Wednesday, November 01, 2006

the RRC and work hours revisited

in a series of interesting and somewhat humorous comments on my last post, an anonymous reader brought up the topic of work hours and the RRC:

"You signed up for this no? Good thing you have the RRC to wipe your nose (and your butt). God forbid you might actually stay up all night. Jeez you are going for a post-call hike. You really think that's what happened before the RRC held your hand? No you were a DOCTOR and worked post call. Tell me, what do you think is going to happen when you get to the REAL WORLD, you are on call all night and then spend the whole next day working? The RRC won't be holding your hand then. ... The present work hour rules have turned the present crop of residents into wussies. I know this from experience. Medicine is not shift work. You don't walk away from the patient when the bell rings. You don't know what I am talking about. In 1 and 3/4 yrs you will...."

for those of you who don't know, RRC stands for the Residency Review Committee. it is the part of the ACGME (American Council of Graduate Medical Education) that oversees residency programs. every few years, all accredited residency programs have a site review to make sure that they are up to standards.

recently, the ACGME instituted restrictions that limit residents to working 80 hours per week, averaged over 4 weeks, no more than 30 hours in a row, no less than 10 hours between shifts and at least 4 days off in a month. these rules echo the Bell Commission reforms that have been in place in New York since the late 1980's after a patient died (Bertrand Bell's daughter, Katie) due to resident fatigue.

anonymous' opinion, it would seem, is that the work hour restrictions have made an entire generation of doctors into "wussies". i'm curious what opinions people have about this, both medical and non-medical readers. does it positively or negatively affect patient care in your experience? if you are a resident currently, is your program in compliance? what are non-US training programs doing to address the issue?


Almost A, DO said...

Did I miss the part where a 30-hour day *didn't* involve being on call all night and then spending the whole next day working? Anonymous may want to check his/her arithmetic - being a resident is still no walk in the park. I find it laughable that anyone would get criticism for "only" working so many hours. And gee, a whole 4 days off a month. Yes indeed, residents today sure are spoiled.

Anonymous said...

I'm a transcriptionist. We had trick or treaters last night until 10 and then waited up till 11 for the kids (17 and 19) to come in for the evening. I got up at 5. I think some doctors would kill to have gotten that much sleep, but you should see some of the stuff I've typed today that my spell check has caught. I would not want my doctor/surgeon to take care of me with the kind of fatigue I am feeling right now. I don't know what the answer is, but fatigue=brain fog and poor judgement. Kudos to all y'all.

Jordan said...

I have mixed feeligns about this. I finished residency in 1999. At that time it was easier then previously but certainly I worked 36 hours in a row on a regular basis without sleep or breaks. The problem cuts two ways. I agree that when a resident hasn't slept they may poorer decisions.

On the other hand now as a medicine attending i am required to make important decisions at all times of the night regardless if i have had sleep or not. In fact. i have gone many nights without sleep as an attending and work full days the next day.

You have to learn sometime in your carrer how to fight through exhaustion.

I do agree that physicians in training do have the more shift work attitude now adays. I think it leads to fragmented care when they become attendings.

Felix Kasza said...

The only appropriate response seems to be that "in my day, we had to bang rocks together in order to make scalpels from flintstone, and for needles, we used the eyeteeth of the sabre-toothed tiger. (Mandibles and maxillae made fine holders, too.)" And so on, and so forth, until that anonymous pomposity-filled gasbag shuts up.

Anonymous said...

yeah....that "pomposity-filled gasbag" is probably just pissed off that he/she was tortured for no reason. I'm a fellow in 2006, and I still have to work 36hr+ days....RRC rules or not.... and I don't think my extra hours are helping anyone.

Wrkinprogress said...

Non-medical opinion, here: if I have a choice, I'll take a well-rested, well-cared-for-by-competent-office-staff physician ANY day.

How did this ever become acceptable in the first place, anyway? There is no glory in fatigue, is there?

Flightfire said...

I'm really curious if there is any research out there on the correlation between number of hours worked and number of mistakes made. We all know that we hit "the wall" at some point when working, but I'm wondering if anyone has quantified where that wall exists for the average doctor/pilot/auto worker, ect.

Medstudentgod said...

As a medical student I find that a lot of my concern with residency programs lies on the "true" hours worked by residents. Often they will say that 30 hours are the longest worked back to back, excluding beeper call, of course.

I believe that a lot of medicine is done simply because people before did it and think that it's a pissing contest. After all, who hasn't heard an attending talk about the month where they worked 72 straight hours and didn't kill anyone? It's like a badge of honor to work absurdly long and dangerous hours since it *proves* your worth.

Medicine is crazy when it comes to thinking along those lines. It has been shown in a recent JAMA article that resident mistakes doubled if they received less than 4 hours of sleep. If they receieved at least 4 then their mistakes lessened. However, there will always be people who "grew up" in the old system and will always fight the RRC.

As an attending you won't get those restrictions, but you also won't be as much a novice - therefore allowing you to make clearer decisions.

If patients truly knew what went on in hospitals there'd be an outpouring of demands for changes. Old Docs need to accept that the regulations are here to stay - for patient safety. Not bragging rights.

VitaminKMD said...

We don't have the 80 hour work week where I work in Canada, but many staff *do* try to get us out by noon post call. Many don't...I'm hitting 100 hours/week on my present rotation.

I value call-- it's where I get experience. Every call I become a little bit better, or at least that's what I tell myself. And I do learn how to think sleep-deprived. But post-call? I run scut, fill out paperwork, and make patient flow faster. I make my staff's life easier. I don't learn any actual clinical medicine.

Shouldn't *that* be the main focus of residency? I don't know. I'm post call NICU and can't stop hearing the sounds of monitors beeping...Maybe I shouldn't be weighing in on this...

Anonymous said...

Actually, some parts of Canada do have the 80-hour rule (Article 12), but it is a huge joke to the attendings. One rant in particular sticks in my mind.

Basically, my uni just pays the fines and gets on with it.

And so do the surgical residents, for the most part. I know a guy who worked six Fridays in a row, because they needed him to. He wasn't happy, but he did it and didn't complain. I wouldn't call it a "pissing contest" per se, more of a "we the staff can't function without a certain amount of work from the residents, and there aren't enough residents to safely cover that number of hours, so suck it up" situation.

Anonymous said...

Okay, I'm basically blowing it out my ass here because I'm not in the medical profession. Having said that, I'd rather see a well-rested resident than one that's been on duty for 48 hours straight. I've written code for 48 hours straight and the end result of that ain't pretty.

I don't buy the argument that it's necessary to have that kind of experience in training to be able to cope with real-world experience, because I think that argument doesn't take the adrenaline factor into account.

dlamming said...

I'm a phd student, not an MD, so a "long day" is 12 or 13 hours. That said, my judgement goes way down hill after about 10 hours, regardless of how well rested I am. I can't really try anything new at the end of the day

Interrobang said...

I'm not a doctor, but I am an occupational health and safety nerd, and to me, this is a straight-up OHS issue. People who work 12+ hour shifts, people who work swing/rotating shifts, people who work nights, and people who work sleep-deprived are all at greater (in some cases, as much as 50% greater) risk of occupational injury or death. Why this is treated as a vanilla job safety issue in every other occupational field and treated as some kind of machismo ritual in medicine is beyond me. Other professions where lives are at stake daily and exceptional circumstances can call for endurance marathons or extreme-stress judgement calls (such as commercial aviation and air-traffic control) are nevertheless strictly regulated in terms of working hours.