More changes to resident work hours on the horizon?
(You'll have to open the PDFs for the Table of Recommendations and Report Brief to read the details.)
In fairness, I must make a couple of disclosures:
- I trained before the era of the 80-hour workweek. It was just coming into being as I was finishing my residency. I have previously in other venues documented my own ambivalence, even as a resident, toward the 80-hour workweek in medical training.
- When I'm on clinical service, I frequently exceed 80 hours in a week. If you start my clock on Monday, I have managed to exceed it by Thursday on more than one occasion. I seldom to never have 10 hours between "shifts" because I don't work "shifts". Days off? They happen when they happen- though even I have acknowledged that I haven't been getting enough of them in the last year or so.
- The people who write the recommendations for the IOM? Just so you know, most are not clinicians. They have NO idea of the implications of their recommendations, both in terms of workload or in terms of training/ education.
I've actually been a bit snarky in some of my discussions of the new IOM recommendations because they are so fundamentally divorced from reality for those of us who work in acute-care, emergency-based, procedural areas of medicine. Sure, I can give my resident a five hour nap time, but what if that's when a new admission happens to show up and it's the only "big" burn they'll get a chance to help resuscitate? From an attending surgeon perspective, it's honestly easier for me to handle a big admission on my own- I'm faster with any of the procedures that need to be done than are any of the residents, and if I'm by myself I don't get slowed down by teaching. But....as my long-time readers know, that's not why I have the job that I have. I love teaching. I love teaching almost as much as I love clinical care, and some days (when the patients, families, or both are making me a little crazy or a lot sad) I love teaching more than clinical care. I'm here to teach. My residents? They're here to learn. It's Graduate Medical Education. And I worry that the last of those three words is somehow getting lost in all of this.
Don't get me wrong- I'm not a fan of the old days when we walked uphill both ways in the snow while barefoot either. It's inhumane, it fractures families and lives, and ultimately education can't occur when someone has only had 15 hours of sleep in 10 days (not that I was ever in that position during my transplant rotation). I blame the inability of the medical profession to self-police for the institution of the 80-hour workweek in the current form anyway- maybe, just maybe, if we had minded the store a bit better people wouldn't have gotten all riled and residents wouldn't be forced to leave in the middle of a tremendous learning experience so they won't violate work hours.
It's a precarious balance, and I'm certain I don't have the answers. I do know that if these more stringent recommendations were to be put into place that we would require substantially more residents (or PAs/NPs, who are a substantially more costly option than residents!) in order for the patient care that occurs on an urgent/ emergent basis to be conducted. Yes, that idea applies not just to surgery- but to any procedural or acute care training program. Perhaps more concerning to me is that my practice doesn't allow me the privilege of the current ACGME regulations that our housestaff are subject to, and that additional reductions in those hours or adjustments in length of shift work would mean that resident workloads and environments will differ even more sharply from the reality of practice.
I have to believe there is a balance somewhere. Striking that balance? That's the challenge- or the opportunity- that we're faced with.
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