For most people, talking about a 16-hour workday is outrageous. For doctors in training, it may not be enough.
Training doctors is not easy. It’s not just a matter of learning what is in the books or latest articles. Under the supervision of attending physicians, young doctors learn the art of doctoring by staying with and caring for their patients. Because of the work they do while they are learning, resident salaries are supported through Medicare… mostly. That’s another issue, but not unrelated to the issue of duty hours.
Twenty years ago, it wasn’t unusual for an intern to arrive at 5 or 5:30 in the morning, work all day, stay up all night on call, and then work the following day until evening rounds were finished. That meant 36-hour shifts and many weeks with more than 100 hours in the hospital. It was clear that this wasn’t sustainable, nor was it safe.
After much debate, in 2003, the initial duty hour regulations were put into effect. In a nutshell, residents couldn’t work over 80 hours a week (on average) and they weren’t allowed to stay longer than 24 hours. If they worked all night, they had to go home the next day. In 2011, the regulations were revised. The major change was that interns (residents in their first year of training) could only work 16 hours in a row instead of 24. On the surface, this made sense. Fewer hours should mean more sleep. More sleep should mean rested interns and fewer mistakes.
I wasn’t surprised to read the article published by Time magazine entitled “Fewer Hours for Doctors-in-Training Leading To More Mistakes.” This report, summarizing the on line JAMA Internal Medicine article from this week, noted that “interns working under the new rules are reporting more mistakes, not enough sleep and symptoms of depression.” In the same issue, authors from Johns Hopkins reported the results of a prospective, randomized crossover trial comparing the new regulations (16 hr work day) to a 24 hours work day with the next day off. They showed no significant difference in the number of hours the interns slept per week between the 16 hour and 24 hour shifts. However, there was a marked decrease in educational opportunities, a significant increase in the number of handoffs, and less resident satisfaction with the 16 hour work day. Most importantly, both the interns and the nurses caring for patients felt that the quality of patient care was decreased by the 16 hour duty hour regulation.
Why would there be more mistakes? Patient care is usually transferred in the morning (to the entire team) and in the evening (to the resident covering the patients at night). That’s roughly every 12 hours. When a portion of the team is rotating on a 16-hour schedule, it results in more handoffs (usually to fewer team members). Increasing the number of times information is transferred between doctors means increasing the risk of communication errors.
If they are working fewer hours why are they not more rested? The new regulations almost require a “night float” system to insure that the patients are taken care of. Working nothing but nights for one week a month followed by 16 hour days is not conducive to being rested.
Why are interns depressed? Remember, decreasing intern work hours didn’t change how much work there was to do in a day – and most hospitals didn’t respond by hiring more people to help. Interns worry that they are “dumping” on their colleagues because they are being required to leave earlier than the other residents. Less obviously, they are learning to be professionals but are being treated like they can’t “take” the hours of the residents one year above them. The message is subtle but real. There’s also a perception that the quality of patient care is decreased by the new system – which is reason enough for a young doctor to feel bad.
Education is clearly impacted. These studies document what we have all observed on the wards. Interns working 16 instead of 24 hours admit and follow fewer patients. In the surgical specialties, they participate in fewer cases. They also attend fewer teaching conferences.
The solution to this complex problem isn’t going to be easy. It’s an ongoing struggle to balance service vs. education, fatigue vs. experience and, maybe most importantly, how we pay for the incredibly important mission of training doctors.
I’m working hard to be part of the solution – along with everyone else in medical education. We owe it to the future physicians we will train and the patients they will take care of.
This is a difficult problem with no easy solution. Trainees in surgical specialties must, like their medical brethren, acquire a large body of cognitive knowledge. The new rules require this to be accomplished with less available time. (At least cognitive skills can be improved easily outside of the hospital environment and all trainees have pretty much unlimited access to the needed body of knowledge.). For those in the surgical specialties, there is the added burden of the intense need to acquire technical skills. The actual performance of surgery is a visual-motor skill. Like most visual-motor skills (sports, playing and instrument, etc) the 10,000 hour rule applies. Acquiring these technical skills, then honing them to the point of mastery, will always require time to get the “reps” in. Most of the inanimate models that we might use to acquire the basic skills are not available outside of the training environment. Polishing the basic skills up to the point of mastery will continue to require a mentor to teach and provide feedback and clinical “reps”; real surgery. Decreased time in the hospital environment means acquiring these skills will take longer. For many, if they do not achieve mastery during training, they may never reach their full potential for lack of an appropriate mentor that has the appropriate knowledge about what skills they need to possess and the time and willingness to work to ensure that they acquire the mastery they both need and want.
We were blessed to have trained when we did, where we did, and with whom we did. The environment we trained in was difficult. To be able to survive and thrive required long hours, hard work, and we were held to very high standards. In retrospect, (easy to say now!) is has all been worth it.
The problem for the current and future generations of trainees is that they must acquire all that we did and more in the areas of: basic cognitive knowledge; exercise of that cognitive knowledge in the delivery of patient care; the exercise of exacting technical skills in the operating room. Add to the mix that they must master an ever changing, ever evolving set of surgical technology and tools that we could not have even dreamed of. This is made all the more difficult by the fact that their faculty must first acquire mastery of these tools and technology first, then pass it on!
Like our medical specialty brethren, surgical trainees must acquire the cognitive knowledge and clinical acumen to correctly make a diagnosis in our patients. They must also have a cognitive knowledge of the best, most current therapy. The difference in the two groups arises, generally, from the application of that therapy. For surgeons, this means “doing” with our hands. It is uncommon in the medical specialties for two physicians to have an equal body of cognitive knowledge, equal clinical acumen, and not be able to achieve the same outcomes when treating their patients. This is not the case, for surgeons. Two surgeons may have the same cognitive knowledge and clinical acumen and both may know the best, most current therapy. Achieving the best outcomes in the application of that therapy absolutely depends on the technical skills of the surgeon. They must have “good hands”. Not all will. This is a huge difference between training medical specialists and surgical specialists.
Surgical skills vary in the population of surgeons as a bell curve. We like to hope that the curve is tall and narrow. Experience does not always show this to be the case. With reduced training hours and less opportunity to achieve those 10,000 hours the bell curve may shift to an unfavorable shape for our patients. Our trainees will be expected to know more, master more technology, achieve better outcomes, and be more cost effective than we were. Oh yes, please do all of this with a reduced training opportunity.
We trained at the feet of the masters of surgery of that time. Dr. DeBakey, Dr. Paul Jordan, Dr. George Jordan, Dr. E. Stanley Crawford; all of these individuals, and many more, served as mentors and/or examples of what a surgeon should aspire to be. The bar was set incredibly high. Every day, I try to jump over the bar they set for excellence in surgery. I take comfort in the fact that they trained me so well and instilled in me the desire to excel to the point that, even when I feel that I failed to make it over that bar, I jumped so high in the effort that my patients are still incredibly well served.
I know that the current generation of trainees has different hopes and goals for their careers than we may have. I hope that most still desire to be the best that they can possibly be in their service to their patients. I hope to be able to instill this desire for excellence in at least some of our current trainees so that they may continue to carry the torch. With reduced hours, it is increasingly difficult. Nevertheless, I take hope in the fact that I know that you, I, and many others are still dedicated to the proposition of repaying our mentors by “paying it forward”.
My own, personal, goal is to push, pull, or drag, kicking and screaming, as many surgeons as I can up into the top of the surgical bell curve. I feel, very strongly, that I owe it to those who did the same for me.