be happening more frequently in the future.

      Reply
  6. Some of the best educational experiences happened in the middle of the night. As a critical care nurse I worked my share of nights and shared them with a host of interns, residents and fellows. We taught each other and made it through the nights, coming out the otherside with the patient still alive!

    Reply
    • I could not agree with you more.

      Reply
  7. “When I was a resident more than 30 years ago, cholecystectomy patients stayed in the hospital for 4 to 6 days.” Right, so when you had to round on patients many were 4-6 days post-op cholecystectomy! A current surgery resident’s dream service.
    I agree and disagree:
    1. A cap on work hours has not made residents happier.
    2. Sorry, Ko is right here. Call was more frequent (Q2, Q3), but easier. It just was.
    3. You are right – how can you get us much training in 40 hours as you did in 100 hours? At that extreme difference it is easy. Now, some of that 100 hours was not that educational…
    4. The jury is out on this, but you are right, most physician suicides are by physicians in practice (just as most physicians are out of training!).

    Reply
    • Edwin, maybe I wasn’t clear about the rounding on cholecystectomy patients. That was in addition to all the other patients, many of whom were just as sick as today’s patients. There were more patients in the hospital, not fewer as Dr. Ko claims.
      ***
      Otherwise, you seem to agree with everything I wrote. Thanks,

      Reply

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