Blog | Wednesday, June 27, 2012

Avoiding the unintended consequences of the new work hours

This letter from residents appears in Academic Medicine, Unintended Consequences of Duty Hours Regulation.

"Prior to this year, 30-hour call shifts were the norm for many residents in our hospital and nationally. The rigor of these shifts taught us to maintain professionalism and compassion amidst life-and-death stakes. Overnight calls, despite the unavoidable fatigue, were training grounds for independent decision making and some of the most exhilarating times of residency. These shifts were often the best opportunities to watch the evolution of disease away from the pages of a textbook and to experience the transition from trainee to doctor under appropriate supervision. Most important, the extended hospital shifts were the time for residents and patients to bond--developing the critical doctor-patient relationship and designing a collaborative plan of care.

"No amount of shift-design or fatigue-mitigation strategies can replace such important experiences--from a medical and humanistic standpoint. The decrease in daily continuity has whittled away the interactions on which the patient-doctor relationship depends. Electronic cross-cover lists have replaced personal interactions as residents' primary source of information. On the whole, the changes have established a norm of perpetual patient transfers from one team to the next, with diminished opportunities for any one team to develop responsibility for a patient. As a result, we residents are losing 'our' patients."

While I empathize with these residents, I will argue that we can provide excellent training. Our family medicine residency in Huntsville, Ala. developed a call schedule that minimizes the negatives and maximizes the positives. The key is responsibility. All interns and residents work a maximum of 14 hour shifts. When you admit a patient, you "own" that patient. They emphasize continuity. Hand-offs occur during rounds with the night and day residents rounding together first thing in the morning with the attending physician.

While I do believe that the old schedule made great physicians, perhaps we can still succeed, if we do design our call systems around principles rather than hours. When we emphasize the patient and the physician patient relationship, then we may even do better.

But then everyone knows that I am a lifelong optimist.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.