Curiously, under the old unlimited-work-hour approach, no resident covering a medical ward ever spoke of working a “shift.” Each morning we would go to the hospital, and we would stay until our work was done, whenever that might be. Each day, one of the three interns (first-year residents) was “on call”—admitting new patients, covering the entire ward overnight and maybe, if efficient and lucky, sleeping. With responsibilities so clear and pointed, it was enormously maturing. Physicians worked “shifts” only in the emergency room, where a different modus operandi—“meet ‘em and street ‘em”—prevailed.
Now that a shift-work mentality pervades teaching hospitals, I wonder what type of physician it produces. Certainly it produces a more self-centered physician, who must be given his or her rest time at the appointed hour, with the status of the patient being secondary. And certainly it provides an opportunity for laziness to bloom, knowing that the wall clock, and not the completion of work, governs one’s departure time from the hospital.
No one would ever say that a well-rested resident is a bad thing. But many people would say there are worse things than a tired resident. Foremost is a resident who does not know what is going on with his or her patients. The more time a resident spends outside the hospital, the less the resident knows about the patient. This includes potentially pivotal information that rarely goes into the medical record or rises above the subconscious, like whether a patient is a complainer or a stoic, or how the patient’s facial expression changes when she is in distress.
It gets worse. Every time a resident goes home, he or she must hand off the care of his or her patients to another resident. Typically, the outgoing resident will speak to the incoming resident for 30 to 60 seconds about each patient. Inevitably, information is lost during these handoffs, just like making a Xerox copy of a Xerox copy of a Xerox copy. All physicians — and patients — know this problem of “handoff entropy.” Smart people have been trying hard to solve it, but they won’t: like physical entropy, handoff entropy is inherently unsolvable.
Let’s jump to the bottom line. What do studies show about the new schedules and their raison d’etre, patient safety? According to the 2011 report of the ACGME[1] (the people who promulgate resident work-hour requirements), the short, disappointing answer is: No detectable improvement in patient outcomes occurs under the new schedules. Thus, I doubt that even shorter work shifts will produce benefits exceeding the consequent increases in handoff entropy and patient unfamiliarity.
Most worrisome is that we have no way to measure whether the new residency schedules are turning out an inferior long-term product. In addition to increasingly evanescent book knowledge, residency teaches four essential eternities not taught in medical school:
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Clinical reflexes–recognizing when a patient is seriously ill and needs urgent attention,
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Humility in the face of nature’s incredible subtlety and complexity–hubris is the physician’s greatest sin,
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Subservience to the patient’s needs—nothing better teaches that the patient comes first than being awakened from a sound sleep, and
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Knowing when to seek help—the single most important attribute of a good resident, or any physician.
None of these essential lessons are measurable with standardized tests and none are strengthened by cutting hours.
Inexperienced doctors—indeed, all doctors—will make mistakes no matter how rested they are. Far better, therefore, for medicine to focus on designing work systems that intercept mistakes before harm comes to patients, rather than sacrificing essential elements of residency training to an apparently inscrutable and capricious god of short-term improvements, who has so far rejected the reformers’ offerings.
[1] Chapter 11 of the report is at:http://www.acgme.org/acgmeweb/Portals/0/PDFs/jgme-11-00-69-74[1].pdf