New medical resident work hours (or, Ask The Intern)

In My Humble Opinion
1

There was a headline on Yahoo’s home page today about the new work hours rules for medical residents. I’m not sure why it was today, since we’ve known about them for a year now and they don’t go into effect until July 1, but I think they’re trying to let the lay public know what’s going on.

That makes sense, since the whole impetus behind the rules was pressure from the general public. Residents have been lobbying for better hours for years, and decreased competition in some specialties has led to more humane conditions, but it took the threat of federal regulation to make them get serious about it.

That being the case, I’ve often wondered about the general public reaction to these rules. (I’m not around many people who exist entirely outside the medical world anymore.) Does it still seem like a lot of hours? Does it make you feel more comfortable knowing that they’re in effect? Does it makes you feel less comfortable knowing that a lot of programs will have to struggle to meet these requirements?

Here are the new rules, in a nutshell:

–Residents are limited to working 80 hours a week, total. In addition, they must have one full day off in seven, averaged over four weeks.

–“On-call” shifts may not be more than 24 hours long, and may not be more frequent than one night in three. (Note: unlike a lot of “real-world” practitioners, a resident who is on call stays in the building, and is often hopping all night.) An additional six hours are allowed for teaching, follow-up, transfer of care, clinic, etc.–basically, everything but admitting new patients. This puts the upper limit for a shift at 30 hours.

–After any given shift, the resident must have ten hours off before the next one. This effectively limits non-call days to 14 hours.

I’m not sure if anyone cares, but since this is a measure aimed at the general public, I was curious to hear what people had to say, and to answer anyone’s questions. (Any more general “Ask the Intern” questions are welcome, as well.)

Dr. J

2

I think these new rules are a good idea. I’ve worked in a teaching hospital (and have been a patient at a teaching hospital), and there were a lot of interns dead on their feet from lack of sleep. It’ll also ease the burden on nurses and other ancillary personnel because hopefully, the interns will be better rested, and so won’t make quite so many mistakes.

Robin

3

Well as a non medical person… I must say the last thing I would want is to be treated by someone who hasn’t slept in the last 30 hours! I know if I’m up more than 18 I’m a zombie who barely knows her own name never mind trying to do something lifesaving for another human being!

When I had my daughter our OB scheduled my induction for his “day” as OB on duty. I was thrilled to have him there but realized how inhuman his day really was. He came in that morning for 8am and I had a C section at 9pm and he was there all night… I saw him when I got moved to my room around 1am and then again around 7 before he went to do office hours. He saw patients the next morning. No wonder my office visits were always cheerier when he had coffee!!!

4

What was the justification for ever requiring residents to work these marathon schedules? Was it purely economic?

I suppose one could argue that the long grueling hours are designed to train a fledgling doctor for the rigors of medical practice. But is that realistic? How often are fully trained physicians required to work 30 hours straight after they’ve completed residency?

5

IANAD, but in interviews I’ve seen…I’ve heard these reasons:

Training docs need to observe the totality of an illness…“see the big picture”, something that has to occur over different time periods.

Sort of a “boot camp” mentality…toughens the docs up to make decisions under pressure yadda yadda.

I’m not saying that I agree with the reasons…

6

All I can say is that it’s about @(%@ time. I wouldn’t want to be in the same room as someone who hadn’t slept in 2 days, let alone have him/her make any medical decisions about me!

7

I’m sure the system was started because of economic reasons and then the other excuses came along later. It seems to me with a job like THIS being sleep-deprived would be the worst thing you could do to them!

I, for one, am inhuman unless I get seven or eight hours of sleep a night. I simply cannot imagine going 30 hours with a nap or two if I’m lucky, and having that sort of responsibility.

In other words – it’s about time.

8

I remember about a year ago they said the regulation was going to require an average of 80 hours a week over the course of 2 weeks, which i guess meant you could work 120 one week, but only 40 the next.

So is 80 hours the total max for every week now?

9

DoctorJ,

What residency are you in? Do you anticipate that there will be much non-compliance with the new rules? I’ve seen surgery residents work two full days with a night of call between despite the new regulations already theorectically in place (ie: all day, all night, all day or ~36 hours). Do you think that medical students will continue to work the longer hours because they technically aren’t making any life-saving decisions? On our medicine service we have call q4 days and work full days post-call . Do you think that residencies will end up having to extend training to meet competencies?

And lastly, any recommendations for externships in the SE in pediatrics or ER? It’s sign-up time.

10

“You know, the only problem with doing one in two call is all the cool cases you miss during the down time”.

Must of heard this five times from consultants during my residency! Now I get to say it to you! :slight_smile:

Really, it’s about time.

Dr_Pap,
Head of Emergency Medicine
Pipsqueak Hospital

11

What happens if you are not physically able to stay up for 24-30 hours? I would guess that some people would not be able to do that. Would those people not be allowed to become doctors?

12

Sorry folks-hate to break it to you but your regular doctor may frequently be up all night. When I took ER call (responsible for all unassigned patients coming to the ER) I would work a full day in the office, then admit up to 7 patients, then work again the next day. Personally, I found that too difficult so initially I scheduled my ER call on weekends, then gave it up altogether. However, I still have occasional times when I am up all night. What is worse, many specialists, like our Cardiologists, take call a week at a time. This means they could be up all night several nights in a row. I am not saying that this is right, just saying that if you are my patient and are admitted to the ICU at midnight I will probably be there with you all night and then work a full day the next day and come back to see you the following evening. I don’t want to sign over care to a hospitalist, but if you don’t want to be up all night (or can’t) then you either have to find another career or choose a specialty where patients don’t get sick at night (Dermatology?).

