Well: Reinventing The Third-Year Medical Student

The studies showing improved performance with less fatigue have been done in sleep labs and with other occupations. It seems intuitive that more rested doctors in training would also perform better. However, patient outcomes depend on many other factors. The benefit of better rest may be offset by the problem of more handoffs of care, which are known to decrease measures of patient safety. We also have no way of telling whether the more humane hours for residents improves their professional attitudes throughout their careers or if we are training a group of doctors who only know how to work shifts and do not feel as connected to their patients throughout an illness. The only thing we do know for sure is that restricting the work of trainees increases the costs of training and healthcare, since someone else must be hired to do the work that once was done by trainees. And no one wants to pay the costs of training doctors.

Perhaps there is a need to focus more on solving the "patient handover" communications problems. If a resident's (current shift) hours are being shortened, and the care of the patient will therefore be handed over to the next resident (to the next shift).There is a revolution in the availability of social media applications; we have twitter, blogs, Facebook, that we've learned to use to stay in touch. For patient care, historically there has been the paper chart, and now the on-line version: the Electronic Medical Record (EMR). Perhaps journalists could explore and educate us as to what the EMR application designers are doing to address the "patient handover" problem? It might be a great NY Times magazine article...Perhaps the NY Times could explore the "reforms" we need to address: the problems with "uncoordinated" care that exists (there is so much being done in this area these days, but I don't think the public is properly informed) - let's focus a bit less on the out of control spiraling costs, and focus a bit more on the quality improvement initiatives for a change, then ask questions like what is it worth to society.

Being a surgeon who worked the 120-140 hours work week and in an academic practice I am torn at writing this but I think the 80 work week is a good thing for all the reason highlighted above. However, there are two problems with the current set up. 1. Educators need to keep residents involved in daily problem solving skills and design new innovative techniques of teaching during a shortened work week. 2 and this is a bigger issue. The residents of the 80 hr work week have to understand that the 80 hr work week simply means that they are losing learning opportunities. Example: A resident operates on a sick patient who undergoes a colon resection who has a complication. If the resident is at home and someone else looks after the complicaiton, the original resident loses an opportunity to learn. Therefore residents have to be prepared to read more, question more and have full command of their patients. The 120-140 hr work week forced me to learn as a default because I was always in the hospital and always responsible. The 80 hr work week removes that responsibility and that default learning and shifts the onus on residents to learn off site. Some do and most do not. I have countless examples of residents going out the night after taking call, staying up late and coming to work even more tired and even less prepared than they left. Teh 80 hour work week demands that residents become adult learners and take responsibility for their own lives. Finally, if we do not have higher standards for the practical aspects of surgery the quality of the surgeon looking after the American population will diminish.

It's good that work hour restrictions haven't seemed to harm patients (yet anyway). As someone who trained in NY, we were following work hour limits well before 2003. or rather, we were following work hour limits when asked by surveyors or completing mandatory time surveys..... I'm sure this has come at great costs in the form of adding administrative layers to track residents, hiring hospitalist physicians, physician assistants and nurse practitioners (masters and maybe even doctoral level nps).A couple of thoughts 1) shortening the number of hours a resident spends in the hospital does not mean that the resident is getting more rest. the resident is just as likely to pursue outside interests as they are to go home and read. there's nothing wrong wth that as it's importance to have pursuits outside of medicine, but we can't say residents are getting more rest.2) except for attendings in Emergency Medicine (in NY anyway) there are no work hour restrictions on attending physicians. emergencies also don't follow any particular schedule. how does a training program prepare you for life after residency when you aren't subject to those controls. do we shutter smaller medical centers who can't attract specialists like neurosurgeons or interventional cardiologists in sufficient fashion to have more than 1 available, potentially on duty for days at a time? do we continue to empower behemoth hospital systems that will promote more IT, more costly care and potentially more impersonal medicine?3) The public has spoken and they want a doctor that is compassionate and humane and can establish long term relationships, but that is also well rested and supremely able intellectually and procedurally, and they want it right away and on the cheap (both to the system and to the "consumer"). Our medical schools, medical centers and residency training programs are not up to that task. it can't be done with our current models and there are no incentives (financial or otherwise) to change that. so the public should prepare for the generation of physicians that arewell rested, but reasonably competent people who have good relationships with their emrs and smartphones, MIGHT return a phone call, and punches out when the day ends, advising patients to go to the ER if they need after hours care because they're not on duty.

