A few weeks ago I was sitting in the physicians work area at 2 AM. I was waiting for the delivery of a high risk preterm infant that was expected to be imminent. I passed the time catching up on some charting and reading an article, and as I sat there, I was struck by the fact that I was all by myself. My residents had previously said goodnight and scurried off to their call rooms for a nap. It was ironic to me that they felt the need to sleep; after all, this was only a 12 hour shift for them. I would round on the unit the next morning and continue caring for patients until 4pm, when my partner would come for sign-out. And yet they slept and I didn’t; they had a call room and I didn’t. In that moment I felt like an old soul from a different generation even though I have only been an attending physician for 4 years. Sure this wasn’t walking uphill both ways in the snow, but I could claim the medical equivalent of that feat, having trained to a large degree before the enforcement of the physician duty hours.
The duty hours are certainly not a bad thing. Thanks in large part to the efforts on a bereaved father who also happened to be a journalist; the dangerous work habits of resident physicians were exposed. Indeed, at one time it was not atypical for residents to work continuously for 36 hours and clock 110 hour work weeks. Tired physicians made errors; sometimes life threating errors. Tired physicians crashed their cars on their way home from work, making them a danger to themselves and others. Tired physicians also weren’t very nice people; they cut corners, they neglected their personal obligations, they could be curt and unpleasant. With public pressure mounting and the legislature ready to step in, the Accreditation Council for graduate medical education (the governing body that is responsible for residency training) opted for self-regulation and in 2003 limitations on physician work hours were made mandatory. Since then the regulations have been reviewed and rewritten and in many respects have become even more restrictive as to the length of time resident physicians are permitted to work. In most residency programs ‘call’ has disappeared and shift-work has taken its place. Nevertheless, the schedules for physicians outside of training and for nurse practitioners and physician assistants have not changed.
However, the effects of the duty hours have not all been positive. Many were shocked to discover that the incidence of medical errors did not fall after the implementation of resident physician work hours. One explanation for this was related to the need to transfer care between many more physicians – two or three in a 24 hour period. Errors could result from these often hurried “hand-offs” when details of a patient’s condition are not well relayed. Still others raised concerns that although our residents were well-rested, they were in fact not as well trained. Particularly in surgical specialties, it was an undeniable fact that residents have less opportunity to hone their skills due to limited opportunities. Concerns also were raised because of a phenomenon known as ‘work compression.’ Residents now had a limited time to complete a number of different tasks. In order to fit it all in, sitting and chatting with a patient was the first thing to go. What then, of all the free time we had now carved out? The intention was in large part to give our residents more time to read and study. In actuality, residents were becoming more like the rest of the workforce; claiming their free time as exactly that - ‘free’ time. Residents were having a life outside work!
Those of us who catch ourselves lamenting the ‘good old days’ usually share one common observation. We are concerned that the duty hours have changed our residents’ work ethic and, at times, excessively shifted the emphasis from caring for patients to caring for ourselves. When I talk to a family about a life-changing diagnosis and no resident is present to hear my approach, I worry, will they know what to say when their turn comes. I worry that their hours have caused them to miss procedural opportunities and interesting lectures. I worry that they are ill-prepared for their work life outside of residency. I worry that efficiency is over-emphasized at the expense of the interpersonal. It is not the endless hours of fatigue for which we are nostalgic, but rather the simple moments spent listening and holding someone’s hand because there is nowhere else that you need to be. And ironically, if you spend enough time thinking about how medicine has changed, it may well keep you up at night.
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