8 Comments

Here is the issue. We restricted the number of hours that the residents can work. We did not increase the number of residents. So we have fewer people for the same amount of work. To compensate, some centers are using ARNPs and PAs to cover the patients on the floors. So, instead of a tired physician with 4 years or medical school and up to 5 years of specialty surgical training, you get a nurse with no surgical experience and a masters degree.

Its really even worse. That regulated resident wont have as much experience as an older doctor. Weird things just dont show up at a hospital at a regularly scheduled time.

Throckmorton’s comment seems right on. The problem isn’t the restriction on hours, it’s that the hospitals responded to the restriction by cutting patient care instead of increasing staff. Note this point in KevinMD’s post:

“The researchers suggested that the reforms mean fewer doctors are available in a hospital at any given time, so that residents have to care for more patients during a shift, and fewer senior-level doctors are available to supervise junior residents.”

Sort of like passing a law to require drivers to turn on their headlights when their windshield wipers are operational, where, as a result, many drivers don’t bother to turn on their wipers in light rain.

All endeavors are constrained by three things: Time, Resources, and Performance. Change one – fewer properly trained resources for example – and you’ll either need more time or have lower performance.

I remember rotations where we took call every other night and never got to bed at all during that time. I remember falling asleep during afternoon rounds. I remember working hard for 32 hours, going home, having dinner, and then sleeping and getting up the next day to do it all over again. I remember attendings who said that the trouble with every-other-night call was tha you missed half the good cases.

That said, the issue of resident workload restriction is complex. Fatigue causes errors, but so do handoffs. If I were seriously ill, would I rather be taken care of by an exausted resident who knew my case well or by a well-rested one who was unfamiliar?

Workload restrictions are common for workers whose performance can endanger human lives (airline crews, railroad crews, commercial truck drivers, etc.) So are they really unreasonable for house staff? The issue is a bit different with doctors. If the plane or train is delayed because the crew has to rest, then the worst thing that happens is that passengers are delayed. If a truck driver has to pull over and rest, the shipment is late, but so what? But in health care, the sick patient can’t be told to postpone complications until the doctor gets his rest.

Nonetheless, the issue is that, for generations, hospitals have regarded house officers as endless troves of free labor. Ask a nurse, a lab tech or a ward clerk to stay late, and they have to be paid overtime. But not so the resident! If it’s the middle of the night and the patient has to go down to radiology for an emergency X-ray, get the house officer to take him. Need blood drawn stat and all the phlemotomists are all busy? I know who to call! ER really swamped tonight? Just get the residents to stay late until they’re all taken care of.

I don’t think the Duke study proved much because it was retrospective and did not control for confounding variables. I’m not denying that handoff can cause problems, but hospitals routinely deal with them in other areas. Nurses work eight-hour shifts and hand off their patients when they leave. Doctors can learn to do the same.

Hospitals cant just increase residents like you buy another car. The slots or positions are funded by Uncle Sam who wont give more slots.

Back in the 1960s, the hospital where I did my internship and residency became concerned about errors committed by tired residents still in the OR on Sunday morning, working on patients they admitted during a 24-hour period of call that began at 8 am Friday (and should have ended 8am Saturday) The system was changed. Any patient whose surgery was still pending at noon on Saturday became the responsibility of the Saturday team. After a period of time, they went back to the old system. Hand-offs induced more errors than fatigue.