December 2nd, 2008
04:20 PM ET

Are your doctors awake?

By Jennifer Pifer-Bixler
CNN Medical Senior Producer

When I was in college, I had emergency surgery.  The whole incident was a blur. One moment I was being poked, the next, I was being wheeled off to the OR.  When I woke up after surgery, I was groggy and feeling NO pain.  For the next few days, morphine was my best friend.  Granted, my memories from that week are pretty limited, but one thing I do remember is a young doctor stopping by my room to check on me.  I have no idea what he said, but I do remember vividly that he tried to stifle a yawn while he was talking to me.  That made ME yawn and in turn, he yawned AGAIN.  Perhaps it was the pain meds, but boy I thought that was hilarious.

The “dueling yawns incident” pops in my mind whenever I hear about the long hours doctors work while they are in residency.  To succeed, not only do these new doctors have to be smart, they must have endurance.  For a long time, there was no limit to how many hours a resident was expected to be on duty.  But in 2003, the Accreditation Council for Graduate Medical Education, the council that evaluates and accredits medical residency programs in the United States, set up new rules limiting the maximum resident work week to an average of 80 hours and the maximum shift length to 30 hours.  However, according to some researchers, even with the 30-hour limit on shifts, there can be a whole host of serious problems.  I recently spoke with Dr. Charles Czeisler at the Harvard Medical School Department of Sleep Medicine.  He studies lack of sleep and its impact on doctors.  Czeisler's research shows that one in five residents admit making a fatigue-related mistake that hurt a patient.  One in 20 admits making a fatigue-related mistake that resulted in death.  In other words, says Czeisler, working 24 hours straight without sleep is comparable to being legally drunk.

That's sobering news.  And it makes me wonder about the doctor who treated me in college.  I wonder now how many hours he had been working.  Now the Institute of Medicine says it it's time to talk about residents’ hours and workloads.  "Fatigue, spotty supervision, and excessive workloads all create conditions that can put patients' safety at risk and undermine residents' ability to learn," said committee chair Dr. Michael M.E. Johns, chancellor of Emory University in Atlanta, Georgia.

Among the recommendations from the IOM:

           * Limit shifts to 16 consecutive hours

           * Give residents more days off

           * Provide transportation home after a long shift.

The IOM acknowledges that there is no easy solution.  In fact, it says there are very valid reasons for some residents to work long hours.  Keep in mind that this is a training time for doctors.  And getting the most experience possible ultimately benefits patients.  Also, the work flow varies from specialty to specialty and experts say 'one size’ doesn't fit all when it comes to schedules. For example, the time a surgeon needs to spend with a patient is different than a dermatologist.

The committee stresses that limiting resident hours is not a “silver bullet.”  It also recommends greater supervision of residents by experienced physicians and limits on patient caseloads based on residents levels of specialty and experience. 

Reaction to the report has been mixed.  Public Citizen http://www.citizen.org says the IOM has missed “a golden opportunity” and doesn't go far enough to protect patients.   Czeisler, however, says it is an important first step.  But he worries that nothing will change unless the federal government gets involved and enacts new laws.

I want to know what you think.  Do you think these recommendations are needed?  Have you ever been treated by a “drowsy doctor?"  And if you are a doctor, do you think working long hours helped or hurt your residency?

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soundoff (55 Responses)

    good recommendations, to enable a balance between the health of patients and the health of the healthcare providers as Dr Sue guides on http://livingalongerhealthylife.com

    December 2, 2008 at 17:32 | Report abuse | Reply
  2. Sapan Amin

    There are two sides of this story for anyone in training, including myself. One is the fact that physicians have to be ready at any time for an emergency and need to be able to think fast in a tough environment. The military doesn't get a break if there is active combat, likewise if there are things going on during a shift we need to be ready. The flip side of this is how fatigue affects physicians, and how this can lead to errors for patients. A complete answer to this is almost non-existent. You want less errors for residents in a practical manner. Make supervision more accessible for them, if there are residents on call, there should be an attending on call in the hospital that should be awake also. Another thing that might work is more shift work (12 hours), like the emergency physicians do, rather than a 24-30 hour call.

