How do physicians on the frontlines feel about the ongoing debate about their working hours? Here are some of the comments to a recent Washington Post article1 on the issue by people identifying themselves as physicians. While we cannot confirm that they are, the comments appear to be well informed and made in good faith. We list a few here that IRB Advisor readers can consider on their own merits:
• A third-year internal medicine resident: “We have 30-hour call every 6 days on the wards and every 4 days in ICU settings. Intern year — first year residents — work a max of 16 hours per shift. I think the study is necessary to evaluate what is the lesser of two evils. Yes, studies clearly show sleep deprivation makes decision making difficult. But are hand offs worse? We don’t know. That’s why it needs to be studied. When I was an intern and had to be the night time coverage (night float), I would cover multiple day teams, which meant I was in charge of 60-90 patients each night. There’s no way to completely relay all that information to the covering person, hence why handoffs — at least in internal medicine — are dangerous. I personally don’t mind 30-hour calls, so I am interested to see what this study shows. [I] definitely think this is more than minimal risk — don’t know how that got through IRB the way it did.”
• Fourth-year medical student: “You have to consider the risks to physicians and medical students in addition to the risk to patients. After three weeks of 30-hour shifts every 4 days, my smoldering depression grew into full-blown suicidal ideation. I recognized that I needed help when I walked past the cleaning supplies cart in the hospital and fantasized about drinking the bleach. Previously, I was working 80-hour workweeks without issue. Such severe disruption of sleep cycles can have a serious effect on students and physicians with pre-existing mental health conditions, and if the patient outcomes from sleep deprived physicians are similar to those from multiple handoffs — and I admit I don’t know the data on this — we should opt for multiple handoffs in order to preserve the health of the physicians as well.”
• Internal medicine resident: “I am currently in a system involved in this trial, and so have done a year without this type of system and am now on 30-hour calls for my medicine wards months. And for some hospitals, it’s better for the physicians and patients. A lot of commenters here seem to think that this is a draconian system imposed down from above with little regard to resident quality of life, patient safety, etc — which could not be further from the truth. I was intimately involved in the design of our call system for this year and for some wards it works really well. It is absolutely true that most of the important medicine for a patient happens in the first 12-24 hours after admission, and it better trains physicians to be able to stay in the hospital to see a patient through that time. It’s better for the patient if the doctor taking care of them is the one who knows them the best.
The reason why handoffs produce mistakes is that it necessitates one or two residents take the patient load of many teams — generally 40 or more patients — overnight. Even if the handoff is excellent there is no way to give that resident all of the information that you — as the patient’s primary doctor — have at your disposal. Even when I am awoken in the middle of the night with a page from a nurse who is concerned about a patient, I am better equipped to understand what to do than someone who has never met my patient.
The point really is that when a tragedy happened, in the Libby Zion case, the entire American residency system changed its work hours restrictions without really asking the question, ‘is there real evidence that this will reduce errors?’ Or will we just substitute one type of error — an exhausted resident — for another type of error — handoffs. A lot of people in the profession think that this is exactly what has happened. Certainly there need to be restrictions on work hours to protect residents and protect patients (like the 80 hour per week max). But you do lose something when you don’t stay in the hospital, and that is experience and knowledge that down the line is incredibly valuable.”
• ICU physician: “I’m not an internist, but I disagree that this is minimal risk. Every single institution participating in this trial should clearly make all of their patients aware so that care can be obtained elsewhere if desired. I’ve reviewed many medication errors, most of which fortunately do not cause harm, but they usually involve an overworked, distracted member of the medical care team who is trying to multitask in a chaotic environment. An intern who hasn’t slept in 28 hours, six weeks out of med school has very little to add or to take away from this kind of situation. At best, he/she’s just in the way, at worst, he/she’s a danger when trying to order pressors or anticoagulation or take care of a critical patient. I think the primary driver of academic internists wanting residents to work more is that they don’t want to have to do more work themselves — they’d rather be at home or in their labs. I wouldn’t get on a plane piloted by someone who hasn’t slept in 30 hours, and you or your parents shouldn’t be admitted to a hospital by that person, either.”
- Bernstein L. Some new doctors are working 30-hour shifts at hospitals around the U.S. Washington Post, October 28, 2015. http://wapo.st/1NaGA5t.