It’s 2 AM, do you know where your resident is?
The answer is, probably in a strategically placed nap.
Dr. J. hasn’t been terribly prolific since being inducted into the Gormogons. This is because he has been on assignment in the New Atlantis Ivory Tower Hospital (NAITH) for the last two weeks. July is a magical time at teaching hospitals. New interns (first year residents) take to the floor and inject energy and enthusiasm into everything they do. Former interns are now in a supervisory role as residents, overseeing the work done by interns and pitching in when needed. Ultimately the buck stops with the attendings who round in the mornings with the team, and leave them to their work during the day.
Well, that’s how it worked from the days of Hippocrates until, oh, say, about 5 or 6 years ago. The American College of Graduate Medical Education, the governing body who oversees resident education in the the US of A, began to enforce serious work hour restrictions.
Now your residents are largely paid for by the Medicare budget. About $90,000 is provided to a hospital per resident. There is a strict number of residents allocated to a hospital. Those numbers don’t change very often.
When Dr. J. was an intern, which wasn’t long before all of this, work hour restrictions were talked about, but never enforced. In 2004, Johns Hopkins University, one of (if not the) top internal medicine residency program was put on notice that it’s residents were not following the rules. That was the warning shot that the ACGME meant business. NIATH and other programs across the country realized that if Hopkins could get in trouble and have their accreditation threatened, anyone could….
When Dr. J. was a resident the typical internal medicine ward service had a 4 day call cycle:
Day 1 – On call – 24 hours – you admit new patients and take care of your old patients, you stay overnight and cover for your colleagues
Day 2 – Post call – about 12 hours – you follow up on all of the needs of your new admissions (and old patients) and discharge whomever is ready to go home. This is a busy day because you have new patient with a lot of diagnostic testing and management decisions to be made.
Day 3 – Short call – you may admit 1 or 2 new patients that come in in the morning, but otherwise you take care of your patients.
Day 4 – Pre-call – you take care of your patients currently in the hospital.
You got 4 days off a month on that service. As an intern you didn’t admit more than 10 new patients. You went home when your work was done for the day on days 2-4 (which typically would be late afternoon).
You would average 81 hours a week. Dr. J. put in more hours as he was a morning person and a bit more diligent than the average bear. Get in early, your patients tests that you order early move them to the front of the line…
An intensive care unit had every third night call. The patients are sicker with fewer new admissions. Dr. J. averaged about 120 hours a week and 3 days off during those months.
Now mind you, Dr. J. thought this was fine. He did his residency at an inefficient hospital with an outstanding program in Northeast. He had it far better than his grey haired superiors who had every other night call, or prior to that literally lived in the hospital (hence the term housestaff), or worst of all had to wear quite unfashionable white pants. An efficient hospital like NAITH would have saved him a few hours a week.
What drove all the changes was the Libby Zion case in the 1980s where an ER resident gave a college student a medication that resulted in a drug-drug interaction and she sadly passed away. This resulted in work hour restrictions being enforced in New York where her Father was a lawyer who wrote for the NYT and took up the cause. It remains unclear to this day as to whether it was simply a reaction to demerol and an antidepressant (MAO inhibitor), or if cocaine was involved. Regardless changes were made in NY which trickled down to the rest of the several states.
Dr. J. feels that residency training during his era was just and reasonable. Residents came in and did the work and stayed until the work was done and went home. Every 4th night (3rd in the ICU) call and one day off a week is fair because residents learn by doing and caring for patients. The more you see, the more you learn. There gets to be a point beyond the work that Dr. J. did where there are probably diminished returns.
The ACGME felt otherwise. So in 2004 the 80 hour work week was enforced. Residents HAD TO LEAVE 6 hours after a 24 hour shift, even if their work wasn’t done and they had to be home for at least 10 hours. As a consequence, the work ethic of Gen-Y doctors began to slip. They began to see their training as shift work. While exceptions abound, they all didn’t seem above average anymore. There also grew a cohort of rules lawyers. Residents who would remind you of the rules. Dr. J. thought he got rid of rules lawyers when he hung up his d20, but he was wrong. NAITH and other residency programs were compliant.
The ACGME still was not satisfied.
This year, the ACGME decreed that interns cannot stay at the hospital longer than 16 hours.They must have 10 hours off between shifts. (Turning 16 hours into 14 hours to prevent shift creep).
Upper level residents cannot stay longer than 24 hours and ‘strategic napping between 10PM and 8AM is strongly suggested.’
So NAITH was smart, and they beta-tested their new rules from April-June to work out kinks in the new system before they took effect. The interns HATED the new rules because they felt like they were spinning their wheels spending 2-3 hours handing off patients or being handed off patients. There are data to suggest that handoffs increase medical errors in their own right. They still weren’t able to get out on time and provide what they deemed quality care. The attending (aka real) doctors have taken it upon themselves to round twice a day rather than once to shorten morning rounds so the teams can leave sooner.
There are also less residents to go around. With the decrease in man-hours, and constant numbers of residents, the residents are devoted more to inpatient services and less to consultative services where they gain specialty education. As a consequence the specialist trainees on those services are spend more time as worker bees and less time as teachers to the residents.
So, in summary (hopefully you have learned by now, gentle reader, that Dr. J. sums up so you don’t have to read the entire exposition of you get bored), the current generation of residents, are working harder while they are at work. Much of the work is redundant handoffs to reduce the likelihood of medical errors created by the increased number of handoffs. They are caring for a smaller number of patients (because of ACGME rules). They are also spending less time overall taking care of fewer patients and following seeing less of the patient’s initial care to through to the end (because they have to go home). Consequently, they are learning less because they are being conditioned to a shift work mentality. Dr. J. suspects that this is partly well meaning do-gooderism on behalf of those who mourn Libby Zion, but also to condition the next generation of doctors to be willing to see the profession, nay, the art, as simply a job. If it’s just a job, then they will be willing to be paid less.
Which they will, under Obamacare…