    December 2, 2008 at 17:46 | Report abuse | Reply
  3. Edward Abel

    Sleep is a biological necessity, and as mentioned if a doctor doesn't get enough rest it could be compared to being legally drunk, it is then a matter of when not if a mistake will occur.Will the surgeon leave a medical instrument inside you when he closes? Will you die because he didn't get sleep and is not alert ?. Yes, Yes, Yes there should be time limits for resident work hours and thorough supervision from experienced doctors.When a person becomes too tired / sleepy the only consuming thought becomes when can I lay down and rest and if rest is delayed too long that doctor or anyone will eventually be sleeping while they are on their feet, AKA SLEEPWALKING.

    December 2, 2008 at 17:58 | Report abuse | Reply
  4. Jean

    I was a med student when the ACGME rules first went into effect, and enjoyed as a resident the 80 hour rule. During my intern year I had 30 hour shifts about every 4-5 days for a year. It was tough. Programs are shifting from the 30 hour shift to 12 hour shifts, but this has flaws with patient hand-off issues.
    I think it's great to have a goal of less tired trainees, but what I found most innovative some programs is the reduction of number of patients cared for by the resident. The ACGME states that an intern can be responsible for up to 12 patients for a day, and a resident up to 24 patients if they are supervising 2 interns. They cap the amount of patients that can be admitted to 10 patients per shift for residents and 5 for interns. For community based patients, these numbers are reasonable. But increasingly, the hospitals that are training our residents are academic centers. These institutions have a much higher acuity patient population that are often referred from the community hospitals due to their complexities. Many academic centers are bursting at the seams with patients but the total number of residents or number of attending physicians haven't been increased accordingly. This leads more to overworked and overstressed residents than work hours. Hospitals find residents are cheap labor, but the safest programs are the ones that focus on education by way of exposure but also time for the residents to sleep and read. Hospitals that step up and bite the bullet to incorporate private non-teaching services in order to lessen the burden on the residents would likely have residents that slept more and took better care of patients they do have.

    December 3, 2008 at 00:01 | Report abuse | Reply
  5. C.C.

    Would CNN be able to investigate and do a story on how doctors are trained in different countries? This is important because as long as the information is unknown, the medical field in this country can go on pretending that they have to have their hazing ritual.

    Having grown up in a community of immigrant doctors (from countries as developed as the United States), I hear that medical training in both medical school and residency is not as poorly scheduled elsewhere. Is it a coincidence that nearly all of the doctors I have visited who were intelligent, compassionate, and helpful were trained in other countries from Asia to South America, while all of the doctors I have visited who were rude, stupid, and angry, were trained in this country?

    In addition to doing a study on medical training in different countries, there should be a study on whether there is a diversity of schedules at different medical schools and residencies in this country. Which schools and residency programs have the best schedules and culture, and which have the worst?

    For medical school applicants and residency applicants, if you want things to change, you also have to vote with your feet. This is positive and negative feedback. When the best and brightest choose programs with the best schedules and culture and avoid the bad ones no matter their so-called rank, then they have to change.

    December 3, 2008 at 00:44 | Report abuse | Reply
  6. cris

    I am a doctor and YES we need to restrict work hours for residents. Residency is like indentured servitude, you cannot protest or say ANYTHING, because they can fire you and then you will never be a doctor. I saw this happen to several interns where I did my residency, and it scared the rest into silence. So, it is a situation that can be very abusive. It is financially abusive already. Residents make no money, but are accumulating interest and sometimes need to take out loans to survive, especially if they have kids. No surprise that many docs wait to have kids. I still don't have any! There are a few old school doctors who still think it is necessary to abuse interns and residents with 40 hour straight shifts, they also think it is appropriate to humiliate them and ridiculize them on rounds. I am glad things are changing and people are more focused on respecting everyone, something that civil rights movements seemed to have brought about. It took clinical studies and the threat of lawsuits to change things for residents. Why can't people just use common sense?

    December 3, 2008 at 08:20 | Report abuse | Reply
  7. Alan

    I am a surgical resident and find the outside pressures to further reduce work hours counterproductive. This article makes a good point "the time a surgeon needs to spend with a patient is different than a dermatologist." This fact is lost in the numerous restrictions that are constantly placed on physicians in training. I never hear anyone asking the patients and the advocacy groups, "How do you think the "supervising" physicians learned enough to supervise?" "Would you like a physician who when they finish "training" is forced to learn on the job when there is absolutely no supervision because of all the work hour restrictions imposed on them when they were a resident?" The old addage "You can't have your cake and eat it too" prevails here. People want the best doctors, the lowest costs, and shortest waiting times. Well, there will be a serious problem if we restrict hours any further and force residents to be in training for 20+years. Do the math...4 years of undergrad, 4 years of med school, then residency. My surgery training will already push 9 years. If I am only allowed to work a fraction of the time I do now, then what's the natural solution...extend training time–10, 12, 14, 16 years.....??? What would I do when I finish my training with $200,000+ in debt?? What about a family, am I allowed to start one or will that get in the way of the perfect doctor who is at the patient's beckon 24/7?

