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On-call hours

Via Gruntdoc, this post from former infantryman in the United States Marines (a group who aren't generally known to be weak whiners) and now emergency medicine resident Panda Bear M.D. about on-call hours in medicine:

....The fact that your program has bitten off more than it can chew and cannot maintain it's commitments is not your problem. You are the low guy on the totem pole and are not getting paid to solve the program's problems. It is actually a leadership problem on the part of the program who are committing the cardinal sin of leadership: Not standing up for their subordinates.

Read the post, and read the comments. Everyone who knows me knows that I hate call -- give me the power to change one thing in medical training and it would be this. Residents are on-duty without sleep for far many hours in a row. The threat of federal legislation a few years back led the ACGME to implement an 80-hour work week rule, but this rule is often violated, and the rule itself isn't strong enough. Believe me, you can be worked beyond physiological reason under the current 80-hour rule.

The most fascinating thing to me about the whole thing is the seeming complicity of the residents. Panda Bear describes it thusly: "their thinking is cluttered with duckspeak from the medical establishment which not only hides the reality of the situation but sets the conditions of any potential debate to preclude anything but the party orthodoxy." Even if you don't agree that the residents are brainwashed, it's clear that they aren't the ones pushing for a more rational and physiologically sound schedule.

Consider this study performed at the University of Chicago by Dr. Vineet Arora and her colleagues. Despite finding that a nap period significantly reduced overall fatigue for on-call medicine interns, "use of coverage by interns on the nap schedule was impaired by their desire to care for their patients and concerns about discontinuity of care." In other words, when given the opportunity to sign over their pagers in the small hours of the night and sleep, medicine interns chose not to do it (although they did sign over their cross-cover patients).

These residents gave different reasons for not signing out their pagers, including a concern for patient care and a desire to stay informed about what was happening with "their" patients. Is this reluctance to just go to bed the result of brainwashing? The study can't tell us. There's really no way to know. The question is whether the reluctance of interns to sleep is something we ought to encourage, defer to, or override. I tend to think the latter, because I don't think sleep-deprived interns deliver good patient care. But, as Panda Bear's post points out, there's no definitive study out there that tells us how many hours are too much.

Given the economic incentives of hospitals, the absence of such a study means that the problem will probably get worse before it gets better. And we should be asking: what kind of evidence must we have before we take action to solve the problem?

Comments

If all I was covering on call were my own patients, I probably wouldn't mind it as much. As it stands, however, because the residents are spread so thin, on call you tend to crosscover many, many more patients than you can possibly know anything about.

On my last medicine rotation (my last, ever)I cross-covered up to 150 patients of whom I probably knew about fifteen or so. I had to educate some of the nurses who were irate that I knew nothing about their patients. This can be pretty unsafe because when the pager is going off every five minutes, you cannot go see every patient for whom a decision is required and have to rely on the nurse to fill you in.

We also have to admit patients and do consults on call, each one of which is a full-time job.

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