Readers interested in medical liability issues, or health care in general, may find Kevin MD’s thoughts on the issue of medical residents and sleep to be of interest. His thoughts are particularly useful because they’re counterintuitive.
Anyone who attended medical school before 2003 (when real restrictions on resident working hours were put in place), or just hung out with medical students and young doctors as I did (the nurses who attended their parties were far more, ahem, interesting than whatshername from Criminal Procedure) can tell stories about the brutal, seemingly insane hours that students and most especially residents were forced to work in order to move on in the world. 20 hour shifts weren’t unheard of, nor were possibly exaggerated tales of shifts in excess of 36 hours. Truck drivers aren’t allowed to work the hours that residents used to and still do work, for good reason. The hour restrictions, we were told, would or might result in a marked improvement in patient care.
Moreover, anyone who has brought or defended medical malpractice cases can tell anecdotal horror stories of the resident who added a zero to the prescription dosage, or cut a few millimeters too deep. Some lawyers have gotten very rich spinning such stories for juries.
And yet, and yet … There’s no empirical evidence (to date) that the restrictions on resident hours have produced significant improvement in patient outcomes. Nor is there empirical evidence that patient care suffers as a result of more frequent “doctor turnover” as one resident passes care to another who is unfamiliar with the patient’s history, but Kevin MD makes a persuasive case that it has. As for the impact on medical costs of employing additional doctors to cover patients, that’s indisputable, at least if one doesn’t take litigation expenses into account.
Note that I don’t agree with Kevin MD, though my evidence, like his, is mostly anecdotal. My longest experience without sleep was DJ’ing at a college radio station for 40 consecutive hours, and I had to call a friend (oddly enough, a medical resident) to drive me home and pour me into bed. On the other hand, I’m pretty sure my second longest experience without sleep was just before my first argument before an appellate court. I won the argument handily, but I slept well the night afterward.
Anecdotal, non-empirical comments from doctors and nurses who read Overlawyered would be particularly welcome here.
13 Comments
I am an OB/GYN. The biggest problem will come when these hour restricted doctors have to go out in the real world. There are no hour restrictions when you are the attending.
We recently hired a new associate. She made comments like, “So you work after your day on call!” Well yes we do even when we’ve been up all night. Since I am in a nonacademic large community hospital we don’t have residents that can cover for us at night. We take 3 days of call in a row for weekends. So we’re on call from 7 am Friday to 7am Monday, and then we work all day in the office on Monday.
Since we are in a rural area, if we didn’t work after call there would be a gigantic back log of patients waiting to be seen in the office.
My worst day in residency was a 34 hour shift when I was on my Internal Medicine rotation. I got to the hospital at 5 am to pre-round, and then worked all day. I got about 45 minutes of sleep that night from about 4 am to 4:45. I then was at the hospital until about 3 when I got to come home. I lived 10 miles from the hospital and I don’t remember anything about the drive home.
The worst call that I remember on the OB/GYN service was a Saturday call where I never even saw the call room. I did get to deliver 12 or 13 babies that night. My fellow intern also never slept and she too delivered 12 or 13 babies that day. At least we got to go home at 9 am on Sunday.
Old-time surgeon’s question: Why shouldn’t a resident get every other night off?
Answer: Because he/she will miss half the cases.
The principle effect of work hour limitations has been to increase discretionary time for residents. This translates to very little extra sleep, if any, according to their sleep diaries. Not surprisingly they do report improved feelings of well being.
Every resident we’ve hired into our group for the last 3 years has commented to the effect, ‘damn, you guys really work hard’ once they became attendings. The difference is we (who’ve been around for a while) found attending practice to be a welcome relief, whereas the new guys have not really had their mettle tested yet.
SSFC, I only take issue with your characterization of lawyers “spinning” tales of sleep deprivation into big bucks. Many of us know doctors who work too many hours in a row. This is dangerous for patients, despite a lack of a meta-study confirming that hour restrictions equal better or safer care. The following study is one of many illustrating a basic concept echoed in your post (where you referred to truckers): fewer hours of sleep is a bad idea for anyone entrusted with the safety of others, particularly those entrusted with the care of the sick and injured. These people need more sleep. http://archives.cnn.com/2000/HEALTH/09/20/sleep.deprivation/
You mentioned your argument before an appellate court – while I understand the rigors of preparing for trial or an oral argument, there must have been a point at which you were able to make the personal determination (as opposed to the “I’m still on shift” attitude) that you were either as prepared as you could be, or your client would benefit more from your sleep than additional preparation.