    There is a total disconnect with what the public perceives as a doctor and a doctor in training. Unfortunately, a lot of that is a result of poor communication to the public through (dare I say it) the media. (I swear I didn't get that from Palin). The question posed in the article "Have you ever been treated by a "drowsy doctor?" is ludicrous. Are you trying to create hysteria and panic? What if I yawn in front of a patient now? Will they demand a new doctor? Will they complain to the hospital administration? Stigmatizing doctors who are trying to the right thing is the wrong approach. We are on a slippery slope here. If we continue to drive great minds away from medicine with the prospect of never-ending residency programs, then we will have to outsource more of our medical care to Foreign Medical Graduates.

    December 3, 2008 at 09:03 | Report abuse | Reply
  8. ACinCincy

    What a lot of people don't know is that you can have an Advanced Directive on file for you at your prefered hospital, specifying (among other things) that you refuse to be treated or observed by Students and Residents.

    I understand emergencies happen where there may not be time to wait for another physician, but this is one way a patient can take charge of their own circumstances.

    Just because someone is "learning" (which is valuable, don't get me wrong) does not mean I should automatically expect to be their next specimen simply because I am convenient.

    December 3, 2008 at 09:47 | Report abuse | Reply
  9. leon F. Hirzel III M.D.

    I did a General Surgery Internship with N.Y. Medical College affiliated hospitals from 78-80. The number of hours in shifts and per week avg. 110 hrs. We were always exausted and the miracle of it all is that alot of bad things that could have happened did not by the grace of God. Over all it was a remarkable experince never to be repeated again. No question that readding time was limitted and it would have been a better training if the number of hours were less.

    December 3, 2008 at 12:00 | Report abuse | Reply
  10. Jonathan

    A few years ago my brother broke his arm pretty bad skiing. He was airlifted to Denver and was going to go into surgery until the surgeon walked in and told my parents the real story: no surgery tonight, I'm too tired and don't want to make a mistake. My father took that as the most respectful thing a doctor has ever done for him. Now I'm in medical school and I knew going in that sleep was going to take a back seat for at least the next 7 years. It's a rough line to dance. Do you limit hours to help the residents physically or do you give them more hours to help the residents learn? It's tough, but it's the price I knew I was going to pay going in to this.

    December 3, 2008 at 15:28 | Report abuse | Reply
  11. A Med Student

    If people in the country want good health care, they need to take better care of health care providers first and foremost. It is a prerequisite to good health care. No compromises.

    December 3, 2008 at 16:16 | Report abuse | Reply
  12. Doreen DiPasquale, MD

    I have been repeatedly disappointed, sometimes embarrassed tin the conveyance of information regarding the condition of health care and the providers of health care professionals on the morning segments. I trust and can listen to Dr. Gupta. Otherwise, "physican's without sleep" ?! I have been trained as a surgeon and sleep has nothing to do with performance.

    December 3, 2008 at 16:44 | Report abuse | Reply
  13. Jim

    This is in response to the comment by ACinCincy. With all do respect... what is good for the goose is good for the gander. If EVERYONE had your attitude about being a patient that is cared for in a teaching hospital by quality residents who are simply trying to do their job, then eventually there would be NO experienced attending physicians at some point. Would you rather have a resident with an experienced supervising attending physician taking care of you? Or an inexperienced attending who had few opportunities to gain real experience as a a resident taking care of you? Be careful with what you wish for!!!

