Medical training was grueling during my residency nearly 20 years ago. After completing four years of medical school, new MDs routinely worked 110+ hours per week in their area of specialty, for anywhere from three to 13 years. It was not unusual to work stretches of 30-40 hours in a row without sleep. Three times after a work shift of 35 or more hours, I fell asleep at the wheel on my way home from the hospital and rear-ended someone. (Thankfully, nobody was ever hurt.)
When working, the combination of adrenaline and caffeine kept me sharp, and I never felt that my care of sick kids was ever less than the best I could give. In every situation during residency, I was working in a team of physicians at many levels of training, and we constantly provided checks on each other’s thinking. Medical students with years less experience than myself, other residents of roughly my training level and fellows and very senior attending-level doctors with decades of experience worked together on every child’s case.
The goal of the residency years was to teach me everything I would need to be a safe, effective and knowledgeable pediatrician able to function independently at the end of my training. It was an incredible experience, and I would have changed none of it (except for those three fender-bender moments).
But the system of cramming so much learning into a relatively short number of years by working extraordinary hours has been controversial. In 2003, fueled by concerns about medical resident fatigue and errors and under pressure from Congress, the Accreditation Council for Graduate Medical Education issued national regulations for medical resident duty coined the “80 Hour Work Week.”
The new rules mandated:
- Maximum duty hours of 80 hours a week averaged over 4 weeks.
- No shift longer than 30 hours (direct patient care for up to 16 hours, plus protected sleep period of five hours with remaining time for transition and education).
- Maximum call schedule of every third night (no averaging).
- Minimum time off between shifts of 10 hours after a day shift, 12 hours after a night shift and 14 hours after an extended duty shift.
- Maximum of four consecutive in-hospital night shifts.
- Mandatory five days off per month with one day off per week (no averaging) and one 48-hour period off each month.
The rules have now been in place for several years and have generated interesting and controversial results, including:
- More “hand-offs,” where physicians leaving their shifts have to checkout all the details of every patient’s care to the shift of doctors coming on, increasing the chance of “dropped” important details.
- More disjointed care for patients, who used to be followed by their doctor team for long stretches until they had made it through their surgery or scary health issues — which often didn’t fit neatly into a specified shift length.
- Fewer surgical cases completed by young surgical residents coming out of training compared with their counterparts of my era.
- Pressure on physicians in training to conceal how many hours they are working.
- Widespread use of “night float” systems, whereby one team of doctors has to work nights for weeks in a row — causing significant sleep disturbance as residents go on and off of these night shifts every few weeks.
- Less opportunity to train outside of the hospital in clinical settings similar to what physicians like myself do every day. Instead, all hands are needed “on deck” at the hospital, decreasing young physician’s opportunity for learning from mentors in outpatient clinics.
- Dissatisfaction by residency directors. A recent research article surveying attitudes about the people in charge of training young pediatricians showed that most of them were not happy with the net result of the 80-hour work week.
What’s the right answer? How do you teach young physicians a vast amount of crucial knowledge in a safe and effective manor in the minimum time required? I’m not sure I know. The average physician coming out of school now has a debt of over $300,000 to repay, so everyone is eager to get a job and start paying off their loans.
Thus, my answer of “make residency longer” doesn’t sound good to most young doctors going through training. But it seems to me that if you’re not allowed to work the crazy brutal hours we used to work, which clearly had its significant drawbacks, the only way to get the exposure we had to sick patients is to add another year.
I hasten to add that the physicians who are recently out of training and are joining Eugene Pediatrics are excellent young doctors. Drs. Chase, Romanoski and Sidor are all incredibly bright doctors and have a vast fund of knowledge. I would let any of them take care of my own children without hesitation. These individuals were among the shining stars of their residency programs, and I made sure to hand-select the best of every class to join our practice here in Eugene. In general, I suspect the mandates of the 80-hour work week have had less an impact on the “thinking” specialties like pediatrics than they have had on surgical specialties.
The medical profession is increasingly under a microscope, as we see national health care reform unfold. All of it is a work in progress. So, it should come as no surprise that the way doctors are trained is also being studied. I will be among those fascinated with the results, as should we all be.
After all, we are all patients at times, too.