Resident Work Limits: Solving the Wrong Problem
There is no question that a medical education is a rigorous experience with tough mental and physical challenges. The training period is great preparation for the real world life of a physician. Working long hours compacts years of experience into the training period. There is also no question that many physicians in training are chronically fatigued and overtaxed beyond the point of diminished performance. No one can argue with the adverse effects of fatigue on performance. Experts point out the impressive safety record achieved by the airline industry that limits pilots to about 80 flight hours a month. In an effort to combat the negative effects of fatigue on the training experience, academic medicine has now limited physicians in training to 30 consecutive work hours and an 80-hour workweek.
Many practicing physicians perceive a major disconnect with the academic community over this issue. In the rarefied atmosphere of academic medicine there is frequently an abundance of physicians. Many patients have multiple caregivers with medical students, interns, residents, and staff physicians assigned to them. Also, in a few large urban areas there is an oversupply of physicians. But in most of the United States there is a chronic physician shortage, which is compensated for by the available physicians working long hours.
Residency training offers the opportunity to learn to condition yourself to combat fatigue and improve performance under stress. Many perceive the training period to be the ultimate boot camp preparing physicians to serve under the most adverse conditions. To adapt a phrase from the military, practice like you train, and train like you practice. For most physicians, artificially limiting work hours is not a realistic simulation of the real world. You can’t train for a marathon by limiting training sessions to a couple of miles. Artifical limits on training hours would condition young physicians to expect the same conditions in their future practice.
In the real world, much of medicine operates in the crisis mode. There is no obstetrician who has not worked over 30 continuous hours doing multiple complicated and unpredictable deliveries. There are not many trauma surgeons who have not worked over 30 hours treating mass causalities from sequential or large accidents. Limiting work hours in training seems like a good idea, but until it translates to an adequate physician supply to staff real world challenges it will be largely meaningless and counterproductive.
Everyone would agree that under ideal circumstances a physician should be completely rested and alert. We would also agree that in a crisis, physicians should not abandon patients because of arbitrary work rules. The problem with work limit rules is that much of medicine is practiced in the crisis mode. Until the physician manpower shortage is solved, physician work limits are an empty promise.
November 24th, 2007 at 8:01 pm
There is no manpower crisis. There’s a work ethic crisis. Increasingly American medical schools turn out physicians who are more concerned with personal gain than patient care. This intrinsic conflict of interest breeds a form of professional slothfulness that literally permeates every aspect of modern healthcare.
Until physicians take back the responsibility and regain the trust placed by their patients we shall continue to have to deal with illusory issues such as this. There is no need to break the backs of housestaff simply to continue to allow lazy attending staff to continue to abdicate legitimate patient-care duties.
Academic physicians should go back to the old-fashioned way of making money- earn it.