Does more sleep make for better doctors?
Dr. Pauline Chen does a masterful job in discussing this controversy. I will quote her ending, but I urge you to read the entire story.
In fact, the much-touted cap of 80 hours is hardly based on scientific evidence or extensive testing. In a letter last year to The Journal of the American Medical Association, Dr. Bertrand Bell, who was crucial in getting residency reforms passed in the 1980s, wrote, “The specific ’80-hour week’ was actually determined by a colleague on my porch and was based on the following informal reasoning….” That reasoning included, as Dr. Bell continued in the letter, the idea that “it is reasonable for residents to work a 10-hour day for 5 days a week [and] it is humane for people to work every fourth night.” After a series of mathematical calculations, his colleague came up with the now hallowed figure. And “eureka,” Dr. Bell wrote, “that equals an 80-hour week.”
The medical profession needs to address how we can create a safer environment for patients and a more humane workplace for residents. And the recent Institute of Medicine report is an important first step. But the takeaway message is not that we should proceed with costly reforms but that we desperately need more research on what changes have already been made.
Further resident duty hours reform without adequate evidence could lead to an entirely different and equally difficult set of problems for doctors and patients. It could fundamentally affect how we interact with one another. We as patients might have to work a little harder to recall the name of the doctor watching over us on the current shift. We might have to adjust our expectations of those physicians and surgeons caring for us, as the clinical experience of future doctors could be vastly different from that of the doctors we see now. And in a culture of handovers and shifts, where individuals are interchangeable, we might have to accept that each of us, doctor and patient, and our individual contributions to the doctor-patient relationship, would no longer be as unique as we might otherwise have once liked to believe.
Because even the most well intended reform efforts will not come without strings attached.
The problem with these "reforms" stems from a lack of understanding of how we learn medicine.
Now I have commenters who disagree. One ob-gyn resident wrote a harsh rant about the lack of learning in her residency. As I read her rant, she works in a program where little teaching occurs. I work in two residency programs - an internal medicine residency and a family medicine residency. In both residencies, much teaching occurs.
Obviously, I know internal medicine the best. Our program devotes at least 4 hours each day to teaching. We spend about 2 hours (3 hours on post call days) discussing and seeing our patients. We have 1 hour for morning report (with hand picked clinician educators) and a daily noon conference. Additionally, we have multiple subspecialty conferences.
The ob-gyn resident chose the wrong residency. Changing the work hours will not improve her education. She can only really learn from patients. Will she see appropriate numbers of patients?
Our residents (in both programs) resist leaving until the finish caring for their patients. I am supposed to tell them to leave (although I am not physically there), but I must admit that I have pride that they care about patient care and education.
With the current rules, residents are supposed to forego noon conferences if they have worked the previous night. Some will opine that 16 hour shifts will solve this problem, but they are wrong. Once we increase shift work, we have even less residents available for conferences.
As we are experiencing these work hour reforms, we are also asked to insure the residents have a structured curriculum. As I ponder this I feel a bit like Yosarrian. As I discussed these new recommendations with a program director yesterday, I saw great angst. This program director has great dedication to housestaff education, and now he wonders how we can possibly provide a high quality education to our residents.
If our residents do not get adequate training; if our residents do not see enough sick patients; then their patients will suffer in the future. We need better trained physicians more than we need well rested residents. I know that sounds a bit cold, but I purposely chose a difficult residency so that I would become a better physician.
We should hold all residencies to high educational standards. I emphasize with ob-gyn resident, for she describes an undesirable residency. But her bad experience is not a reason to change a system that actually works for the public.
I agree that exhaustion is not good for residents, or for patients, and that an increased emphasis on patient safety and the importance of sleep is clearly needed in the medical profession. But I can’t help but wonder if we may also risk losing something by trying, prematurely perhaps, to fit the unpredictability of the illness experience and the individuality of human relationships into a scheduling grid that has little proven efficacy.
Amen