    December 3, 2008 at 22:31 | Report abuse | Reply
  14. Janet

    I'm just a medical student and few people realize that many of us work 90+ hours/week on average. Therefore I know for a fact that once I get over 75 hours my ability to learn drops greatly. Of course I'm ignorant about what residents go through and why wouldn't I be, however I cannot believe a 110 hour work week is going to improve my skills as a physician. I don't think I could study and actually learn when I've been drinking, likewise I certainly don't believe I would learn when performing an operation after putting in 100 hours in just a few days. As was mentioned before, I believe this is more of an economic issue than academic. Residents get paid dirt are billed out at an insane ratio to their compensation and as Chris said, cannot protest anything without risking everything. I just hope to God that I don't become brainwashed into believing the quote, "The only problem with being on call every other night is that you only get to handle half the patients"

    December 4, 2008 at 02:30 | Report abuse | Reply
  15. gasdoc

    Alan's comment above is spot on: what is CNN and the author trying to accomplish by telling the story of the yawning young physician? I am an anesthesiology resident (incidentally just coming home after a 24 hour shift during which I was anesthetizing patients for 22 hours). By 4 AM this morning I had stubble on my face, I am sure my eyes were red and perhaps I was not the most bubbly individual in the world. I would hate to think that my patient's last conscious thought before I gave them medication to start their anesthetic was that their anesthesiologist – the person who keeps them ALIVE while their surgeon is working – was anything less than a competent, dedicated physician.

    There is already enough misinformation about complicated health-care topics in the media. Resident education is one of these. Like medicine itself, education of residents is a furiously interwoven web of service, science, education, economics and psychology. These cannot be teased apart, and they certainly cannot be dumbed down to a blog entry that barely fills two printed pages! I am sure that we all can agree that the resident education process needs review, revision and improvement. The further limiting of work hours, however, is not likely to be a tenable solution for those specialities that matter most to the majority of patients (internal medicine and general surgery), where continuity of care is just as important as any factor supposedly related to physician fatigue.

    Let us also not forget that residents, as cheap labor, provide a great deal of the health care to the under and uninsured. Health care would become more expensive in this country if more residents were suddenly required in order to accomplish the same amount of work.

    Additionally, we cannot forget a very important aspect of medical training: the development of confidence. It can be a very scary thing to go from being a medical student, not responsible for anything other than making good grades, to suddenly being an M.D and having to make decisions that determine the course of action for numerous support staff as well as the flow of tens of thousands of dollars in diagnostic testing. For those of us who also need technical expertise to intubate, start invasive monitoring lines and conduct surgery, nothing builds confidence more than successfully managing a patient when you are at your worst. Soldiers talk about how their training kicks in during the heat of battle. I view the 3AM operating room in the same way. All of us are relying on our training to care for our patient. We must develop the confidence to trust that we know what we know.

    Finally, regarding some comments about refusing care from residents: if you ever end up in a teaching institution to receive care, think long and hard about who you refuse to let treat you. Particularly in specialities that involve manual procedures (placing needles, catheters, etc), the residents are the ones who are doing most of that work in the hospital. I have seen more than one Prima-Donna patient suffer because they wanted a professorial theoretician to do the work rather than a competent resident who just finished doing a dozen of the same thing.

    The September 10, 2008 issue of JAMA has a nice article that explores the reasons behind why US medical students choose certain specialities for residency training. US (as contrasted to foreign educated) medical students are, in growing numbers, eschewing the "difficult" specialities like Internal Medicine and General Surgery, for "lifestyle" specialities like Dermatology, Radiology and Emergency Medicine. I believe it is this mind set that drives these desires to further limit work hours. Next time you think about supporting such an initiative, just think about what kind of professional you expect your physician to be. Should they be a shift worker who punches a card like a line cook? Or should they be a dedicated professional who takes the time necessary to do the job right? Speaking for myself, the answer is obvious.

    December 4, 2008 at 09:58 | Report abuse | Reply
  16. Brian Clay, MD

    To ACinCincy:

    I would point out that these recommendations, if adopted by the ACGME, apply only to residents. The attending physicians supervising them have no such rules, and there is no reason to think that, absent a regulatory mandate, the work schedules for attending physicians are going to have the same sleep-protection and duration-limitations aspects as those for residents.

    When you demand to be cared for only by the attending, remember that he may very well be the most fatigued physician in the hospital.

    December 4, 2008 at 12:48 | Report abuse | Reply
  17. take me back to the good ol' days...

    I am a neurosurgery resident at a major university hospital. When I started residency, I was thrilled with the work hour restrictions. However, as I progress through residency, I resent these restrictions more and more. The work hours do nothing more than limit the exposure and experience we get as residents. Therefore, residencies have already started adding years to our training programs. My daughter was born my freshman year in college and she will graduate about the time I am done with residency. At this rate, I will end up paying for her wedding one day while still in training! At some point, we simply cannot keep cutting experience/exposure by slashing work hours and try to compensate by lengthening the time in training.

