Duty Hours, Interns and Training Doctors

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.

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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.

Starting Internship (I know what you are worried about)

I sat at the table this week with our new interns and the outgoing chief residents. Listening to our new interns as they asked questions, I realized everyone starting their internship has the same fears, whether or not they express them:  Will I kill or hurt someone?  Will I look stupid?  What if they find out I’m not as smart as everyone else?  Will I get divorced/separated/alienated from my friends?  Will I gain weight?  How am I going to find time to take care of myself?

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What you are feeling is normal. Every doctor who ever started an internship felt exactly the same way.  The best way to manage your (healthy) fear is to have a strategy.   I’ve written in the past about how to succeed as an intern.  But if I were going to condense that advice into three easy rules (for every day except your day off)  it would be these:

1.    Read at least one section from a textbook in your field every day

2.    Learn something (in detail) from at least one patient every day

3.    Do something to take care of yourself every day

 

Read at least one section from a textbook in your field every day.

Your goal for the year should be to read a major textbook in your field cover to cover.  You don’t have to buy the physical book.  It’s fine if it’s on line or downloaded onto your iPad.

Once you have the book, make a list or spreadsheet of all the sections in all the chapters.  For most textbooks, it’s probably going to be a list somewhere between 150 and 200 topics.  When you look at the 48-50 weeks you will be working this year, it works out to basically a topic a day (with some days for review).

The real goal is not just to read these topics, but to really learn them.  So, when you read, don’t just skim.  Read to learn.  That means taking notes – and reviewing them.

Put a chart on the wall with the list and give yourself a gold star when you finish a topic if you have to, but find a way to make sure you cover all the topics (at a steady pace) during the year.

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Learn something (in detail) from at least one patient every day.

It’s really easy, as an intern, to get caught up in the work and forget that you are fundamentally here to learn – not to provide service.  Make it a daily habit to learn in detail about one patient in your care.  It will overlap nicely with your goal to read a complete textbook.  When you admit a patient with pneumonia, read the section (and make notes) on pneumonia and then check it off your list.

One other important point (that none of us like to hear) – You will make mistakes. Be humble, be honest, and learn from your mistakes. The mistakes you make (and maybe more importantly your “near misses”) are absolutely your most valuable teacher.  When you do make a mistake, use it as the topic you will review for the day. You are going to be really upset but be easy on yourself.  Being upset is the mark of someone who cares, but don’t let it escalate beyond a healthy response. Talk to your mentors and senior residents.  They’ve been there.

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Do at least one thing to take care of yourself every day.

This may sound trivial, but it’s not. If you can, try to eat well, get some exercise and be social every day.  At a minimum, though, pick one specific thing you are going to do for yourself and then do it.

Eat well

Get Some Exercise

Be social

The Hospital Never Sleeps – And Neither Do the Patients

I recently spent the night in the hospital with a friend who underwent a minor procedure.  It was a fascinating experience to watch the hospital “from the other side”.  Overall, I was very impressed  – the nurses, patient assistants, technicians, clerks and food service personnel were universally professional and kind.

But then we went to sleep…. or tried to.  Vital signs, meds, and necessary events were more or less over for the day by 10pm.  The unavoidable noise in the hall, unfamiliar bed, and the events of the day made it difficult to get to sleep, but we both drifted off around midnight.

At 4am there was a cheery “Sorry to bother you, but I’m here to get your weight”.  She couldn’t have been nicer but when I asked why my friend had to be awakened at 4am (!) for a weight (!) she responded, “We have to have the weights, labs, x-rays and vitals all completed before the day shift starts at 6am.”

Not too long after this experience, I admitted a long-term (and adored) patient of mine for an elective procedure.  Her parents reminded me that last time she was admitted I wrote an order to forgo the middle of the night vital signs so their daughter (and they) could sleep.  Coming on the heels of the night I spent with my friend, it made me think about how we manage sleep in the hospital.

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Why do we wake patients up to weigh them?

There are patients who absolutely must be woken up for medical reasons.  If you are admitted for a hypertensive crisis, you need to have your blood pressure checked during the night. Waking patients up in the middle of the night for things that could easily be accomplished during daytime hours is done for three reasons, none of which are medically necessary:

1) To distribute work to the less burdened night-time staff from the day time shifts

2) To have the data available for morning rounds.

3) Because of pressure to get the patient out of the hospital at a certain time

Is there really no way to off load the busy day time shift without waking up patients?  Would it really change things if stable patients (particularly if they are on monitors!) were allowed to sleep through the night?  Would it change therapy if the daily weights were at 10 in the morning instead of 4 in the morning?

There’s no question it’s nice to have data for morning rounds – but is it really essential?  How much of this is a holdover from the paper chart era? In the era of the electronic medical record, access to data- at any time of the day or night – is easier than it used to be.  Granted, morning report or rounds would be different, but I think it’s something we could figure out.

There is financial (and other) pressure to get patients out of the hospital.  But have we looked at ways to manage this that don’t involve waking up patients?  For example, there are hospitals that count the “day” in the hospital by the patient census at midnight.  As long as you are out of the bed at midnight you don’t get charged for the day.

