Long hours in medical and surgical residency

The New York Times health blog “Well” today posted:

A national panel of medical experts proposed significant and costly changes for training new doctors in the nation’s hospitals, recommending mandatory sleep breaks and more structured shift changes to reduce the risk of fatigue-related errors.

 The report was issued by the Institute of Medicine (IOM).  As expected, there are hundreds of comments on the blog.  Many established doctors defend current training practices (or lament the loss of even more grueling ones in the past) as the best way to get maximal experience during training.  Some residents also defend current practice, while others recount mistakes made while sleep-deprived, and call the system senseless.  Most self-identified laypeople condemn as obviously poor patient care a system where doctors work for over 24 hours without sleep.

Sleep deprivation during medical/surgical training has been an interest of mine since I was in training myself in the 1980s.  I even wrote a paper on it as a medical student.  This is my commentary I posted to the “Well” blog.  I invite your thoughts here.

I’m a psychiatrist involved in medical education my whole career. It’s a relatively easy specialty in terms of training hours. But I was a med student and had a medical internship like other MDs, and was appalled by the hazing justified as a necessary educational experience. Like a fraternity initiation, each generation of doctors imposes it on the next to keep medicine special, to maintain a sharp in-group/out-group distinction. It is also perpetuated institutionally thanks to the unbeatable economics of paying a highly trained, intelligent workforce minimum wage.

There is no way to learn everything in training, whether residency is 3 years or 10. The conceit that the current system teaches residents “everything they need to know” leads to calls to add residency years to make up for reduced hours. But how did we determine we’re teaching residents the “right” amount now?

In an era of evidence-based medicine it is medical training itself that resists the application of empirical science. Plenty of studies show cognitive and interpersonal deficits with sleep deprivation. There are none I’m aware of that show these effects can be trained out of people, nor that long call hours “teach” residents to make hard decisions in the middle of the night. If we rely on personal anecdotes, my experience says that sleep deprivation teaches trainees that working half-awake is acceptable as long as you survive the ordeal, that procedures are more important than talking with patients — there goes prevention and lifestyle changes — and that anyone who criticizes this heroic undertaking is a wimp who “just doesn’t get it.”

Certain rote practices like CPR or running a code improve with mindless repetition, but sensitive interpersonal skills (eg, discussing a patient’s cancer diagnosis) do not improve by “practicing” them over and over when you can’t think straight. The human qualities of great doctors — caring, sensitivity, interpersonal nuance — are profound gifts. It is a cruel and misguided system that devalues these gifts in order to to maximize the repetition of protocols and procedures.

Where to go from here?

1) Obviously, the IOM’s changes will cost money. Other countries with excellent health care systems have found a way, and we can too.

2) Medicine is already too complicated to sign-out (ie, hand off) patients in the informal way we do now. Electronic medical records with built-in error checking is inevitable in the near future. It’s a good thing, particularly at this error-prone step.

3) The “ownership” of patients is a real issue, and may be made worse by a shift-work mentality. The solution is not to avoid shifts — they are inevitable in any business that is open 24/7 — but to (re-)instill a cultural norm that caring about *people* is expected, and frankly more important than memorizing the last 5 days of electrolyte values. I’d rather be treated by a well-rested doctor who cares about me but has to look up the labs.

http://www.stevenreidbordmd.com/blog.html

— Steven Reidbord MD

1 comment to Long hours in medical and surgical residency

  • Gabor Kovacs

    I agree.

    Residents in any specialty in this country often think, they are getting the best possible training in the world. In reality training is artificially retarded from the get go. Why not go to medical school right after high school? Why all the superfluous basic curricula instead of immediate exposure to patients and clinical experience combined with basic sciences? Why can’t we have a more pleasant and educational residency training system?

    Learning medicine should be motivated by joyous curiosity, not by competitiveness to get a good grade. Medical education should be fun and only available to those capable individuals who actually care about the health and well being of all people in this world, including themselves.

    Many residents and attending physicians are not humane enough to scorn the very activities in this world that are the most detrimental to human health: corporations, warmongering, social misery, barbaric safety conditions on our roads, unhealthy behaviors in general, and so forth and so on.

    I am not surprised to see the brainwashed and self-depreciating attitude of many medical residents in this country, considering the state of barbarism and humanitarian/political apathy of the American public.

    Change is needed not only within the confines of our medical health and education system, but also in our society in general.

    Gabor Kovacs, Chicago, IL

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