    Further, when the public hears about 88 hour work weeks (yes, programs can get a 10% extension) and 30+ hour shifts, they assume the doctors are fatigued to a point where they can no longer perform their duties safely. I could not disagree more. Residency is much like training for a marathon. Over time, one's endurance improves and after a few years working 30+ hours straight and 88+ hrs in a week is not a problem. In fact, I wish my junior residents and I had the option to stay longer. When I have a practice some day and have worked throught the night and another emergency comes in, am I to tell the patient's family, "Sorry, I am going home. I do not want to go over my work hours. Go find another neurosurgeon?" As the saying goes, "If the training is hard, the war will be easy."

    I wish each specialty was allowed to govern the work hours of their residents independantly. The ACGME needs to stop acting as though all specialties are the same. How am I to expect that I am as well trained as my predecessors working a fraction of the hours and performing a fraction of the cases?

    December 4, 2008 at 12:52 | Report abuse | Reply
  18. E.J.

    The problem with work hour restrictions is that once you finish residency, you are an attending working 100+ hour weeks. How will we be able to function at a level of excellence post-training if we haven't learned to deal with long hours as a resident? Residents are supervised by attending physicians who traditionally were well rested and "protected" from long hours so they can think clearly as they oversee the residents' work. Now the attendings are working long hours, exhausted, and are the final say in patient care decisions. Residents are working shorter hours and are the protected ones – who will have to transition to long hours with no guidance as attendings. Patient care advocates don't realize the long-term implications of work hour restrictions. It is making for lazy residents, increased patient care hand-offs which means you have a 1 in 3 chance of having a physician take care of you who actually knows your case, and in the future will lead to a generation of physicians unprepared for the long hours a head.

    December 4, 2008 at 13:29 | Report abuse | Reply
  19. stacy

    I was a second year resident when the change to the 80 hour work week was implemented. A disadvantage to this rule is that it becomes more shift work. We had the mentality that we would stay and follow up on the labs, tests, etc on a patient. The groups after us were very content to hand this off to the next shift. I think some learning is lost in this. Yes, patient care can be compromised with sleepy residents, but how about the repeated signing off of patients to other residents? Continuity of care is important as well.

    December 4, 2008 at 13:41 | Report abuse | Reply
  20. BJ

    How do work hour restrictions in residency prepare you for being an attending, when you are older and less equiped to deal with lack of sleep and there are no work hour regulations?

    December 4, 2008 at 16:42 | Report abuse | Reply
  21. C.W.S.

    I finished my residency right before the 2003 law was put into effect. If only I'd been born a few years later!

    With 100+ work hours per week and 36+ hour shifts with no sleep every 4th day, I would frequently fall asleep while driving on the freeway at 65 mph despite having taken a nap in my car before heading out of the hospital parking garage. Sometimes I'd fall asleep while driving TO work. (Thank goodness for the ridged bumps on the shoulder of the road. They woke me on a number of occasions.)

    I'm just glad that I never made a mistake that harmed any patients. And I'm thankful I didn't somehow kill myself while driving to or from work. I'd had some friends who actually did get into accidents. And I know other residents worked even more hours than I did.

    I'm glad of the 80 hours per week/30 hour shift limit. And while I can understand that restricting more hours means less learning time, I really don't think it's worth risking lives to maintain such insane schedules. And learning is so much more efficient when one is actually awake enough to absorb the information.

    December 5, 2008 at 09:03 | Report abuse | Reply
  22. Chuck

    With almost 20 years of working as a RN in a teaching facility I can tell you that the abuse that med students are put through is completely unjust. The "way we have always done it" mentality seems to run rampant in our "modern" health care system. Do physicians need to be quick thinkers? Yes they do, but I wish someone would make it possible for them to think. I worked third shift for most of my career and would catch the mistakes and prevent fatal errors. The attending physician's would basically humiliate the most fatigued resident in many cases. Of course the attending would show up freshly shaven and showered and fully rested. Legalized abuse in any form is simply unacceptable. The "rite of passage" or the hazing that takes place is beyond infantile and the patient population pays for it. Thought to note.... The majority of resident's are kind and considerate even though they are working 90 to 100 hours per week and the attendings that come in, well rested, are almost infantile. How does that change come to pass? We ignore the arrgance because we know you will only be there for a few minutes. Explode then exit.

