I’m certain that the practice goes back far beyond that, but I’m sure that was one of the many justifications used to keep from doing anything about it until the last few years.
As an intern there are definitely good and bad sides to the work hours regulation.
Positive aspects would include less likelihood for mistakes caused by sleep-deprivation (good for patients) and knowing there is a light at the end of the tunnel (i.e., knowing that the pain will definitely end by a set time).
Negative aspects include that the amount of work residents do is not decreased, just compressed into fewer hours. Hours are taken away from resident education – the work has to be done and lectures/conferences end up taking a backseat. Plus, you can be so rushed to get through everything by the time to “clock out” that more errors are made than when you are able to go through the “to do” list more methodically. Also, the transfer of care from the post-call residents to on-call can be shaky at times.
Plus in real life I don’t think the responsbility of the physician ends after 30 hours. If one of my patients is dying, even if I’m not directly providing the care because of being post-call I feel I have an obligation to be there for the patient and his/her family.
Then on a lighter note, there are always the complaints from the old folks about how they worked ninety hours straight, drew all their own labs, cooked all the patients’ meals, and walked home in the snow. 
That’s true, and I’ve been preaching on that point since the beginning. I think this will eventually change, though, at least in primary care-type programs like mine. So many programs are skirting the line that they’re going to have to make fundamental changes instead of just trying to put 10 pounds of shit in an 8-pound bag.
The drawback here is that most programs will require more residents, and there just aren’t any in primary care; this means a lot of programs that have trouble filling now will probably close.
I always hated lectures and conferences, so I always saw that as a plus. Seriously, I learn by taking care of patients. reading about their problems, and discussing them on rounds or with my interns. It does suck for the people who get a lot from the lectures, though.
The only response to the check-out issue is just getting better at it; we all have to check out eventually, and we’ll be doing so from now on, so we need to just get good at it.
Yes, and the one drawback is that sometimes a resident does feel the need to be there longer than the 30 hours. That’s a very rare situation for the resident (as it should be for a doc in real life–otherwise he needs to re-examine his setup), as opposed to the far more common situation of an intern being given far too many patients and then having the attending drag rounds out for five hours. If there were a way to allow the former while discouraging the latter, I’d be all for it, but I’ve yet to see it.
Never forget that back in those days (at least, in the days of my attendings), a patient with an acute MI was put in the hospital for six weeks, and the only thing ordered for him was a stool softener.
When do mistakes happen most?
Anecdotally, my experience has been that mistakes happen most under two circumstances: when people are rushing; and when information is inadequately transferred. Again, I wouldn’t say that sleep deprivation is good but I am unconvinced that it is the primary cause of many significant errors.
As Dr. J notes, the work needs to be done. How do you get it done? Fewer hours for the same workload just causes more rusing and less careful handoff in the hurry to leave more time to get the work done. Hire more nurses to do more of what is dumped on the residents? There’s a nursing shortage out there and good nurses are both hard to get hired and very expensive right now (no surprise after years of being dissed and dumped on by hospital administrations). More residents? This presumes that you can afford them, that significantly increasing the numbers of docs out there looking for work in practice after residency is a good thing, and that you could attract them to these primary care residency spots in high numbers. None of which is likely true and filling the spots with foriegn grads is more difficult in this now post 9/11 world. Make the attendings come in and do more? It is already hard to keep docs interested in working for an academic center. They make less and have more administrative BS to put up with. If they do research the sirens of big Pharma are always singing. If they are interested in actual practice there are private practice options with much nicer lifestyles. Nagannahappen. Not prudent at this juncture.
Making the rules is nice, but obviously it is hard to enforce. Few are going to leave before they have finished what needs to be done. The machismo/dedication that Dr J himself evinces (“if anyone stayed late, it was going to be me.”) begins before internship. We all want the good rep. No one wants to dump their unfinished work on the next shift.
Internship year sucked. Personally, my wife and I had our first child that year and she experienced a severe postpartum depression. I felt like a rubber band that should have snapped a few tugs back, what with trying to be a good doc (and earn the respect of my peers) and trying to be a good Dad and husband. I’d love to see meaningful change.
But wishing it, or mandating it (without attending to the costs and consequences), won’t make it so. Present a real pragmatic solution and I’d be interested in listening. Otherwise it is a lot of posturing, easy solutions for a politician to legislate or a bueracrat to propose, but which actually solves nothing or worse yet causes more harm in the long run.
Also Dr. J, I’m no fan of lectures, but morning reports, meaningful case presentations, Journal Clubs, meaningful evidence based reviews (rather than just reciting the most recent guideline) take time and energy. Push more into less time and they will get even more short shrift then they do now. Let alone actually learning how to effectively communicate, how to care without getting burned out, and all of that stuff that we docs are so often accused of doing so poorly.
