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Safety and Numbers

By Dr. Sachin D. Shah
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Ask any physician who is either in training, or has completed training, and they’re likely to agree: Residency is hard.

As a resident, you are expected to work long hours, including most weekends, and are regularly on call, which usually entails working all day, overnight, and into the next day--sometimes as often as every third night.  The relentless work schedule is thought of among many physicians as a rite of passage in medicine, and part of the lore of becoming a doctor.  But the issue is a bit more complicated.

In 2003, because of mounting pressure from patient groups and politicians, the Acccreditation Council for Graduate Medical Education (ACGME), which oversees U.S. residency programs, instituted a limit on resident duty hours, restricting the work week to no more than 80 hours.  These rules also limited continuous patient care to 24 hours per shift (with an additional 6 hours permitted to complete certain patient care activities), and mandated an average of one day off every week.

I started residency in 2006, a few years after the new rules were instituted, when hospitals and training programs were just getting the hang of the duty hour regulations.  Still, I routinely worked 80 hours a week, and was on call every 3 to 4 nights 8-9 months out of the year.  I completed my residency last year, in the summer of 2010, right around the time the first revisions of the original duty hour restrictions were being settled upon.

Starting this coming academic year, the rules will again change for residency training.  These recommendations were based on studies showing that being awake more than 16 hours at a time is equivalent to having a blood alcohol level of 0.05%.  The Institute of Medicine (IOM) also weighed in, recommending limiting all resident work shifts to 16 hours, and requiring a mandatory 5 hour nap for anyone working more than 16 hours.  

An ACGME task force ended up enacting a policy limiting interns to a maximum of 16 hour work shifts, and requiring more supervision for them.  Residents are still able to work 24 hour shifts (with the 6 hour extension for certain patient care activities), but the rules completely change the game in residency, as they effectively end all day and overnight call for interns.

Having finished residency less than a year ago, the issue resonates with me as I reflect on my training during the last four years.  The hours were long, but I consider the experience I got caring for patients to be invaluable in becoming comfortable with acuity and clinically competent and confident as a physician.  Internship and residency are fundamentally about seeing a lot of patients and learning how to care for them by doing so directly.

To follow the natural history of a serious, acute illness as an ICU intern taught me pathphysiology and clinical reasoning in a way I could never have learned otherwise.  To make real decisions cross covering the floors overnight, when you’re responsible for scores of patients, many of whom you don’t directly know, teaches you how to triage, make quick decisions, and follow through.  These are valuable skill sets in medicine.

It’s crucial, however, to always feel supported, to have a clear, functional structure in place where you can ask for help, and that’s the hallmark of good training programs.  I understand, however, that it isn’t always the case, and the regulations requiring more intern supervision are designed to safeguard against such situations when patient safety is put at risk.

And patient safety is the major reason the issue of resident work hours has become such a controversial, public topic and subject to such drastic changes--these studies have shown that patient lives are at stake.  But we also have to consider the quality of the training we’re providing to our residents as they grow, with experience, into independent, seasoned physicians.  It’s a delicate balance, because our patients’ welfare and our physicians’ training are inextricably linked.

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