Sunday, April 9, 2017

As an Intern, I Support the ACGME's Increased Duty Hour Limits

Last month, the ACGME formally increased its work-hour limits for resident physicians, a change that was widely covered in the press.

This decision has also been significantly mis-reported.  While it may seem like all residents will now work for longer hours, in reality, only first year interns will be allowed to work longer 24 hour shifts, where the previous maximum was 16- a limit adopted in 2011.  2nd year and up, the restrictions will not change: 24 hour shifts, no more often than every 3rd day, with an 80 hour per week average which were the restrictions adopted in 2003.


Public opinion polls consistently claim that the public wants stricter limits for duty hours.  Such opinions are misinformed- if they were asked "do you want surgeons in the US to have less cases before they are allowed to operate independently?" or "do you want a doctor who has no idea who you are or what your problem is to take care of you overnight?", I suspect their answer would be quite different.

As a first year resident, I personally support the ACGME's increase in the duty hour limits.  Quite simply, I would actually be more well rested had a system like this been in place.  This conclusion is not true for all specialties or situations.  In many cases, forcing residents to work such hours is simply a money-saver for the institution, with no learning benefit.  But for many surgical specialties, the current limits made no sense.

For General Surgery, my specialty, academic hospitals with sick patients demand 24 hour in-house coverage with a resident.  A surgical intern has to be there to go to the bedside to see a patient whose nurse calls about a change in status and evaluate new admits from the emergency department.  This is true as well for neurosurgery, critical care, and orthopaedics to some extent.  How should such coverage be arranged?  There are three primary options:

1) 24 call every 3, 4, or 5 days depending on the staffing
2) 6 days working 12 hour "nights" from 6PM to 6AM, followed by a return to days
3) A month or longer of straight "night float"

Until now, the only options available to programs were the latter two, and both are awful.  My program uses the second option, also known as rotating shift work for interns- and I am typing this now at 2AM because I cannot sleep.  I just worked a week of nights, and my body can not fall asleep- so I will go to work 4:50 AM until 6-7 PM with no sleep for 36 hours by the end.  And then my body will slowly reset back to days and I will finally get back into something approaching normalacy for a few weeks- before the cycle starts again next month.  Rotating shift work has also been linked to terrible health outcomes in the long term, including increased all-cause mortality and increased cancer and heart disease.  Is this an awful system?  Yes- but it has advantages.  I am only separated from the waking world for a week, I still attend educational conferences associated with that service, and for most of the month I get to operate and learn as normal from the service's practices.

Contrast this to the other system: straight nights.  This is where an intern or 2nd year simply works nights for a month at a time, with no interruption.  For that month, they barely see their fellow residents or their friends.  No dinner outings, no catching up, no celebrating birthdays- nothing.  Especially for surgical programs which unlike medicine may require 2 or 3 months of nights due to their smaller number of residents able to share the call burden, this is a significant psychological strain.  In addition, there is often little educational benefit from straight night float.  Scurrying around the hospital, unable to learn the nuances of patients and services since they rarely if ever spend significant time with attendings or senior residents on the service, interns know even less about their patients than on rotating night shifts as above.  This is again more acute for surgical services, who must learn a wide variety of techniques on several different services.  Missing out on a month of pediatric, acute care, or colorectal surgery may mean giving up a significant educational opportunity- in contrast to a medicine program where doing 5 months of general medicine wards is little different than doing 6 months of the same.

Both of these systems had serious drawbacks.   And I would be remiss if I did not mention that 24 hour call is not without it's drawbacks as well- fatigue and mistakes from it are very real.  But especially for the rotating, 6-nights-in-a-row schedule, the idea that I'm more well rested than had I done 24 hours straight is laughable.

Ultimately, is 24 hour call the best option?  Maybe for some doctors, maybe not for others.  But the simple reality is that removing the 16 hour restriction is not some horrific injustice that will lead to worse care and more tired doctors- rather, allowing programs the additional flexibility to choose schedules that match their patients' and their trainees' needs is simply the best way forward.