There is no fellow that has not felt sheepish when they are instructed to go home after reaching 80 hours, but attendings who have no work hour restrictions stay on...which I think is a main hurdle to work hour enforcement. Cardiology is a demanding specialty that can require long hours, and someone has to finish the work after the housestaff has gone home.

Work hours restrictions have definitely changed the nature of training. The heirarchical roles where attending supervises fellow supervises resident supervises intern is shifting to a divide-and-conquer strategy where housestaff divvy up the work to get everything done at the expense of knowing every patient. Interns were once expected to get all the scut done on all their patients while the senior housestaff managed; now interns/residents/fellows are dividing the scut which comes at the expense of interns learning management of clinical scenarios from their senior housestaff at an earlier point in their training. Meanwhile, attendings still have to manage every single patient, so their jobs have probably become more difficult since the new work hour rules have been put into place. Attendings have to spend more time directly managing more junior housestaff.

Work hours restrictions were put into place to reduce physician error, both in the workplace (e.g., prescribing the incorrect dose or wrong medication) and at home (e.g., falling asleep while driving home post-call). But with increased handoffs/signouts which are error-prone, I am not sure that patient care is necessarily improving, and with the increased demands on our generation at home (more likely to have working spouses, increased education debt load, finishing training later in life when we are more likely to have children -- cardiology used to be a 1-year fellowship!), I'm not sure that limiting work hours is necessarily making home life any better either. 

With all that being said, I don't have a ready solution. Hiring physician extenders seems like a good solution, but justifying their cost will be difficult particularly in specialties which are not as well renumerated.

Brian Choi, Asst Moderator

Brian's comments are spot on. I started medical school in 1997 and have been in the heart of my training during the transition period to work hour restrictions. The comment about work "flowing uphill" is well said, particularly in relation to attendings picking up the slack and work being divided up. My disagreement is that I think work hour restrictions truly have been helpful at protecting trainees (especially residents) lives outside the hospital. The problem is that being a doctor makes good doctors - being at home might make happy doctors but not necessarily well-trained ones. It makes sense that fatigue leads to errors over the short-term. What I think is missed by much of the research on this topic is how error rates are affected over the long-term by limiting work hours (particularly when they result in everyone focusing on getting taks completed with little time for learning). The biggest change I have seen during this transition period is that is that the level of commitment to the medical profession by younger and younger trainees seems to have become less and less. They seem to be happier, more well-balanced people - but at some cost. Life is always a trade off. Will the pendulum swing back the other direction at some point, or is this a permanent trend?

Prior medical training culture, in which work hours were unlimited, re-inforced a culture of complete dedication to patient care...but something's gotta give, and life outside of training became sacrificed. There definitely is a generational difference in our approach to work, and I think that the post-war (WW2, that is) generation of physicians accepted the sacrifice of home life. Not to play pop psychologist, but perhaps they saw the sacrifices their parents made during the Great Depression and during the War, and spending extra time at the office paled in comparison. Furthermore, almost all physicians at that time were male and their spouses stayed at home, which made this arrangement possible. Our generation, on the other hand, saw the impact of this arrangement first-hand and have chosen to go another way. Women don't have to stay at home. Kids benefit from having two parents. The economic collapse of the Great Depression and the horrors of massive casualties are learned from history books, not directly from our parents, and the possibility of repeating such experiences is gratefully remote. In short, being well-balanced matters more for us.

Now put yourself in the patient's seat -- who would you want as your physician, the doctor that has given up everything for the sake of his/her patients or the happy doctor that can't take a decent physical exam? The doctor that is available to the patient 24/7 or one that is impossible to reach once the answering service takes over and then you get some half-sleeping moonlighting cardiology fellow?

I do think that there is a lot of unnecessary nonsense to medical training -- the "hazing" aspect that can exist, where things are made difficult for the sake of them being difficult, and there will be an entrenched "burlap underwear" phenomenon that makes this culture persistant (i.e., I once wore the burlap underwear when I was in training, and now, so will you). At the same time, there needs to be some period in every physician's training where they do commit themselves fully to patient care so they can learn what it means to be a dedicated physician, and shortening work hours should not lose that aspect of our training. Perhaps it means setting aside 3-6 years of your life, but there will undoubtedly be great personal costs.

While I completely agree that there is...what did you call it, Brian..."a lot of unnecessary nonsense to medical training"...and that limiting the hours has resulted in less unnecessary nonsense, I think the strongest commentary I can give on workhour regulations is the following...I'm incredibly grateful that I essentially completed residence *before* the regulations went into effect, because I think I got a better training, and am a better doctor, as a result.   That's not necessarily implying that I think I'm better than today's trainees will be...but I know that for me personally, I learned more than I would in the current systems.  I completely agree with Larry that medicine as a field has not yet done a good job of examining the effects of workhours on error rates.  It's an interesting equation, right - we're making physician trainees' lives better, but what is the consequence of that on patient care, both short-term and long-term. 

 

 

Amy got it right ...

"I completely agree with Larry that medicine as a field has not yet done a good job of examining the effects of workhours on error rates.  It's an interesting equation, right - we're making physician trainees' lives better, but what is the consequence of that on patient care, both short-term and long-term. "

... and here's why:  Case Study in Catheter Ablation "A story all Interventional Cardiologists Should Read"

 

It is so nice to see the comments above.  I think you are all spot on.  I have noticed that the trainees today often respond to questions regarding patients with "I don't know, I'm not following that patient."  There is no longer the sense of ownership over a patient's care.  I think there is a sense that the fellow or the attending is in charge and will be responsible.  I completely support and understand the need for the work hour restrictions.  However, I agree that I am a much better doctor having trained at a time when I stayed until my work was completed and I never passed off work to a colleague that was critical to my patients' care.