Sleep is important for recovery from illness or injury.

There are numerous studies that suggest that the immune system in particular is affected by disruption of sleep.  The data are not conclusive, but many physicians, nurses and scientists have published work suggesting that protecting sleep for ill or injured patients might be important:

Sometimes it’s not about the patient.

In babies with necrotizing enterocolitis, we order abdominal x-rays every 8 hours for at least a day or two (to look for air in the abdomen.).  If the x-ray shows “free air” (like the one below), it means they need emergency surgery to deal with the perforated bowel.

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The standard schedule in our hospital for q8 (every 8 hours) x-rays is 6am, 2pm and 10pm.  Here’s the problem with that schedule as far as hospital efficiency goes:

  • The 6am xray, if it shows a problem, will result in action around 7.  If the baby needs surgery, the operating room is already set up for the 7:30 cases.  Because the OR schedules is usually very full at the beginning of the day, we often then have to “bump” (postpone) a patient to do this emergency case.
  • The 2pm x-ray will result in the surgery being posted around 3,  a complicated time in the OR since day time nursing staff is leaving and the remaining cases are being juggled.
  • The 10pm xray will start the process rolling at 11 or so – putting the surgeon in the OR in the middle of the night.

Since the timing of the x-ray has a big effect on the timing of the surgery, it becomes a variable that really affects what happens. Here’s what happens if you change the schedule to 3am, 10am, and 8pm

  • The 3am xray, if it shows a problem, will result in action around 4. Surgeons are the early-birds of the hospital. Since they will be waking up early anyway, the case can easily be started at 5 or 6, which helps with the OR schedule and keeps the surgeon from being up all night.
  • The 10am x-ray will result in the surgery being posted around 11 – this is a time when “holes” in the OR schedule are easier to find, and getting the baby into the operating room will be easier.
  • The 8pm xray will start the process rolling at 9 or so – which means the surgeon is more likely to get some sleep.

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What’s the bottom line?  We don’t think about some of the unintended consequences of our orders.  Sleep is important – for both patients and the people taking care of them. It’s worth thinking about.

How to Spend Your Day Off

“I know I should study for the Absite this weekend, but I haven’t had a real day off in over a month”.

Here’s the scenario. It’s Friday evening. You’ll be back at work on Sunday. You’re sleep deprived because you are a resident.  You haven’t spent any quality time with your significant other, friends or family because you haven’t had any real time off. Next week has plenty of call and it would really help if you planned out good food for the week and cooked something.  And, by the way, you have the inservice exam coming up, so you really should study.

There is no one answer how to balance these things. Everyone will be a little different in what is most important to them, and different weeks will be different, too. But, there are some basic concepts to think about that might help you plan how to spend your time off.

  • Sleep is actually a high priority even though it feels like you are giving up social time.  Whether it’s visiting friends, studying or just goofing off, you won’t get the benefit of your time off if you are completely exhausted. If you are sleep deprived, try going to sleep really early (8 or so) the night before your day off and see if it doesn’t make a big difference.
  • Good food is important. Be efficient, but be conscious about what and when you eat. Use a little of your down time to think about your week, plan what you are going to eat, and go shopping. Find a good recipe for something easy to make and make a big batch for the week. Or at least buy good quality frozen food that serves the same purpose.
  • Get some exercise, but be realistic. A serious workout can use up a big hunk of a day off. For some, that’s great – the hours will be more than worth it. For others, don’t beat yourself up. It’s far better to figure out how to do 30 minutes 3 or 4 times a week than to be a “weekend warrior” for 4 hours on your day off.
  • Don’t plan for huge blocks of study time on your day off. You’ll wear out your neural pathways and you just won’t remember what you are trying to learn. Like exercise, a little every day is much, much more effective than a big block on the weekend. Plan now for the big test months from now… pace yourself!  (If you’ve just started studying for the Absite later this month – go for it. But, as soon as the exam is over, map out a way to study for next year so you don’t do the same thing again.)
  • Absolutely use a significant part of your day off to socialize with your family or friends. It’s very isolating to live in the hospital and these hours are critically important.
  • Once you think about what’s important to you, and make a decision about your day – enjoy it! The worst way to spend a day off is to spend the time worrying that you should be doing something else. There’s a reason that almost every religion in the world has the concept of “Sabbath”. Human beings need real down time once a week to refuel.  It’s not “wasted” time, it’s essential time.

Book Recomendation: Iron Doc by Mamta Gautam, MD

I became aware of this book last week through one of the anesthesia residents at work (whose chairman made this book required reading for all residents in his department).  Dr. Gautam is a psychiatrist who has specialized in caring for physicians and is an expert in physician wellness.  She uses training for an Ironman triathalon as an analogy.  Physicians have to “train” for different roles (personal and professional) if we want to prevent burnout.  She proposes a training program that helps keep balance in the complicated life of a doctor. The book primarily addresses physicians already in practice, but the information is very applicable to trainees, as well.

