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Wednesday, June 27, 2007

Some of the unintended consequences of restrictions on house officer hours

The NEJM (June 28,2007) has two commentaries regarding the fall out and continuing analysis of the effects of the changes in house officer hours and rules governing how much time the trainees can work at the hospital.One of the two is available full text for free and can be found here. There is also an audio file interviewing Dr. Ethan Fried, a residency program director.

There is a tension between the hoped-for reduction in errors by having better rested residents and the fear of increased errors and dropped balls by having frequent hand-offs between teams of residents. Dr. Fried believes there may be more risk of the latter in the first day of admission to a hospital but also believes that the supervision and backup by more senior residents can mitigate that tendency.

In addition to the issue of is-the -new- system -less- error prone, there is the fact that since house officers are working less someone else has to. Accordingly, there is a trend to having non-teaching services maned by hospitalists and NPs and PAs at a cost some institutions are hard pressed to bear.

But, in my view even more important is what the new system might do to the evolving competency and mind set of the residents. This issue is discussed by Dr.Wes with his usual insightful analysis.
He wonders if an error free residency what we really want? Do we not learn in part by making errors in an environment where we are buffered and protected by our mentors and more senior colleagues?How will this cohort of residents fare when they are truly out on their own and there will be no team to hand off to when they have been up most of the night taking care of patients and fielding phone calls? Will they call their office and tell them they won't be in until noon because they need their protected ten hours post call ?.

The ACGME kicked off this major change in post graduate medical education in July 2003 and now four years later we seem to be seeing the fall out of a program that may have been initiated and mandated without sufficient planning regarding what now seems obvious collateral effects.The jury is still out regarding if this restricted duty plan actually improves safety or paradoxically has the opposite effect while increasing costs.

When I am old (OK, older) and sick will I want my medical advocate (wife) to insist on a physician who finished his training before July 2003? I have ranted before about the effects of changes in the IM program brought about by ACGME that in my opinion result in a marked loss of the sense of personal responsibility by the doctor for the patient. Teams and systems and protocols and flow charts are no substitute for a physician who believes she is personally responsible for the medical welfare of her patient even if she may be tired. A shift work mentality may be fine for a factory worker but when I grew up medically it was unthinkable for a physician.


Anonymous said...

Oh her Christ's sake. I am so sick of the mentality that we have to be chattel slaves to a hospital that uses us as low-payed labor to keep the meat moving in an out of their patient mills.

Blah blah blah. If you can't train somebody for a job, any job, in eighty hours a week for three to six years then something is wrong with how you conduct training.

Sleep is pretty important too. Why should any person be deprived of it for during the many years of medical training. The hospital doesn't give a rat's ass about residents and work them 24 hours a day, seven days a week if it could.

The fact is that I want to sleep eight hours every day and that I have some family and social responsibilities outside the salt mine. Screw the old school doctors lamenting the fact that we are no longer the scut-whores over whom they used to have absolute authority.

P. Bear
Emergency Medicine Resident PGY-2

Anonymous said...

This article is just infuriating. Typical if the "I suffered, so you need to suffer too" mentality that I see so often in older docs. The writing is on the wall, and the simple fact is that this generation of graduating physicians does not feel the necessity to whore themselves to a hospital at the expense of their family, their outside life, and their health.

And another thing, if you are going to expect me to work 80+ hours a week, at least have the decency to pay me the same as the newly minted RN from the local community college who is making $25 an hour.

Anonymous said...

As a potential hospital patient, I sure as hell don't want a inexperienced surgical resident who hasn't slept for 24 hours operating on me. We'd be in an uproar if commercial pilots trained in the same manner as doctors. Both have the potential to kill if sleep deprived.