For those of you not familiar with the field, medical residents (medical school graduates undergoing their specialty training) work long hours on a meager salary for 3+ years to gain the experience necessary to become a competent physician. Over the last few years residents have had to comply with increasingly limited work hours, much as a result of a high-profile lawsuit involving a fatality presumed to be due to a medical error. In 2003 it began with a 80-hour maximum work week on average, and a limit of 30 hours for a shift. In 2011 they limited it even further, prohibiting interns (first-year residents) from working shifts longer than 16 hours. This was all intended to reduce medical errors and provide residents with a higher “well-being.”
This may all sounds reasonable, but according to a new study it turns out the 2011 changes appear to have actually increased the concern for medical errors. Let me illustrate. Imagine you have diabetes and are admitted for pneumonia. What happens all around the nation is you are seen in the emergency room, get a chest x-ray and a few blood tests, and the diagnosis of pneumonia and the decision to admit you is made. After that an admitting intern comes to interview and examine you. He or she will review your medical records and find out all there is to know about your diabetes, insulin schedule and other home medications, and other medical problems. The intern is supervised by more experienced residents and an attending physician, but he or she is your doctor for the duration of your stay. He or she will be around for the critical first hours of your stay.
Not anymore, actually. The way it works now is that the intern will ‘sign-out’ to another intern for the rest of the night. The new intern typically has a short summary of your health history and current problem, but does not know the potentially relevant details of your health history that the first intern discussed with you. With luck no complications will arise during the second intern’s shift that make that knowledge important. And the next day you might be lucky enough to get the intern who admitted you and knows you best, but maybe not.
Sign-outs are unavoidable, but the new duty hour restrictions have basically tripled them. The residents have much less chance to take ownership of their patients’ care.
The other problem is that residents are essentially expected to do the same work in a shorter amount of time. What do we all do when we are rushed? We cut corners and/or skim over steps that we think are less important. In medicine sometimes that’s fine, but we are talking about inexperienced interns. The whole point is to allow them the time to process the information and make the right medical decisions. They learn to be efficient with the experiences they have as a resident. They are being robbed of that.