Here’s her website if you are interested:  http://www.drgautam.com/gautam/books.htm

Post Call Recovery

I’m on call this weekend.  As we started rounds this morning, the conversation turned to one of our superstar residents who (uncharacteristically) was late to rounds.  He was up all night and overslept after falling asleep in the wee hours of the morning.  What struck me was what he told us… “I knew something was wrong when I woke up feeling good.”  Being on call, and being up all night is part of medical training (and practice).  And it’s not just an occasional event – we often have to do it every three or four days.  It’s essentially iatrogenic jet-lag and it takes some time to learn how to manage this kind of fatigue.

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Being tired after call takes two major forms:  with sleep and without sleep.  Depending on the type of call, the recovery is different.  If you have been inundated with work, but were able to sleep, you will be physically (somewhat) and emotionally (a lot) tired.  The treatment for this is play.  You need to spend some time doing something that is not related to work, preferably in the company of friends.  You need time to process what you have just seen and done, but, more importantly, you need to feel like you are still connected to the world outside of work.  Physical activity is essential.  Even if you get home late, do something to stretch and use your body.  Even a 15 minute walk outside followed by 5 minutes of stretching will do the trick.  If you live with a significant other, make sure you have dinner together and really talk.  Put on some nice music.  Call a friend.  Go out to eat.  Whatever you do, don’t “numb out” by drinking a beer in front of the TV set.

Being tired without sleep is a physiologically abnormal state for human beings.  No matter how much the culture says you should be “tough enough” to go without sleep, it’s crazy.  We are designed to sleep 7-9 hours every night and, when we don’t, we don’t function as well.  There is an amazing amount of literature on the effect of sleep deprivation on performance, competence and health.  Suffice it to say that we all realize we don’t want the pilot of our plane to have been up for 24 hours prior to our flight.  It’s no different for a doctors.

There is  literature on this problem, but these are studies that doctors don’t often review.  A sleepless call night is basically a shift in your body clock i.e. jet-lag. The big difference is that the light cues are the same after call (unlike when you fly to Europe).  So what have business executives and airline pilots learned about dealing with this kind of time shift?

  • Stay hydrated.  It may sound silly, but paying attention to drinking enough water will make a big difference.  How much is enough?  Enough to keep your urine clear.  It is amazing how, during a busy day, you can forget to drink water.  Start looking for the drinking fountains and stop for a drink when you see them.  Carry a water bottle in your on-call bag and pull it out when you are doing sign outs, or taking a break.  Having a bag of cut up lemons helps, too.  A tall glass of ice water with fresh lemon in it is a fabulous treat in the middle of a busy night.  Mild dehydration will increase your level of fatigue.  Watch out for soft drinks and tea – the caffeine may give you a little kick (and there is nothing wrong with that from time to time) but, if you drink a lot of caffeine,  it will really mess up your sleep cycle when you do get to sleep.  Also, tea and coffee act as a diuretic, so your net hydration may be negative.  Water is by far the best choice.
  • Don’t skip meals.  Most importantly, don’t skip breakfast.  Most students and residents have to get up really early to get to work. And, most people just don’t feel like eating a big breakfast at 5:30 in the morning.  Eat something before you leave the house (a cereal bar or piece of fruit, for example) and then take something more substantial for later in the morning.  Even if it’s only an energy bar in the pocket of your white coat – take something and then eat it!
  • Don’t go too long without food during a long shift.  You need to eat something every 3-4 hours if you are working hard.  You should carry at least one snack in your coat pocket such as a small bag of nuts, an energy bar, some raisins, or some dried fruit.

Probably the worst mistake people make in recovering from call is what they do once they leave the hospital.  You can really help your recovery, enjoy your time off more, and return to work ready if you realize one fact:   You have shifted your biologic clock by staying awake all night.  If you go home the next morning (or afternoon) and sleep for 8-10 hours, you will have shifted it even more.   So how do you best recover?

  • No matter how tired you are, your first stop should be the gym, a park, or someplace you can work out.  This does not have to be (and shouldn’t be) a hard workout.  This should be a “work out the stress” workout.  Don’t push yourself hard, but work up a little sweat.  Even if it’s just 20 minutes of walking in a park, you will feel better.
  • Treat yourself well.  Take a nice long shower when you get home.  Make yourself a nice meal, but not junk food.  Eating a lot of protein and fat will put you in a fatigue tail-spin.
  • Take a nap, but make yourself get up so you can sleep that night.  3-4 hours is usually about right.  Make arrangements to have dinner with friends, if you live alone.  If you have a significant other, make plans to do something together in the evening.  If you want to have a glass of wine, or one beer, do so – but don’t have more than that.  It will mess up your sleep and it’s not worth it.
  • Don’t drink caffeine after the morning.   Even though you will be sluggish in the afternoon, don’t sabotage your night time sleep with caffeine.
  • Go to sleep early.  In addition to being sleep deprived, you will also feel socially deprived.  It’s natural to want to go out with friends when you feel this way.  However, they are not as sleep deprived as you are, and they don’t have to do this again in a few days.  If you’ve had a hard call, with very little sleep, you should plan to get 10-12 hours of sleep the next night.  You have to get at least 8 hours.  In other words, if you have to be up at 6, you should be in bed no later than 10 pm, but, as crazy as it sounds, if you can get to sleep at 8, it will be better.