Not really machismo or dedication. As the supervising resident, it was my job to see that my team was within WHR compliance, so the best incentive for me to do that was a policy of “if anybody catches hell, it’s going to be me”. (This is why my interns loved me.) 90% of the time, we all got out in time with no problems.
I agree with everything you said. Even with my unfailing support of the WHR, I don’t think they’re a solution to anything–they just give residency programs an incentive to find solutions, which they didn’t have before. I believe that it’s possible to provide good patient care and good learning within the stated limits, but programs aren’t going to make the effort to figure out how to do it until those limits are externally enforced. It means the next few years are going to be rocky, but most programs are figuring out ways to do it. (It’s working very well for our program.)
If we get down the road in a few years and programs that are really trying are still struggling, or if we find learning and/or patient care are going downhill despite our best efforts, we can re-examine things. But if you think about it, the norm for internal medicine interns is now q4 call (that is, every fourth night overnight shifts); it was not that long ago when the norm was q3, and for my more senior attendings the norm was q2. I don’t think we’ve lost anything along the way, and we’ve gained more doctors with their lives, families, and souls intact. Maybe we can go further.
As for lectures, my view is jaundiced because many residents at my medical school would spend 3-4 hours a day in educational activities that were totally unrelated to the patients they were taking care of, and most of them were just awful. I prefer the way my program does it–we have a single noon conference every day, and otherwise the learning activities are built into the process of patient care, to the point that we tried to have morning report several years ago and it was redundant. It’s one of the reasons why I chose this program.
The upshot of the 80hr workweek at the institution where I completed my residency in 2003:
Interns ‘cross cover’ (that is to say, manage the patients of other surgical services, like the GI surgery intern covering the vascular surgery patients) for twice as many services, so that fewer interns need be on call on a given night.
Because the intern is now the go-to guy for up to 200+ patients, their nights are really hopping. They no longer have any time to see patients in the ED, so this is passed up to the 3rd year residents, who are also covering the ICUs and going to traumas (and cross-covering for more patients as well).
Senior residents are now on euphamistic ‘home call’, where you do not in theory sleep in the hospital but you are on pager and can sometimes drive to and from the hospital several times a night. Because the intern and junior resident are now so busy with ward calls and ICU calls, the senior residents now do appendectomies and hernia operations by themselves at night, which is of no learning benefit to them and pisses off the attendings.
A typical team has an intern, junior resident, and senior resident. The interns are on q4 call, the juniors maybe q4 or q3, and the chief is on permanent home call (Don’t leave town or have a beer until your vacation comes up). When the intern or junior is post-call, they leave at noon or so, so now a 3-person team is down to 2 people for up to 4 days a week. Plus, according to the administration, for senior residents only time spent in the hospital counted toward your 80 hr workweek: not time spent on the phone, driving to and from the hospital, etc. If you think it sucks to spend nights on call in the hospital 3x/week, you haven’t lived through the pain of driving in from home 3-4 times a night for six weeks straight (Don’t stay in the hospital between consults! You’ll run out of working hours by Thursday!).
Back in MY day as an intern, I was frequently on q2 call, which sucked, BUT I knew that if I got in trouble I could call another intern (there were usually 3 on per night) or my junior resident. IF the junior was busy I could call the ICU junior or the trauma junior. If they were busy I could call the senior. Nowadays, the lone intern is really screwed if the lone junior is running a code in the unit and the lone senior is in the OR with the attending. Oh, and don’t forget to cover clinic three days a week! What do you mean, everybody went home?
Clearly I was not fond of their solution to the work hours problem. In a perfect world, the hospital would have been found to be sitting over a diamond mine, so that the department could hire nurse practitioners to take care of >50% of the intern duties like discharge paperwork and chasing down lab work, consult reports, etc. A night float system would have split us into ‘day’ and ‘night’ shifts. All of these changes were taking place in a setting where the nurses were on strike at one point, the hospital was often running at 100% capacity, and the surgical services were experiencing such a boom that elective procedures were often scheduled as late as 9PM. Suffice it to say that widespread work hour reporting fraud ensued.
At least it’s better than it used to be, when ‘resident’ meant just that - that you LIVED in the hospital until your training was over, married men and women need not apply, draw your own blood and run your own labs, etc. etc.
The bottom line is that, there are many things that are considered malpractice in hospitals that may be technically “legal”. Why should overworking employees be any different?
The bar analogy works, bars are responsible for drunk drivers if they serve too much alcohol, and this is a more passive action. If hospitals FORCE interns to work to the point that they are going to create errors, then they are responsible. It is not that they are only allowing them to do this, they are basically forcing them to do so, and it is considered standard procedure for them to work that number of hours.