Limiting work hours: residents and parents?

The Accreditation Council for Graduate Medical Education has enacted further restrictions on resident work hours.  No more than 80 hours per week of work for resident physicians, averaged over one month.  And no more than 16 hours of continuous work for first year residents (24 after that), which includes patient care, academic lectures, etc.

Whenever they do this sort of thing, everyone seems excited that it will make everyone safer.  After all, residents won’t be working as much, so they’ll be more rested and make much better decisions.  It’s all ‘win-win,’ as physicians in training and patients alike are safer.

I guess.  The problem of course is that after training, work hours aren’t restricted.  There is no set limit on the amount of work physician can be expected to do, especially in small solo practices, or practices in busy community hospitals.

I understand the imperative to let them rest.  I understand that fatigue leads to mistakes.  I get it!  But does the ACGME get it?  If physicians don’t learn to work with fatigue, don’t learn to make decisions and do procedures when they’re weary, then they won’t be able to do it later when they are completely, and totally, accountable for the patients in their charge.

Have I ever been fatigued and made a mistake? Probably.  But for the most part, I have learned that some of medicine is a kind of wonderful auto-pilot learned by hard repetition.  In an age of check-lists, it’s a kind of innate, well-practiced algorithm that kicks in when sleeplessness limits our creativity.  The fact that it isn’t printed on a chart or embedded in a computer program does not change what it is.

And it can only be learned by practice.  Kind of like parenting.  As a parent, there are no work-hour restrictions.  When your darling child is sick, you simply get up.  And when they vomit all night, you clean them, comfort them and if necessary drag yourself to work wondering when you’ll get your turn at the toilet.

When your kids are tired you carry them to bed and when they need help completing assignments you stay up. When they have to be fed as infants you feed them and when they have to be transported as teens, you take them.  You can’t tap out.

Medicine is a lot like that.  Once you’re out, seeing patients, and accountable, once residency is over, you can’t tap out.

I’ll make a prediction here.  Physicians are already ditching call responsibilities left and right.  But when new physicians realized just how hard it is to change from restricted work hours to unrestricted work hours, they’ll give up on call responsibilities so fast you won’t be able to say ‘circadian rhythm.’

You see, sometimes, life just makes you tired.  And in order to do what needs to be done, whether it’s surgery or raising children, you just have to deal with it.  And be tired.

10 thoughts on “Limiting work hours: residents and parents?

  1. 80 hours a week doesn’t seem like much of a break to me, and I don’t want someone putting my new lungs in at a teaching hospital with that weirdness behavior that comes from being up 48 hours.
    You had to do it, and I totally understand your point but as a recipient, I don’t want a nurse who has been up for 24 hours taking care of me, why would I want a physician doing the same. I love you Ed but I disagree w/you on this one.

  2. The problem is there is no restriction on a doctor’s hours, which there should be. A doctor is not a parent wiping a kids vomit up, a doctor is a person who is often making a critical life or death decision and those are truly not related to each other. A kid sick at home will recover in short order and fatigue gets a rest; a doctor is under constant fatigue due to his work hours, for years often, potentially until retirement. Many studies show that fatigue causes accident, that is why truck drivers are now limited in driving hours, why in the world would we not limit work hours for doctors, 12 max is enough, beyond that and you are not as good as you were four hour before that. Other studies have shown that after 8 hours workers return on effort goes down markedly, why would this not be true of physicians, they are human as well. I would ALWAYS want a doctor who was well awake and not in any way running on autopilot of some sort working on my family, or me. So, instead of thinking the ACGME did the wrong thing maybe we should be looking at the other things we are doing wrong instead…

    • Steve, first, great to hear from you! To the point: it’s relatively easy to make truck-drivers. We have a fairly limited (and getting more limited) pool of physicians willing to take call duties. And in particular, if one practices in a small hospital and/or rural setting, it’s even harder to find staff. So, your child has a ruptured appendix and is so sick he’s unstable; too unstable to transfer. The hospital has one surgeon available and he’s been up 24 hours. Do you just give him a rest? And parenthood isn’t always so easy. Parents with sick children, chronically sick, don’t get to take time off. Just a couple things to consider. Until we have many more physicians, and physicians willing to go anywhere and everywhere to practice, working tired will probably have to continue.

  3. Ed, good to know you are well, sorry to hear about your dad’s condition, we are praying for him. You have valid points, especially where the appendix is ruptured, I guess my thought on that is how often do you find yourself in a position that you have to work like that, can this be the exception, or is it the common occurrence? Regardless of my opinion it is as an outsider and I am not aware of the intricacies surrounding the medical community so I now bow to your wisdom here.

  4. I strongly disagree with this. You are making the same argument that attending physicians made prior to the work hour restrictions, only veiled under a disguise. It’s the same “we had to do it, so you should have to do it” only with some lipstick. When an attending physician feels that he or she is too fatigued to safely continue they need to step up and say so. To ignore that and continue on is a reckless disregard for their duty to their patients. There are times when 24 hour shifts are needed, but only in very low volume situations where there is down time to rest.

    We are the same as many other industries before us. If we do not regulate ourselves and deal with the elephant in the room, which is working while fatigued, then someone else (meaning the government) will surely step in and tell us how to do things. I’m sure we all agree that less additional government involvement in our day-to-day activities would be a good thing.

  5. These residency work hour restrictions simply do not reflect the reality of the private practice world. It’s all well and good to wish that your doctor isn’t tired and that he doesn’t have to work too much. In real life, there simply aren’t enough doctors to work 8 or 12 hours and go home. As it is, many hospitals are already short on specialists. Pass a law demanding that none work more than 12 hours in a day, and care will simply evaporate. “Oh, sorry, Dr. X has already worked 12 hours today, I can’t call him to (take out your appendix / stent your coronary artery / evacuate your subdural hematoma / stop your hemorrhage / etc.)” just does not fly. Even if you wanted to open up three times more medical school positions, we’re decades away from making those positions available and those physicians making it into the workforce. Sorry, but this is reality, every night of every day. Virtually every single night at virtually every single community hospital throughout the entire country, physicians are roused from sleep for work, after they have already worked an entire day, and will have to work an entire day the next day. There is ABSOLUTELY NO WAY AROUND THIS NOR WILL THERE BE FOR THE FORESEEABLE FUTURE. Wishing and believing otherwise simply does not make it so.
    In fact, there is a crude though nonetheless incisive saying about wishing in one hand that some may need to review.

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