Wednesday, December 10, 2008

The 80 Hour Work Week

This has been a hot point ever since it was introduced several years ago. Recently, it has come to the attention of several prominent bloggers; see here or here or even here. It seems the recent hullabaloo came after the Institute of Medicine released a report on resident duty hours where they recommend decreasing the length of a shift even further, to 16 hours, with more naps, at an estimated cost of $1.7 billion to hire the additional staff necessary to make up the gaps in coverage. All of the above links give excellent, thorough analysis of the situation, including some of the history of the 80-hour work week idea, so I won't repeat it.

As a med student, I didn't log or keep track of my duty hours in any way. I'm reasonably sure that I worked around 80 hours a week on my medicine rotations, and possibly on surgery, but likely no more. I was gung-ho for the cap rules at that time. Many attendings who talked about it gave crappy reasons for hating the 80 hours, like "I went through it, so should you." I never heard a rational, reasoned argument against it in med school. I felt like, 80 hours sucks and is a lot, but it could be worse, so why not?

Then I became an intern.

One of my rotations in the past few months had a night float system for covering patients overnight when your team wasn't on call. It was a terrible system. Essentially, multiple teams would print out 1-page spreadsheets of their patients and then come "check out" to me, usually while I was trying to write notes or admit patients or otherwise do my work. These check out sheets had only the barest of information on them: name, MRN, age, 1-liner about their problem, code status, and anything specifically for me to check up on overnight. Stat electrolytes, stat PTT's for heparin drips, stat H&H for GI bleeders--they'd give me a time, and I'd write down when I should check it. All in all, I estimate that I'd hold about 80 patients' worth of information in my hands by around 6 pm, including my own (the float shift would start after a full day call of admissions, so I'd still be working up my own patients and writing H&P's while taking checkout and seeing float patients).

Then the pages would start. "Mr. so and so is asking for pain meds." I'd go to the proper sheet, look him up, and voila! Absolutely no reason listed for him to have pain. I'd go into the EMR, look him up, no notes documenting pain but "he says he has bursitis in his shoulder and he really wants Vicodin." On principle, I'd try negotiating ("give him ibuprofen first") but usually ended up just writing for PRN Vicodin to save my sanity, as every time the pager would go off for Mr. Bursitis I'd die a little more inside.

Then "Mrs. X's fingerstick reads 'Hi' and I rechecked it twice". Or "Mr. B is having a-fib and his heartrate is 150 and his blood pressure is 90/60." And so on, and so forth. Every time the pager went off, I'd shuffle through a huge stack of papers, trying to figure out who the F the nurse was asking about (and usually trying to decipher the accent), then I'd look them up and try to decide what the hell to do. I had a back-up resident who helped me with anything serious, but still. Being the main doctor overnight for so many patients, almost none of whom you know, is seriously frightening. The potential for error on my part, as I tried desperately to flick through the comptuter for 30 seconds while the nurse waited impatiently on the phone, was huge.

Much has been made recently of the sleep vs handoffs argument. It is true that handoffs can increase the potential for error. I'm not sure if there are any studies that can truly say that handoffs increase the error MORE than working >80 hours (or longer than >30 in a shift)--if there were, the answer would be easy. I will say that after working my first of these night float shifts, I was much less cavalier about checking stuff out to the float. As float, I barely had time to go to the bathroom or examine my own patients, let alone check labs q 1 hour for other peoples' patients.

Obviously, there are programs that have different (and probably better) ways of handling cross-cover. The Day Float resident is a great idea: someone who shows up during post-call rounds, learns all the patients, then stays into the afternoon to finish orders with the attending when the rest of the team leaves around noon. Having a limit to the number of patients allowed per resident on cross-cover might be okay, so long as you can put extra residents on the float shift. Big hospitals will have to have different solutions than small hospitals, where one resident could feasibly cover all of medicine or surgery overnight.

Given the choice, when I desperately wanted to go home but I needed to see if Mr. Y had pneumonia or my patients needed morning labs or I needed to check the orders to see if everything was done, I chose every time to stay and do it myself. I'm not bragging about myself in this, because most residents do the same thing. When they slap "MD" on your coat and it suddenly grows a few feet in length, there's an enormous sense of responsibility that falls on you. Suddenly, these are YOUR patients. If something gets overlooked and the patient gets sick in the middle of the night, that's not the float's fault, it's yours. Yes, this is partly the over-exaggerated compulsion and perfectionism that is part of most doctors, but it's partly true. In my current system, no cross-cover will ever take as good of care of my patients as I do (and when I'm the cross-cover, I can't possibly do as well as that patient's team). Having someone hassling me about breaking duty hours just added to my stress. (And to be honest, it really hasn't been too much of an issue--I've gone over 30 just a couple of times, and never averaged more than 80, and have always had my 4 days off per month.)

So, what I'm saying is, the 80 hour rule is kind of a pain in the ass. I agree that going back to q3 call with no restrictions on duty hours is medieval at best, and I'd hate to see that happen. I get tired enough working 70-80 hours per week. However, further restricting the hours without helping programs find manageable solutions to handoffs is not going to make it any better. Balancing patient and resident safety is paramount, and should not be mutually exclusive concerns.

I'd like to make one seemingly tangential comment. I've heard a lot of whining that residents aren't going to noon conference because the 30 hour rule prohibits it. Actually, if you arrive at 7 am, 30 hours is up at 1 pm the next day. If you want residents to come to noon conference post-call, just decree that they are not allowed in the building before 7 am the preceding day. And then tell their attendings not to round for 6 hours post-call, so they can get their work done and make it TO the conference. Ideally, there would be food at this conference, which is my favorite motivator. This is not an impossible situation to solve, people.


Barbie said...

Being night float is awful. You barely know a think about the patients, you are all alone (or so it feels) and the pager never shuts up because you are covering >100 pnts overnight. The worst pages were the ones right after sign out. "The intern for Miss X said she was going to order IVF for her but never did. Can you put the order in?" or "The family is here and want to discuss how thing are going with a doctor. Can you come up?" But at least at my hospital, you don't have to admit on night float.
What I am excited about in the recommendations is the 48hrs off every 4 weeks. 2-days in a row, heaven!

The Gonzfather said...

" I'm not sure if there are any studies that can truly say that handoffs increase the error MORE than working >80 hours (or longer than >30 in a shift)--if there were, the answer would be easy."

As a former chemist, I do recall that the more the number of flask/beaker transfers, the more likely an error would occur. Don't see why real-world brain-to-brain transfers would be any different. :)

I filled out the IOM survey today....I agree with most of their ideas, but not with this naptime idea. While that might work for medicine or surgery who have large teams and many residents at their disposal, it won't work for fields like psychiatry, ortho, etc who usually only have one resident staying in-house overnight because then you would need to have a different resident interrupt their sleep to allow someone else to nap for 5 hours? And does the slee-relief resident get the next day off or do they just go sleep-deprived? Logic, donde esta?

Tiny Shrink said...

Agreed--how are they going to keep track of the naptime requirement? As it is, some of the rules are kind of ridiculous (no new patients post-call) but aren't regulated in any way, so who's checking? You may just end up with more residencies going to shift work, which increases the number of purely "work" rotations and may lengthen a residency to add more electives.