* * Anonymous Doc

Friday, August 5, 2011

There's an article in this weekend's New York Times Magazine (link is here) about sleep-deprived residents and work hour limits. They've changed the rules for interns this year-- we used to be able to work 30 hours in a row-- now it's just 16 hours. (Of course, they've kept it at 30 for everyone who's not an intern-- so those of us supervising interns, who supposedly know a little bit more about what to do, and are actually the ones making the medical decisions-- we can still be just as exhausted as before.)

The article basically says that while it's probably good to limit work hours and not have exhausted, sleep-deprived doctors, it's only part of the problem, and just as important are making sure patient handoffs are done in a smart way, and care is coordinated between hospitals and outpatient providers so that everyone knows everything that is going on.

Can't really argue with any of that.

But here's my problem. There's already enough ammunition for doctors to accuse residents of having it too easy-- why give them more? This is the only topic of conversation any doctor out of residency can come up with when meeting a resident. "You guys have it so easy. Back in my day, we worked 168 hours a week and if we fell asleep, they shot us in the face! We also weren't allowed to wear gloves, and had to clean the hospital floor with our tongues."

I understand this happens in every industry-- the people from the past will always say they had it tougher. But at some point that can't be true. It didn't start out as 24 hour a day / 7 day a week shifts and just get easier and easier.

And-- I would argue that the problem isn't really the 30 hour shifts as much as it is the alternation between day schedule and night schedule. Sure, you can limit shifts to 16 hours-- but if you're coming in Monday morning at 7 and working until 11 at night-- then coming in for your next shift on Tuesday night at 7 and working until 11 Wednesday morning-- then back Thursday morning at 7 to do your 16 hours again-- you will be exhausted, confused, and no better than if you did 30 and then got 20 hours off to recuperate. The weekly max is still 80. Hospitals are going to get that 80 in however they can. You end up with more days off if you're working 27 hour shifts than if you can only work 16 at a time. You end up having to introduce a night float system if you didn't already have one. So you end up messing people's sleep up just as much, if not more. And where did they come up with 16? You work a 16 hour shift, you're not well-rested if you have to be back 8 hours later (and I think less than 10 hours between shifts is against the rules anyway).

I looked at a couple of the comments on the Times piece-- there were only 3 or 4 comments when I read the piece, there may be more now-- and it was doctors saying the limits are stupid because working so many hours as residents trained them to work those kinds of hours as attendings. Now, those are surgeons and specialists who do work those hours, and I suppose I can make the argument that they should be trained in how to do so-- although I'm not convinced that you can't ease people into long hours once they have expertise and knowledge, as opposed to forcing endless shifts on interns who don't know what they're doing yet-- but for the rest of us, who want to have normal lives and normal schedules when we're practicing, what's the justification for shifts that are more than 8 hours long, right?

The patient handoff argument never really made sense to me as a reason to have longer shifts, because you're just delaying the inevitable. Handoffs have to happen. They happen all the time. Patients are here for days and days and days. Whether there are 3 handoffs or 4 handoffs-- does that really make a difference?

Not to mention that if they really wanted to address the problem of doctors not knowing anything about their patients, they would ban the trading of shifts (which happens all the time, so people are subbing for people and have no idea who the patients are or what they need to be watching for) and they wouldn't allow hospitals to hire moonlighters to cover overnight.

1 comment:

  1. I agree with your comments about alternating days/nights being harder on the system than call shifts. I've always found 28-hour call shifts bearable, but I struggle with 8-hour emergency shifts because they change between days, evenings, and nights. I would far rather be on call than doing shift work. As for night float systems, my residency program has a very good night float system (2-6 weeks of night float per year in two-week blocks), which would meet the 16-hour work rule and which has the advantage of saving us from weeknight call while on the internal medicine wards. While it isn't something that works for every program, it's a big advantage to the program that I'm in.