I as the spouse of a rural FP, my wife is very busy with call. In the real world, an attending has no work restrictions because call is done so that other docs may have some time off. During call, especially weekend call, she is usually gone all day and often up during the night answering pages. She regularly curses it. Call during the week is less brutal, but can still be rough. It would be best for young docs to have experienced tough call so they are prepared for the real world.
I have to agree with some of the earlier comments. I am afraid that there are no work hour limits out in practice. In fact there is the opposite. If you are on staff at a hospital you must take call for unattached patients who present to the er except in very few situations. So, if you are in a small specialty, no are it. For example, in general surgery the ER will call you constantly. You cant say, “Gosh, I just finished a whole says worth of surgery, so I am off duty”. It is actually against the law to not come in. This is because of EMTALA and COBRA laws. If a hopsital provides a certain service, it must have a call schedule and can not refuse to see patients that fall into that category.
Another thing to consider is this. With the cut backs in working hours, there is a cutback in experience. This is especially in emergency cases which usually happen at night. Would you rather have your surgeon be someone who has done 200 emergency splenectomies or one who has just finished and has done half to one third? Should we increase residency years to compensate for the education that is lost? Neurosurgery is at least 7 years after medschool, general surgery at least 5.
Medical centers are replacing MD physcians in specialty training with PAs with only 3 years of training. (No medschool) or ARNPs with 3 years. (An intern has at least 4 years of medical school.)
Question: Accepting the fact that more experienced attending physicians must work long hours, does it still make sense to reduce the hours of less-experienced resident physicians?
I teach at a family medicine residency. I am 52, and was a resident in the early 80’s when the 36 hour day was common. The extended work hours are not about gaining experience, it is dollars. Hospitals love the cheap labor. The docs who work as long as I do now do it because our employers say we have to, or the self employed doc can’t stay in business any other way. The Work ups done by a resident after 24-36 hours of being up are useless. They are superficial, and often wrong, creating even more intersting liability issues. Maybe the residencies should be made longer to make up for the fewer patients the residents see, but that is quite an expense. I have had too many residents driving home at 5 pm after working 36 hours, fall asleep at the wheel. It is a silly archaic system (just my opinion of course, offered to keep the conversation going)
I tend to agree with you Russell. The next time I visit a hospital as a patient, I have a new addition to the litany of questions that I already ask any doctor I see: When did you last sleep?
I have to agree with Russell. I shared a house with my MD sister in the early 80s when she was doing her internship and residency. 36 hr. shifts were not uncommon and frankly, she was barely functional as a person (much less a medical professional) at quitting time. I also recall that her compensation was less than mine, working as a low level computer guy. So, I think money clearly enters into it.
Is it really necessary to have emperical studies to tell you that someone who has been working for over 24 hrs. straight is likely to have a noticable decrease in performance? Any doctor can tell you that 🙂
I’ve had a few decades of experience (non-medical) working long shifts and seemingly endless on call rotations and I can tell you that the error rates for myself and my colleagues rises noticably and dramatically after hour 16.
A good chunk of it has to do with the necessary brainwashing soon to be hatched doctors must get: they must make godlike decisions that no human being should have to make, but are inherent to the job. Get you sleep-deprived enough, yet still having to order this and that, well, it gets ground into you, you can. Sleep-deprived enough, self confidence issues just don’t signify, and you learn a pavlovian type ability to deal with life and death in a dehumanized, robotic state, which is what a doctor has to do. Or so the practice thinks.
Now, back those zombified being programmed pre-doctors with a few experienced and capable nurses, and the body count can be kept down maybe. But it has to be recogized, training doctors is as much about inculcating attitude and confidence, necessary to make terrifying decisions, as it is about improving technical skills. There is a reason that old-school internships and Gitmo techniques have a certain amount in common.
It is called brainwashing.
I am on the faculty of a Chicago medical school and trained in the early 1980s. I worked between 90 and 110 hours a week. I can’t honestly say that the longest shifts made me a better physician, though they did make me more cynical (if that was possible). My wife notes that after long, 36 hour plus shifts, I would come in and be simply incoherent about the simplest things.
However: I did have the benefit of seeing emergent disease problems through to their completion. I did have the experience of being fatigued and learning how do deal with that in my decision-making. And I saw a lot more, and did a lot more, than the current residents at my program see and do. I have a knowledge base that 25 years later makes me the physician that I am today. The young doctors coming out today will have a different knowledge base due to the difference in hours, as well as technology, life experience and changes in education style.
Will they be better docs? I don’t know but I worry about the future. Doubtless those who trained me said the same thing.
Those stories of excessively long shifts aren’t all exaggerated. I trained in MA pre-work hour regs and my longest shift was 52 hours without sleep. I crashed my car on the drive home and in my q2 calls and 120 hour weeks contemplated suicide. Oh yeah, good times. Try it some time.