November 10th, 2009
Duty Hours – What are your thoughts?
Andrew M. Kates, MD
Fellows: Do you feel like you spend too much — or not enough — time in the hospital? Over the last several years, there have been dramatic changes to the number of hours that residents and fellows are permitted to spend in the hospital during a given period of time, during both the day and the work week.
A letter from Thomas Nasca, M.D., the CEO of ACGME and the Vice Chair of the Task Force for the Revision of the Duty Hour Standards, provides an interesting perspective on the rationale behind the changes in duty hours and the effects (both positive and negative) that these changes have had.
So, what do you think?
Do the changes in duty hours leave the physician-in-training more or less prepared to handle the challenges of practicing medicine in the “real world,” where duty hours do not exist?
What do you see as the positive and negative effects of these changes?
Can you describe times when your training was limited due these changes?
Can you describe times you felt pressured to not comply with these requirements? How did you handle this?
How do you think these changes affect cardiology differently than the other subspecialites? Or do they?
4 Responses to “Duty Hours – What are your thoughts?”
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Primum non nocere
Don’t even get me started on “Duty Hours.” The fundamental concept behind limiting resident work hours to ensure patient safety and house-staff sanity is obviously a good one, but the untoward consequences are alarming, and often ignored. And the model chosen by the authorities, just restricting it based on one criterion, “number of hours,” is fundamentally wrong!
There are a number of factors that need to be addressed, both provider-related and patient-related:
Provider-related:
1) Lack of personal responsibility for each patient
2) Lack of personal accountability towards each and every outcome
3) Diminished opportunities for critical decision making
4) Loss of hands-on experience and real-time learning and feedback regarding incorrect diagnostic decisions as well as incorrect management decisions
5) Ineffective feedback from faculty, due to fragmented nature of faculty-student interactions
Patient-related:
1) Lost opportunity to form a strong patient-physician bond, due to constant “breaks” in interactions due to “on-off” shift-work-style scheduling
2) Hesitation of patient to express their true feelings and opinions due to the lack of trust and unfamiliarity with an individual housestaff
Students entering medical school need to understand that MEDICINE is a true-calling, a profession that requires your utmost dedication and commitment. It is not a JOB! Our patients trust us; they rely on us, our presence, our hard work, and compassion to get them through their illnesses and sufferings. There is no room for, “Sorry, I am past my 80-hours and I cannot sit here and listen to you talk about your concerns. Just let the next guy who comes on duty know if you decided for-or-against your CABG for your LM disease.” There is no room for that in the real world; and there should be no room for that during house staff training.
If we want to train caring, compassionate, and dedicated physicians, we have to train them as such throughout the entire process: medical school, internship, residency, and fellowship. You cannot expect this generation of doctors to work on a 80-hour, or the ridiculously idiotic, proposed 55-hour work-week, and then expect them to wake-up the next day and take on all the responsibilities that come-along with becoming an independent attending physician!
The consequences of these actions will be very apparent in 10-15 years when there is distrust and lack of confidence in physicians with the next generation of doctors!
I agree with some of the above. As a 2nd year cardiology fellow, I have experienced the shift in the work-hour limitations, beginning my Internal Medicine training when they were not rigorously enforced, and ending it just when they were. Fellowship training is somewhat different, but there is pressure being applied there. It is highly problematic to institute the specific RRC and IOM regulations in the system we have in place now, given the inherent structure of the training programs, and it is frustrating for houseofficers to feel their work habits are being overseen by a group of people they’ve never met (many of whom are not doctors). This has been written about, and debated, ad infinitum. In theory, the new system COULD make it possible for physicians to take care of more patients, given that it essentialy mandated a team-centered approach, with perhaps more responsibility and more accountability. Furthermore, if could possibly afford more self-directed learning. But I do not think that there will be “distrust and lack of confidence in physicians with the next generation of doctors.” I do not know any colleague of mine who feels that they are doing just a “job,” or who would walk away from a patient’s history or to voice their opinions regarding management. I do not feel they are any more or less compassionate having worked the hours they have (or have not). The people I work with feel the same way I do–that the study and practice medicine is a privilege—and they act on that privilege accordingly, despite growing external pressures. I feel incredibly fortunate to have met role-models–both clinical and research mentors–who set an example of the physician I hope to be like, to grow into. They all trained in the “old model,” which is one of the reasons I have reservations about the new work-hour rules (although I do understand them). Time will tell whether the current set of trainees can grow into these physicians.
In my own experience I believe that there are both positive and negatives that have come from this change. For the most part, I believe that many of the negatives can be overcome by viewing the duty hours not as an absolute but as a strong reccomendation. While ACGME may not view it this way, when it is in the best interest of your patient to continue providing care beyond your “30 hours” or “80-hour” week, there is a strong argument for continuing to provide that care. Conversely, there are also times, when I feel that continuing to work having not slept for 30 hours when there are others available who can fill in and do just as well, maybe better considering their overall level of functioning, probably is not in the best interest of the patient. To my knowledge all the studies that have looked at outcomes in the setting of duty hour restrictions have either shown a benefit in the new ‘era’, or have not shown a significant difference. I am not aware of any studies which have shown harm. Given that, and in light of the new proposed recommendations, I think it is unlikely that we will revert back to the old system anytime in the near future. As a result, I think a critical aspect of medical education moving forward will be to make clinical education more efficient. Steps have been made at many institutions to do this and I think that further steps need to be taken so that there can be continued improvements not only in patient care but also in medical education in light of these changes. Doing so will help ensure that this generation of physicians continues practice medicine which is most beneficial for our patients.
Hot topic
Andy has obviously hit a nerve here! At our insitution (UT Southwestern) the work hour changes have had a far greater impact on resident as compared to fellow training, but the trickle down to faculty and fellows is enormous. Personally I have absolutely no gripe with a limited number of hours worked per week. My problem is with the 30 hour period of consecutive work. This makes it so difficult to both teach and take care of patients and seems ridiculously inflexible to me. With even a few more hours post-call we could all design systems that work for both patient care and education. In the past few years rounding for me has become a much more time consuming endeavor as a result of the changes.
The lack of flexibility put us in a position that we are all trying to create systems we don’t believe are ideal to meet an arbitrary standard we don’t agree on. There must be more “adult” ways to manage this.