October 29, 2004

Sleepy doctors

The rationale for keeping resident physicians in the hospital for thirty six hours straight and working them up to one hundred hours a week has been steadily weakening, as evidence accumulates linking sleepy residents with reduced performance and a higher rate of patient-care mistakes.

Dr. Bard-Parker summarizes two new studies in the New England Journal of Medicine that support the common-sense intuition that sleepy interns are more error-prone. He rightly points out that these studies haven't completely resolved the issue. As residents spend less time in the hospital, the frequency of patient hand-offs from one resident to another will likely increase. This lack of continuity may itself be a source of error, as Dr. Centor points out.

It seems that the best solution--the one which results in the highest quality patient care--would be to structure residency work hours to balance out these two effects. Most likely, the ideal balance would be different for different specialties and medical settings. Work hours might be much shorter (or longer) in the ICU than on the medicine floors, the psych unit, or the emergency department. If this is correct, then the current ACGME regulations might have to be amended to account for the different practice realities of different specialties.

Another option would be simply to rescind the regulations and trust the specialties to exercise self-regulation of resident work hours that favors patients. While most residency program directors might favor this option, I wonder if it would be wise. Apart from the irrational traditionalism that some program directors still cling to, there are very real financial and institutional pressures that might lead to residents working hours that were best for the bottom line instead of for the patients. This was the reason for the ACGME restrictions in the first place (or, if you're more cynical, it was the threat of work-hours legislation). Assuming the right mix of leadership and institutional support, however, this would allow for the flexibility that is certainly required to set the best policies.

Apart from this, though, is another concern, suggested by some of the comments on Dr. Bard-Parker's post, and by the article cited in his previous post. Shortened work hours might be negatively affecting the ability and willingness of residents to take responsibility for the patients they care for.

My own suspicion is that if you need to work a surgeon, or any physician, 100 hours a week to ensure that they are adequately committed to patient care, you've picked the wrong resident in the first place. No one is suggesting that surgery, or any other medical specialty, should be a "lifestyle" profession. This idea, it seems to me, is a relic of the traditionalist view that physicians must martyr themselves to demonstrate their commitment to patients. It's a different question, of course, whether a resident might not have to occasionally pull 100 hours a week in order to provide the highest level of patient care. But to claim that a resident who doesn't do this isn't sufficiently responsible or committed is irrational.

Anyway, for a good sense of what it might be like to work long hours as a resident, read this.

For your diarrhea quote of the day, go here.

Posted by Carey at October 29, 2004 10:11 PM