“Every patient is different from other patients,” Dr. Horwitz said. “They aren’t interchangeable like airplanes, where pilots can be confident that one 747 jet has pretty much the same buttons and toggle switches as another 747 jet.” If your blog had a like button, I would click it.

A better way to frame the findings of all the studies is that shorter work hours lead to equal outcomes for patients, with a more humane treatment of the residents. Working 80 hour weeks is pretty brutal, especially since those are just the hours you report, but in reality most residents spend more time in the hospital and even more time working from home. It doesn't leave much time to even read up on patient care - a lot of interns just do what they are told, without much opportunity to read and try to be more active in decision making. My favorite is the concept of a "golden weekend" - it's the one full weekend a month that a resident actually has free. An not every month will have one. On average, most residents doing floor rotations get 4 days off in a month. A lot of people here like to complain about doctors, but until you've experienced the kind of physical and mental exhaustion that residents and fellows go through, you really don't understand where they are coming from. Now throw in low pay (something like $10 per hour), financial stress from the tons of loans, lack of any interaction with people outside the hospital, and being treated like crap by patients, families, nurses, and attending physicians, and you really have a dream job. Yes, lawyers and investment bankers can also get worked pretty hard, but at least they get paid. I'm a future pediatrician, and after all my training, my maximum pay will never top what all my lawyer and consultant friends got as starting salaries.Money is obviously not the most important factor in career choice, and doctors will certainly never starve. But it really doesn't feel fair to have to work so hard when you know that society doesn't value your training and hard work. The time of the smartest college students going to medical school is quickly ending. Unless medical education, residency training, and our health care system change drastically, it'll become harder and harder to find experienced and competent physicians.

Work rules for residents may keep them rested, but it is no training for the real world. Many primary care physicians in the US still take call, getting up at night to answer numerous phone calls (uncompensated) or admit a patient to the hospital, then have a full work day to deal with the next day.

ATTTENTION YOUNG DOCTORS IN TRAINING: Don't allow your hours to interfere with your quest for knowledge. At the end of your training you will need to know how to care for the illnesses that you are specializing in. Your hours may be limited, but don't let it interfere with your education!!! There are plenty of patient experiences to be had during your on duty time.

My take on the finding that work-hour restrictions don't affect patient safety is actually positive. When work-hours went into effect, there was great fear that patient safety would be compromised. We now see, through multiple studies, that this isn't the case. We may have traded one evil (36 hour call) for another (handoffs) -- in which case, let's work on improving handoff protocol, e.g. more structured handoff -- and let the residents go home trusting their colleagues won't kill their patients overnight.And to Dr. Horwitz, there are definitely still residents working 100-hours a week. They just can't report it because their program might lose accreditation and they'll lose their career. (What residency program will train someone who has a reputation as a troublemaker?) But as you know, if it isn't logged in the computer, it didn't happen, right?

Yes, the jury is still out, but one thing we know is that it costs more!

In medicine, the more you see, the more you do, the more you learn. If you limit hours then you would have to lengthen the residency. Even then you may not make up for continuity of care which is critical to learning and preventing repeat mistakes.Fatigue is overstated. In fact, just because a resident leaves the hospital, doesn't mean he or she goes home to sleep.

Those 48 hour shifts are to be blame for the heath care professionals dismal performance, malpractice, and hi' drug use. Tales of Md trainees stealing Meth to wake up, and morphine, to sleep, are not uncommon

Even doctors as human beings need to find the balance between leisure and the pursuit of money. Any of us that should go under surgery looks for a named or experienced doctor . But these are often work under pressure and sometimes even do not behave with comfort the patient to their patients. A doctor are in a need of rest and in order to do their job in in clear mind and be judiciously. http://www.lifestyle-after50.com/leisure.html

If there is no evidence that it changes patient care either way, then perhaps we should allow the doctors to "have a life" be more rested. Let it help someone.

If residents were viewed as students instead of as a source of cheap labor then the intern who was in the middle of a crucial surgery could be allowed to continue and given time later to recuperate, minimizing interruptions in continuity of care while allowing residents to work a reasonable schedule.