13

To take out a bunch of answers at once:

Residents work the hours they do because there is that much work to be done. You can limit the number of hours a resident can work, but it’s a lot harder to reduce the work load. The other reason they do these hours is that every generation worked longer and harder and walked further to the hospital through the snow (uphill both ways, with an onion on their belt) than the one after it, so those in charge have seen no reason to change things.

I’ve yet to see someone who just absolutely couldn’t handle the long waking hours. Then again, tenacity is the one overriding characteristic you’ll see in successful medical students and residents. It’s hard to predict–people who thought they needed ten hours a night to function do fine for 36 straight, but people like me who get by just fine on four hours a night find that we really, really need those four hours.

No, it’s worse–it’s averaged over four weeks! So, by that rule, you could work 160 hours for two weeks and have two weeks off. Of course, the other rules about days off and the ten-hour break offset this, so it’s hard to get screwed too badly.

psychobunny–how common is it in your area for an internist (which you are, IIRC) to still do both inpatient and outpatient? I know it’s area-dependent, but it’s becoming almost unheard of around here. I don’t like giving up the continuity and the personal touch, but I think there are definite upsides to the clinician/hospitalist model.

14

I’m doing Internal Medicine at Moses Cone in Greensboro, NC.

Not among programs that want to stay open. The whole point of these new rules is that they are now rules instead of guidelines, and they’re going to have to crack down. If they hadn’t done this voluntarily, the threat was that Congress was going to mandate a centrally-monitored clock-in/clock-out system, which would have been a colossal pain in the ass.

I can’t imagine that programs are going to require longer hours of its students than its residents. Similar rules need to be in place for students–stricter ones, really, since students need more time to, you know, study.

Medicine programs certainly won’t–the hours being cut off are not high-yield hours. Surgery programs might, but I have a feeling that they could muddle by on 80 hours a week if they put their minds to it.

As for peds/ER residencies, I can’t say much. There are a lot of great community-type programs here in NC, but I don’t know who has peds. CMC in Charlotte probably does–that was a great program. I really liked the hospital at USF in Tampa. Are you matching? Good luck!

15

One of my attendings had a comment on this that I thought I’d add.

Another intern was on overnight Sunday night, and at around noon the next day, one of his patients was starting to go bad, had to be intubated, etc. This intern stayed until the patient was stable before signing out.

“Next year”, this attending said, “you won’t be able to do that. You’ll have to go home at noon or 1:00, even though your patient is going south, even though you weren’t all that tired.” (He had had an easy night.) “We can’t let doctors think they can go home while their patients are still doing badly, like they’re shift workers or something.”

I disagree, but in practice more than in principle. Yes, I would agree that a doctor shouldn’t have to go home while he is still willing and able to help. For one thing, though, doctors are very proud people, and probably aren’t the best judges of when they have reached the limits of their abilities. Besides, what if he got that patient stabilized and another one crashed? And then another one? At some point, a resident has to trust his colleagues and turn his patients over to the next guy.

But shouldn’t he have the option to stay if he can and wants to? The trouble with that is that anything not forbidden becomes mandatory. Say he had been working for 30 solid hours and was hallucinating when that patient started to go bad. “Sure, you can go home if you want to,” they’d say, but they wouldn’t mean it. A resident who regularly (or even occasionally) exercised that option would be branded as lazy by his fellow residents, and when his review came up, he’d hear those words that every resident or med student hates to hear–“You need to step up.” We’d be no better off than where we are now.

I guess the reason I feel strongly about this is that I handle a lack of sleep worse than most people. If I’ve been working for 24 hours, my brain simply stops working. With caffeine I can go through the motions, but I don’t make big decisions on my own or do anything that might compromise patient care. I hand things over and go home to sleep as soon as humanly possible (though I do everything I can to make it easier on the next guy). I can tell that some people have been unhappy with me, but I have to recognize when I can no longer contribute to patient care and become a danger. I’m glad that next year, I’ll be able to do that more effectively.

16

I’ve never understood the “bootcamp” mentality that many doctors seem to have about this issue. I recall seeing several interviews with docs who seemed to think their entire profession would go down the drain if interns didn’t work 200 hours per day. Ridiculous.

Know any airline pilots? They have some really strict rules about how long they can work and how much off time is required. It’s about time the doctors did the same.

In the larger context, the whole culture in the U.S. towards manic work is silly and counterproductive in the end. Nearly everyone could use more sleep and more personal time. My friends from other countries are shocked that we Americans generally get only two weeks of vacation a year. They think we have no time to actually live.

17

My longest shift was 56 hours in-hospital as a 3rd year resident. There’s no substitute for being there long enough to see how it turns out, and see what made it turn out that way.

However, the net effect of that was tremendous Resident abuse in a lot of systems, so overall I think it’s better to have some concrete rules. Will there be occasions where both training and patients suffer, due to lack of continuity? Probably. But I think there will be fewer instances of such suffering under the new system vs. the old.

How do you anticipate your life changing after July 1, Doctor J?

18

I also think it’s about time. The new, amended hours still sound pretty rigorous to me.

How do you anticipate the workload will be managed with the reduced hours? I’ve heard speculation that hospitals will hire more Physician Assistants and Nurse Practitioners to help fill the gap.

19

My life will change more as a result of the transition from intern to supervising resident than by the new hours, especially since our system is fairly progressive as it is. (24 hour shifts are not all that common for us anyway, since we have night float.) I will have the responsibility to see that people who started at 7:00 AM yesterday are out by 1:00 PM today, and I’ll have the authority to make that happen.

My hospital will barely notice, as we only have family practice and internal medicine residency programs (with a few pediatricians floating down from Chapel Hill). We won’t have to do anything new to manage the workload, since we’re just trimming a few hours here and there; we’ll just have to do better about working together and sharing the load. Full-on teaching hospitals will almost have to hire physician extenders, involve more private attendings, and they may come to rely more on medical students.