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Residency work hours — evidence, please

sleeping_docVineet Arora, an internist at the University of Chicago, has an interesting post up at Kevin MD (reposted from her own blog) about the controversy between those who want to reduce resident work hours and those who worry about an increased number of handoffs between residents. Both sides say patient safety is the goal.

Arora does an admirable job of describing the controversy without advocating for her favored solution, or even revealing whether or not she has one. She points out that there isn’t a whole lot of evidence backing either side of the debate. So for now, what we’re mostly left with is anecdotal evidence, common sense, and politico-economic pressures for partisans on both sides to wield against one another.

Subject to correction by actual evidence, my anecdotal, common-sense take on the controversy is this:

  • we can and should reduce resident work hours from what they are now (or at least, from what they were before the ACGME work-hour restrictions were implemented), but this means that we must be more careful about how we conduct patient handoffs.
  • all else being equal, physicians in training with less experience will become fatigued at different rates than experienced and fully trained attending physicians. Not enough attention has been paid to this issue, I suspect. It makes sense that an experienced internist would be less fatigued by 30-straight hours of assessing patients and making decisions about their care than would a second-year resident, for whom all the patient presentations and therapeutic decisions take up so much more conscious brainpower. An experienced attending might be able to admit a patient with pneumonia “in their sleep” because she’s done it so many times before, but the same admission probably requires a much more well-rested resident.
  • each specialty has different working environments that contribute differently to fatigue. An hour of duty in the ER is probably more fatiguing than an hour of duty on an internal medicine floor or in a pediatrics clinic. So, each specialty ought to be subjected to different work-hours requirements.
  • handoffs have the potential to contribute to patient safety if done right. In the ER where handoffs are regular and frequent, patient care plans often get better after the handoff process where the outgoing physician has to think about how he’s going to present his patients, and the oncoming doc has to clarify each patient in her own mind by asking questions. In an ideal handoff, the patient gets the benefit of two doctors simultaneously thinking intently about their condition.

One thing that I’m very glad to see is that it isn’t enough, anymore, simply to say “I used to work three days straight without sleep, so you need to do it too.” The old-guard attendings that relied on that strategem have been, not to use a too-inflammatory term, defeated. These days, you’ve got to actually make an argument for long work hours, instead of just harrumphing and frowning and talking about how young physicians just don’t have the same kind of commitment to patients that their elders do.

I hold out hope that as we do more studies and subject this issue to more objective analysis, we’ll find that the old harrumphers are discredited even more thoroughly. If we do handoffs right, for example, no internal medicine resident ought to have to work for thirty straight hours in the ICU. I eagerly anticipate real data proving me right.

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