Saturday, March 29, 2008

Hours Violations: in which I state the obvious

I've been reading a book by a fairly well known surgeon -at least in the blog realm and whose webpage helped guide me to his accounts of residency training. I have been amazed at his descriptions of the quantity of time he spent in the hospital including a 2 month stint where he never left. What's more is the distinct void I perceive in his life during this time and how he viewed the demands then and now, despite the sheer exhaustion, as necessary to produce a qualified and competent surgeon. In his introduction he bemoans the work-hour reductions, calling them a "pathetic, embarrasing, and paltry 80 hours..." implying overtly that in a few years he expects more deaths to occur due to reduced skill levels and knowledge than ever occurred from fatigue. I might just agree.

It's not hard to believe that the work hour restrictions have upset a lot of the older docs out there who view their interruptive nature as ample fodder for shift mentality and weak residents - both mentally and physically. I've been on the fence about the benefits - since I'm quite sure that having overly exhausted residents invariably leads to poor patient care, but also am quick to acknowledge that the sign out process absolutely results in less knowledge and poorer patient care. Despite this duality, I continue to hold the belief that some of the older docs see the restrictions as an aggregious afront merely because of bitterness at having lost several years in their training while we, the apparent coddled and weak heirs, talk about our social lives, families, and aspirations beyond the hospital-tiled walls. I don't have a definitive answer on whether the restrictions are a blessing or curse, but I have enough sense to comprehend the concerns that attendings and residents have alike when dealing with patient care and violations.

With all that being said, it's important to understand that since 2000 the rule to average 80 hours over 4 weeks has been in place. Not just brought up in vague armchair discussions, but fully implemented and, though weakly, enforced. It's lost it's virtuous shine long ago and hospitals should have made the adjustments by now. Yet we still find various programs continuing to ignore them, risking not only their accredidation but their resident's well-being. Imagine having to work a year or more where your program wasn't accredited - you may even have to try and sign on elsewhere and you'll understand some of the concern residents have when they're over hours regularly. It is prudent of the residency program to understand the serious nature of the regulations and do what they can to turn out highly qualified physicians while regularly meeting the hours.

Yet, I don't know why every residency must meet the same criteria. For instance: anesthesia and emergency medicine have long held their residents to a 24 hour limit while on call. This was done based on the nature of the work - critically ill patients, highly lethal drug combinations being given, and the distinct truth that a patient can die quicker in these professions from a slip of the drug needle than from a slip of the hand. The nature of surgery, on the other hand, demands that the resident be in the hospital more often for both exposure and endurance - all necessary for a truly capable surgeon beyond resident training.

When I was on the floor for surgery we had one resident and two interns - one of which was a family med intern doing their month for the year. They were in charge of the ICU, the floor, ER coverage, and running codes - all while still getting in the OR. I know for a fact that the surgery resident and intern never met 80 hours. They were there nearly everyday, all day, for 2 months as this was mandatory to get through the work. In other institutions I've seen residents in the OR as long or longer than my anesthesia residents and still had the duty to pre-round each morning and round on post-ops. I know for a fact they weren't meeting the hours restrictions either.

Surgery training itself is longer than many others - 5 years or more during which you're required to take care of patients both in the OR and in the hospital. A lot different from medical docs who don't have the burden of fitting in an 8-10 hour OR schedule into their patient to-do lists.

Surgeons were training at 120-140 hours a week just a decade ago as they felt this immersion was requisite in obtaining highly skilled physicians. Would it not be more feasible for them to meet their training goals and still meet work hour regulations if specialties that generally need more time were alotted 100 hour weeks? The writer's assertion, mentioned earlier, of an impending increase in mortalities if we don't recognize the fallacy in the 80 hours for surgical training is quite insightful.

Let me be more blunt - would you want a surgeon who hasn't seen as much OR time taking care of you? Would you want any doctor for that matter whose training was abreviated for any reason taking care of you? No one needs to be there 24/7, but I think we can admit there's a need for those who, just by the nature of the work, demand more hands-on experience to receive more training before they go at it alone.


Old MD Girl said...

Or, do you want a surgeon who has the motor skills of a drunk person cutting you. Sure, you may get used to feeling exhausted all the time, but you never stop having the coordination of a drunk person when you don't sleep for 24 hours (or 26 or 48) hours straight. The "endurance" argument is a bunch of bullshit. If they're really worried, make the programs a year longer.

M said...

2006, AMA conducts a Safe Hours audit and "the results in the surgical category come as something of a surprise," (verbatim) because 36% of surgical interns/registrars (residents) work at "high risk" (106-113 hours a week) whilst a further 49% are at "significant risk".

(Asinine comments from those behind our National Code of Practice. Funny that these risk labels don't contain any enforceable measures yet somehow mangle their way into accreditation processes for training surgeons...)

It's a double edged sword for surgical interns and registrars in Australia because accreditation from the Royal Aus. College now requires you to gain all your experience and exposure between the flags.

It's a moot point to argue. Work hour restrictions have to be more flexible when it comes to surgery.

Fatigue is no defence for negligence by a doctor in an action by a patient, but neither is incompetence.

M said...

Hmm. I really should have clarified that "high risk" is a label ultimately stuck on the foreheads of those that choose to work a 70 hour week in Australian hospitals.

I'm all for establishing enforcable limits; fatigue leads to bad medicine but it's a delicate balancing act. Tailor it for each residency.

Anonymous said...

methinks thou doth protest too sure spend a lot of time trying to convince yourself and us of why you didn't want to be a surgeon/why being a surgeon sucks...hope you happy with your second choice of careers.

MSG said...


I which way did you take this post as a protestation? It was actually an agreement with the notion that surgery training requires additional hours beyond that of 80/wk. And I've been more than forthcoming about my reasons for not entering a surgical residency - long hours, time away from family, less control over lifestyle after residency, etc. I love surgery, but anesthesia allows me to be in the OR, doing manipulative and complicated procedures, and more ability to be with my family and control my hours. Sheesh.

Bruce said...

I wonder if any studies have been done on success of surgical outcomes as a function of total number of hours spent in training? It seems like a no brainer that more training = better surgeon.

What I question is the marginal benefit of hours 80-100 of the week. Or for that matter, hours 24-30 of a given shift. Leaving aside for the moment the questionable level of care being provided, are you really learning anything? After being awake for 24 hrs straight?

The idea of a longer residency w/fewer hours per week makes sense to me, but then I don't want to be a surgeon. Most who I know that want to go the surgery route are more the "balls to the wall" type than the "life balance" type. So they might rather do 5 yrs of 100 hrs/wk than 6-7 yrs of 80 hr weeks.

Liana said...

Did you read my recent post about cardiac arrhythmias and pediatric fellows on call?

Anyway, I think it's quite obvious which side of the debate I've chosen... but that's why I went into family med. Ironically I've now worked 34 hours on 4 hours of sleep, but that's neither here nor there...

There was a BMJ study which found post-op complication rates were 45% higher if the resident was post-call. Maybe I'm nuts, but I definitely do not want a post-call resident learning on me.

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