Joseph Scherger, MD, MPH
Throughout my career, I have been in favor of restrictions on resident work hours. After watching how surgery residents worked in the 1970s, I wanted none
of that “prison sentence.” After choosing family medicine, I found a program with “civilized” work hours. I do not think much learning happens after working 80 hours in a week, and patients do get harmed by residents who are too fatigued to care or use good judgment.
I embraced the 2003 ACGME resident work hour restrictions since they had flexibility but limited the on-duty time to 80 hours a week and guaranteed some days off each month. Residents could still sit with patients who were going through a long labor and delivery process or who were in end-of-life care. These long experiences are some of the most memorable for residents and do not occur too often to cause chronic fatigue. They showed the resident how well they can work under occasional extreme circumstances, a skill that would be valuable in a crisis.
The 2011 ACGME work hour restrictions are much more specific and prohibit the time for any “work shift.” First-year residents may no longer work on any given day more than 16 hours. That means that if the resident is with a woman in labor or at the bedside of a critically ill patient they must end their work and turn the care over to another resident. Second- and third-year residents must do the same after 24 hours and must be able to have a “strategic nap” after 16 hours. Is this the continuity of care of a family physician? No family physician in practice would ever consider such an abandonment of their patient! This is how emergency room physicians work, and I wonder if these new work restrictions will transform family medicine into shift workers.
There is evidence that we become less effective in our clinical judgment after 12 hours of continuous work and certainly after 16 hours. With that being so, we should train for teamwork where another physician joins us in the care of the patients after we become less effective. That would reinforce that we are not superman and should ask for help but would not take us away from the very situations where we may be doing the most good and are having a great learning experience.
I hope our leaders in the ACGME will make an effort to revise the resident work restrictions again to allow for both continuity of care and teamwork, so we can balance both clinical experience and patient safety.
STFM Blog 
Of course we are training shift workers, and this has been the concern (among others) since the beginning of work hours policies. I’d love to see some evidence of positive outcomes as a result – decreased rates of errors, patient-oriented stats that impact morbidity and/or mortality, and the like. Seems all I have seen is negative impact in areas like board pass rates and perforformance on the inservice training exam.
I really don’t think the rules will allow us to prepare docs for practice in the real world. Our patients will suffer as a result.
I agree with the above comments, but would add that the “one size fits all” approach to resident work hours by the ACGME disadvantages Family Medicine in particular. They presume that all work is shift work done in the hospital. This is fine for anesthesiology, ER, ICU, and maybe even IM which is virtually all inpatient. But FM training is centered around our continuity clinics; our PG2 and PG3s are in clinic 4 half-days a week.
An FM residency could have residents never exceeding 60 hours a week (or, for that matter 50), have a day off every week (not even “on average over the month”) and still be “dinged” if, heaven forfend, a resident should only have 9 hours off instead of 10 between leaving the wards and going to clinic. This is missing the big picture for the sake of monitoring small change.
I agree whole heartedly that we are training shift workers in the only field other than parenting that should not be constrained by time. I know of no illness, disease, or condition that punches a clock or waits until the time is convenient before needing to be addressed. While I agree resident physicians should not be used as low cost high volume labor, I also believe that treating them as hourly employees devalues their education and training and makes medicine seem more like a job and not a proud profession. While I count my current classes among my brightest, I fear that when they return to their rural towns they will be ill prepared to serve the entire community. A community that will expect their doctor be present at their births and deaths, challenges and recuperations, joys and tragedies. They will not want to hear about the hand off, sign out, or shift change. Or worse yet they will accept that care is best designed by guidelines and rules and that every problem must be solved within the allotted twenty minutes.
Dr. Scherger has hit the nail on the head. We have lost sight of the bigger picture–lost in the morass of the regulations from the ACGME. I wholeheartedly agree with the concept of teamwork. That’s where overlap on shifts is absolutely helpful. Our program tries to encourage teamwork but with the regulations it forces our hand into building shift workers. It is very evident in continuity OBs. However there are a few residents who “get it.”. Our programs must instill in our residents the concept of the bigger picture and reinforce what behaviors are to be emulated. I believe this stems from the core competence of professionalism which is unfortunately the hardest to measure and change.
Absolutely, we are training shift workers. It is sad that medical profession in now being treated just like other professions, not that I am looking down at other professions. The thing that separate medical profession from the rest is our stamina and resilience, our ability to mentally, physically and emotionally response to situations that require high order thinking despite high pressure. The new duty hour requirement also may potentially threat continuity of care and patient’s ownership.
I had a third year rural training track resident demand compensation when I told him he and I would be covering the practice for admissions instead of a night float who incidentally didn’t show. His rationale was that it wasn’t his shift per our handbook. I politely told him he was relieved of duty and did it myself.