You say that it will take away from your ability to see a wide variety of cases, from your ability to stay up all day and night to take care of patient problems around the clock, this is true. You acknowledge that fatigue and resident error are problems that exist, as necessary evils it seems. But to add on years is not acceptable and to reduce hours hurts your progression as surgeons.

However, we are missing one important point which stems from the errors and oversights caused by fatigued and overworked residents (which is well documented in the literature). The point that so many seem to gloss over is the care of the patient, which should be ultimate. It should come before all else. If the price to reduce resident error and improve patient outcomes is adding on a year, or two, of residency (at 56 hour weeks) to get that experience that is so necessary, then so be it. The decision to forego patient well-being in an effort to learn everything you need to learn in as few years as possible is unacceptable.

The point is that the hours now are hurting our patients and THAT needs to change.

http://findarticles.com/p/articles/mi_m0999/is_7222_319/ai_58358816

They work 56 hour limit BY LAW, and what’s funnier is they were proposing to set it down to 48 hours. LOL hilarious. If you think 56 hours will ruin the world, then obviously you don’t think very highly of European Medicine. I think they have great doctors.

I think I can offer some perspective from the surgical side. My opinions have a lot of merit because I’ve gone through that transition from college student (and knowing no medical knowledge) to being a fully trained surgeon. I’ve been a junior resident doing “scut work” pre-work hour restrictions, and I’ve worked as a mid level and senior/chief resident post-work hour restriction.

For the most part, Neurosurgical training is 7 years long beyond residency. This new 56 hour work week recommendation would necessitate extending a neurosurgical residency by at least a year… maybe two. Unfortunately, it just takes longer to make a good surgeon than a good ward physician (internal medicine doc etc).

I worked an average of 120-140 hours per week for my PGY2 year as a neurosurgical resident. It was grueling. I did a lot of scut work and there was definitely wasted time. These were the bad things of the old ways. The good thing about the old ways was this… if you had a patient who was going to decompensate at 2am while you were on-call you were the one who had to take care of them. That care… (a decompensating patient) is always difficult and involved. You started to learn subtle signs that patients “might” deteriorate in a few hours, and you would learn to make manuevers to prevent that deterioration earlier in the day or evening. That work you did to “prevent” the deterioration was always less “involved” than the work you’d have to do when the patient was actually decompensating… not to mention it was safer and better for the patient to prevent the episode. You felt ownership for that patient… not only because it is the right philosophy, but because YOU will be the one dealing with the consequences of all of your actions from the daytime. As a result, I used to make sure my patients were in “tip-top” shape during the day/early evening to prevent problems at 2am (on the hope that I could sleep for 2 hours that night while on call).

Now, let me fast forward to the post-work hours restriction. Now, the junior resident who works during the day does not have to be there at night taking care of this decompensating patient. He doesn’t get to see the consequences of his actions directly (yes, he hears about them the next day… but it is not the same). Naturally, he is not as detail oriented in making sure his patients are in “tip top” shape because someone else is coming in a night who will take care of any problems that develop. This is the classic “shift worker” mentality that people use as an argument against work hour restrictions. There is a lack of continuity of care.

With all that being said… unfortunately 120-140 hours per week is insane… I know… I did it. So, while I think the 80 hour work week causes some problems like I mentioned above in resident education… I think it makes work hours “humane” compared to what they were when I was working 120-140 hours per week (only 168 hours in a week btw). And it is clearly here to stay.

Reducing work hours further, for surgical education, would be a disaster. As it is… that resident who is here all night and not here during the day doesn’t get to operate. As a neurosurgical chief resident, y our job is to become competent and efficient in your surgical procedures. That means doing them over and over and over and over. You can intellectually know how to do a procedure. You can learn that very quickly. But to become technically proficient, to be good at it, and efficient… it takes practice practice practice. Something that reducing work hours to 56 hours per week would prevent. When I was a chief resident my job was 1) run the service, make sure all the inpatients were getting adequate care… that meant rounding in the AM before going to the OR and teaching the junior residents what to do for each patient. In order to round on 40-60 patients (yep, that’s how many we’d have on our service at once) we’d have to start around 6am to finish by 7am in order to start my OR cases by 7am. Medicine residents would be amazed at the ability to round on 60 patients in 1 hour but as neurosurgeons we learn how to do this… and without making mistakes. Because mistakes are not acceptable. Usually what that means however is to be efficient on rounds during that 1 hour… the junior residents would have to have all the information about the patients right on the tips of their tongues or at their fingertips. When I rounded it was not acceptable to go look something up on a patient during rounds and not to be prepared for rounds. It wasn’t that I was trying to make my junior work hard… it was I just didn’t have the time to spend looking stuff up on rounds. Otherwise, we’d just have to start rounds even earlier. Rounds are finished, junior residents have their “task lists” for the day, and I go off to the OR.
2) Operate all day long. We’d do 1-4 surgeries per day depending on how long each surgery takes. 7am until whenever we are done. Some days that is 4pm (rarely) most days that means operating until 7pm or later… lets just assume 7pm.

3) Check on post-op patients (have to go see how patients I operated on earlier in the day are doing now, make sure no complications that would necessitate going back to the OR)

4) Discuss all the patients on the service with the junior residents, be aware of the changes updates, squash problems, suggest treatment options, review new head CT’s, MRI’s etc.

5) Go Home (Q2 home call (me and the other chief resident shared this call… thus Q2)

So if you are keeping track… that means AT LEAST 1 hour of work after the OR is finished. Ie… 6am-8pm 5 days per week. That is 70 hours per week. Now remember I’m Q2 weekends… so I have to come in and round, operate on any emergencies or urgencies for the weekend (usually at least 1 surgery or more per weekend) That adds at least 10 hours every 2 weeks. Now we are up to 75 hours per week. All I need is one emergent surgery at 2am at any point during that week while I’m on-call and bam… I’m at 80 hours per week.

So, I’m not sure where I can cut the fat out of that schedule to reduce to 56 hours. I’d have to give up a whole day operating in the OR… which would mean my ability as a surgeon would take a hit. That is not acceptable to us as surgeons.

I’m busy… more to come… maybe.