    December 5, 2008 at 11:44 | Report abuse | Reply
  23. Dee Conant

    We limit truck drivers to 10 hours driving; and we should limit doctors too! How can they make life and death decisions when they are asleep and/or so tired you can not think. If a truck driver might kill a few people on the road, a doctor on 30 hour shifts might kill a dozen or more in an ER. Is he better than a truck driver? Is he exempt? Why?
    The idea that a doctor is superhuman is NOT acceptable and should be stopped. Doctors are trained to recognize disease and try to help those in pain. If fatigue makes them dangerous, why do we continue to allow the practice?

    December 5, 2008 at 14:19 | Report abuse | Reply
  24. Kathy

    Change is absolutely needed. Both patients and residents deserve better. No patient should ever have to suffer the results of a mistake made because a doctor has been awake too many hours. What if it happened to your loved ones??

    December 5, 2008 at 17:52 | Report abuse | Reply
  25. Dino

    I agree that we work our residents too many hours. I remember in the 60's when I was in nursing school it was the intern's responsibility to mix all the IV's for the next 24 hours. At that time we nurses were not allowed to mix IV's. We would lean the intern against the wall in the med room and let him nap while we mixed the IV's ourselves. We did not trust a sleepy student to do this when we had to hang the IV's.

    December 5, 2008 at 18:11 | Report abuse | Reply
  26. Trauma Doc

    1. I am senior surgical resident who is planning a to be a trauma surgeon. I say that work-hour limitations are a good idea but the one-size-fit-all mandates are not the way to go.

    2. As a reply to 'Dee Conant'.
    There is a HUGE difference between doctors and truck drivers' "shifts". Namely, our job requires human interaction, variety, necessity and, particular to my field, adrenaline. Where as truck driving is very monotonous, has limited interaction and they purposely avoid adrenaline stimulating situations. My last patient gets the same attention to detail as the first. Sleep or no sleep.

    3. I imagine that most, if not all, of us would gladly go home to our families and children if given the chance.... but the sick and the injured just keep coming.

    Sickness doesn't know about Christmas or the 80 work week.

    4. Most residents that I know have a tremendous amount of guilt associated with leaving the hospital knowing that there are things left undone to the next "shift" resident (who didn't admit the patient or operate on the patient or console the patient).

    5. Our population is getting older and the average acuity of patients is getting higher every day. Concurrently our physicians are getting older too. The perfect storm is coming: Supervising doctors retiring and residents having government mandated hour limitation. Who will be left to treat the sick?

    6. In reply to the original article.
    "* Limit shifts to 16 consecutive hours"
    This is nice on paper, but for most surgical services this is near our regular surgical day as an attending or as a resident: AM rounds, Surgeries from 7am until done, PM rounds then either home or be on call over night.

    "* Give residents more days off"
    Who is left to take care of patients?

    "* Provide transportation home after a long shift."
    This is also nice on paper... but how do I get BACK to work. I'm broke! I can't afford the taxi the next morning to get back to work, and most suburban public buses don't work that early in the morning.

    December 5, 2008 at 21:44 | Report abuse | Reply
  27. Harper, M.D.

    As an attending physician, since the protected residency hours have been in effect, the more I have seen residents who are less prepared for the real life responsibilities of taking care of patients. As many have already stated, attending physicians are well accustomed to 12 hour days, long weekends of being on call for several days straight, and being ultimately responsible for patient care. While I agree that some of the previous "old school" abuses needed to be tempered and reigned in, the more that we continue to police and limit the vital hours of residency training, the more our future health care providers' education will suffer.

    Emergencies do happen in the middle of the night and are not predictible–I want my physician to be able to handle this–even if he is paged out of a sound sleep to do so.

    December 5, 2008 at 22:49 | Report abuse | Reply
  28. stephen

    as an answer to several points raised
    For those who feel the hours should be limited, who is it that is going to take care of the patients at 3 AM ? Most health care does not take place at academic centers, it happens in community hospitals, and the attendings threre do not have residents and don't have the option of "signing out" to someone else at 7 AM. Since there are already hospitals that have a very hard time finding coverage for emergencies with some specialties, limiting hours would essentially mean there would be few mds willing to take call if they couldnt work clinic or perform procedures the next day. also, training should reflect real practice. As someone who has recently completed residency/chief residency/fellowship/chief fellow/junior acedemic attending/private practice, I have seen this from all angles and we will continue to work through the night and the next day if needed because people have to be taken care of – and that is why we have all committed to this profession. What should happen at 3 AM if you need emergency surgery, would you want the surgeon who has been up since 5 AM the morning before, or would you like to wait until 8 AM?
    I was chief when the new schedule came around, and the majority or errors that I have seen have increased, and are nearly entirely due to poor knowledge regarding specific patient's conditions as the resident was not involved in the admission / initial stabilization/diagnostic worlup done – even when handoffs were done well.
    Tough situtation, but to "limit the work day to -- hours" is not a practical solution for physicians, and certainly would not be acceptable to the majority of patients.

