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By Walter Wiggins
The debate over resident duty-hours has been active in the news recently, with articles emerging that suggest residents are unhappy with the new duty-hour restrictions and that the new duty-hour rules neither provide relief from resident fatigue or increased patient safety1 – the stated primary goals of duty-hour reform.
Another study suggested that resident concerns about making significant medical errors have actually increased since the implementation of the new duty hours2. These startling revelations have prompted a new discussion about the real issue with resident workload3, 4.
The issue, it seems, is that there just aren’t enough residents to cover all of the work and that increases restrictions on duty-hours only exacerbates the disparity. However, mixed opinions exist as to how this problem will be best corrected5.
While the obvious solution would be to increase the number of residents across the US, this approach would be costly and would take years to implement. An alternative solution would be to increase the efficiency of care, reducing the need for more doctors.
This approach would tackle two of the greatest issues facing modern healthcare: cost containment and physician shortage. However, it would also likely take a long time to implement and require significant changes in medical education, as well as the clinical practice of medicine.
Clearly, these issues are important to all of us in medical training, as we will face them sooner or later. But what implications do the duty-hour restrictions have on medical education?
At my institution, medical students are required to abide by the same duty-hour restrictions as interns. That means we may only work a maximum of 16 hours per shift and 80 hours per week, must have at least 10 hours off in between shifts, cannot be assigned overnight call unless it is part of a night-float schedule, and are allotted at least one full day off each week on average throughout the month.
On some services, these guidelines are very easy to follow and do not significantly limit our educational experience. However, on other services, these restrictions create more headache and fatigue than the old system, while providing a lesser educational experience.
Night-float shifts are the worst offenders. The way they’re set up varies based on the service, but often med students find themselves barely getting adjusted to a nocturnal schedule when it is suddenly time to revert back to the usual daytime schedule.
Forget studying and forget life outside of medical school…we’re too focused on not falling asleep at the workstation, or even worse, while rounding with a resident or interacting with a patient. Never mind that this shift causes us miss all of the educational conferences and teaching rounds that occur during the day, either. Nope, we’re too busy trying to track down the intern while simultaneously frantically responding to medication requests, wound checks, and periodic exams for the dozens of patients the service is cross-covering overnight. But at least there’s that random Thursday off before switching back to days after only 3 or 4 night shifts. Maybe, then, it will be possible to find some time when we’re not too bleary-eyed to crack open that book we haven’t touched and study for the shelf that’s coming up next week.
Uh-oh, there goes my pager…no, wait…it was just my imagination. Of course, who pages a med student on night-float…?
1. Sen S et al. Effects of 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013; 173(8):657-62.
2. Choma NN et al. Effect of the ACGME 16-hour rule on efficiency and quality of care: duty hours 2.0. JAMA Intern Med. 2013; 173(9):819-21.
3. Goitein L and Ludmerer KM. Resident workload – let’s treat the disease, not just the symptom. Commentary. JAMA Intern Med. 2013; 173(8):655-6.
4. Chen PW. “The impossible workload for doctors-in-training.” NY Times Well Blog. April 18, 2013. http://well.blogs.nytimes.com/2013/04/18/doing-the-math-on-resident-work-hours/5. Grover A and Fisher ES. “Should hospital residency programs be expanded to increase the number of doctors?” Wall Street Journal. June 16, 2013. http://online.wsj.com/article/SB10001424127887324563004578525454050176758.html