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The Fallacy Of The Current Resident Duty Hour Rules

Fri, 10/04/2013 - 3:42pm
Akhil Narang, M.D.

Discussions of resident duty hour reforms reached the point of ad nauseam a few years ago.  Everyone had their say — program directors (“In 2003 we instituted an 80 hour work week, in 2011 we switched to 16 hour shifts, what’s next – online residencies!?”), senior residents (“What? I have to write H&Ps again? I don’t even know my computer password!”), interns (“I thought I was done with cross-covering after this year”), graduating medical students (“I get to sleep in MY bed most of next year!”), and various supervising bodies (“This is what the public wants. Of course there is evidence that these reforms will work.”).

Now it’s my turn: part of the last class to have experienced 30 hour call cycles as interns — the way it should/shouldn’t be (depending on your bias).

While lamenting to my program director during residency on how my class not only had a difficult intern year but also had to assume “intern responsibilities” during my junior and senior years, he gently reminded me of his experience as an intern. It was routine for him to care for more than 20 patients on the general medicine service. Moreover, the ICU was “open” and any of his patients transferred to the unit continued to be under his care. Generously assuming 1 day off in 7, he worked more 100 hour work weeks than he’d care to remember.

As a junior resident, I was on service with my chair of medicine and he repeated many of the same stories of busy services and how the word housestaff came to be — the residents’ de facto house was the hospital. Was this dangerous? The unfortunate case of Libby Zion (and others) would suggest yes. Did my attendings became outstanding physicians, in part because of the rigorous training? Unequivocally.

Fast forward a few decades: for numerous reasons, including public pressure, an 80 hour work weeks with a maximum of 30 consecutive hours in-house (for a resident) and 16 consecutive hours (for an intern) is the new standard. In a matter of 16 hours, only so much can be accomplished. The work-up, diagnosis, and response to treatment is hardly appreciated in this short time span. The resident, who is permitted to stay in-house for 30 hours, often completes what the intern didn’t have time to do and benefits from observing in real-time the clinical course of the patient. Is this a disservice to the intern? Many would argue “yes.”

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