    December 6, 2008 at 00:57 | Report abuse | Reply
  29. H.P., MD

    The whole work hours issue has its root in money. Each year there are more patients in general and more uninsured patients in particular, so the health care system is forced to do more with the same amount of money, while the cost of medications and devices increases. Since the can be residents threatened with loss of their career their workload is made as high as possible, which reduces the cost per hour of care. workhour restrictions for residents came about after rich patients died publicly of egregious stupidity brought on by extreme fatigue.

    So the "workhours" are reduced, in theory anyway, but there are other ways around this restriction, such as home call by pager, which means waking up every 20 minutes or so to answer the phone, and going into the hospital a couple of times a night then leaving so as to not go over the time restriction. Or the more simple practice of just cheating, as when the program director says "work more but log less hours" with the understanding failure to comply with his demands will lead rapidly to the sidewalk. And the programs are safe doing this, since the ACGME's first response to a resident complaint is to contact the same program director with the name of the resident. Or more easily, as mentioned above, by pushing more hours on the junior attending who also faces the same sidewalk if he complains.

    Nevertheless, there is no good alternative as long as the demand for care increases while reimbursement remains the same.

    December 6, 2008 at 16:19 | Report abuse | Reply
  30. rekha

    working long hours hurt the doctor and patients. No one's brain can function more than 12-15 hours a day, then why have only doctors works for 30 hours shift.

    December 6, 2008 at 17:57 | Report abuse | Reply
  31. VenkER MD

    The enthusiasm and passion shown in this chat is wonderful. Everyone obviously cares greatly for the well-being of the medical students, residents, attendings, and of course the patients. There is likely no easy solution as fewer hours does mean more rested providers it means longer time to acquire the experience; the inverse is also with problems. The answers are likely not be as simple as creating regulations on a truck driver because of the factor of acquiring experience which takes significant time. Like many who posted here, I think before the pendulum was too far in the way of over worked providers. I do think shift hours is a solution that may be well suited to accomplish training, and well being for the provdiers. I do not think health care providers who use shifts are as "gasdoc" implies without dedication...is it a perfect answer, likely no. It does leave room for error every time there is a handoff. Shifts is one way, but I also think we are currently at a nice balance. One other solution is to have two residents on call who alternate periods of sleep and function, but for longer hours. I guess we will see what comes of the system in the coming years.

    December 7, 2008 at 00:22 | Report abuse | Reply
  32. Matt

    As a current resident in the middle of my internship, I have to say I have really appreciated the 80 hour work week/30 hour max shift thus far. At the same time, I personally would worry about decreasing it much further at this point. Recently my residency program tried a new call schedule which included staying in the hospital fewer nights but necessitated picking up new patients in the morning who had been admitted overnight. There is something about admitting your patients yourself that is tremendously beneficial, you can just never get to know a patient's history and medical problems as well when you don't do the work personally, and I noticed that although I was much more well-rested, my patients' care suffered. I simply could not work as well for them. I fear something like this could result on a bigger scale if the work hours are reduced too much.

    Yes the point is education but the fact is there is a lot of work to be done and the more you break the continuity of care, the more things will fall through the cracks.

    I agree with the comment that the key is not so much about hours as it is about adequate supervision.

    December 7, 2008 at 23:35 | Report abuse | Reply
  33. Georgia

    Having worked with residents in a hospital setting, I was well aware of the problem with lack of sleep. When the doctor for whom I worked was giving a lecture, I would actually have to tap various residents on the shoulder to awaken them. Also, I did most of their transcriptions for that department and many times had to correct them because they were so sleep deprived. I would even alert while napping in a private room, when they were needed. It was scary to watch, and I am happy that residents are now getting the attention they need to be able to be alert during their residency. It is also to our benefit as patients.

    December 11, 2008 at 19:51 | Report abuse | Reply
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