Listen to these great quotes from the 2011 Common Program Requirements from the ACGME:
“Residents in the final years of education must be prepared to enter the unsupervised practice of medicine and care for patients over irregular and extended periods.”
“Residents must not work more than 80 hours per week, they must have one free day every week, they must have 8 hours off between shifts [condensed and paraphrased].”
Wait, what? The first statement appears to directly contradict the second. You can’t get there from here.
When I was an internal medicine resident in 2001-2002, I would have been all for duty hour restrictions. I suffered, young grasshopper, uphill both ways, in the snow. When the restrictions came out, I applauded them. Residents would get more sleep! They’d learn more! They’d be more effective! They’d be happier! But none of those things happened. Recent studies published in JAMA suggest that limiting duty hours has no effect on happiness; though it might promote sleep, clinical experience and patient care suffer.
Here’s why: The same amount of stuff has to get done. The value of internship is direct and immediate responsibility for all aspects of patient care. You can’t learn about TPN without writing TPN orders. You can’t learn to understand DKA unless you sit with a patient in the ER all night checking labs and adjusting potassium and insulin. It’s a lot of work and it takes a lot of time. No one is going to do your work if you’re sleeping or “strategically napping,” as the ACGME hilariously “strongly suggests.” If I hand over my DKA patient to the covering intern, how well do you think that intern will be able to take care of my patient when he has his own and 2 or 3 other residents’ patients?
In order for duty hour restrictions to function and make sense, either the amount of work has to change or the amount of work being done by the resident has to change. The amount of work is going up, not down, so we need to think about what our residents are doing with their time. Here is another quote from the Common Program Requirements:
“For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions.”
Ah. Interaction with patients. Those humans sitting in the beds. The ones on your extensive and comprehensive patient list that you spent all night updating on the computer. The ones you haven’t seen all day because you have grand rounds and lectures and board review and dictations and journal club and, overarching all those, another patient list to generate for the covering residents coming on so you can get your day off.
The ACGME says that the learning objectives it lays out must “not be compromised by excessive reliance on residents to fulfill non-physician service obligations.” Here’s a suggestion. Let’s define what non-physician service obligations are and hire someone else to do them. After the first 50 pre-ops you type into the computer in the middle of the night for the convenience of the people on the next day, how much more are you going to learn about pre-ops? How much are you learning while typing labs onto a spreadsheet on the computer, labs that can easily be found elsewhere on that same computer? How valuable is it to pre-round on 20 ICU patients in order to fill in the information, also available elsewhere, on the daily note template? And don’t say: “Make the medical student do it.” They’re paying to be there. Why not hire a nurse or NP or PA, or even a secretary, to be a member of the team and do all the data entry?
A legitimate argument against duty hour restrictions has to do with clinical time and hands-on experience, “operating time” if you will. Here’s a suggestion. Let’s use the time residents are in the hospital to have them doing things that help them learn. In my residency program, there were many days when a solo attending would be doing the trauma case or the triple-A or the difficult airway while residents sat in rooms doing their regularly scheduled list of foot cases, or sleeping through a 14-hour breast reconstruction. After the first 100 toe amputations under MAC, how much more are you going to learn about diabetic foot problems and anesthesia? Stop using residents to fill chairs or call schedules or templates and put them where the learning takes place.
Duty hour restrictions can work, but we have to find ways to make residents’ time valuable to them and not to us.
- Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Int Med. 2013;173(8):657-662. http://archinte.jamanetwork.com/article.aspx?articleid=1672284.