Monday, August 04, 2008

Resident Work Hour Restrictions: "Attending" to the Consequences

From the Fellow's Corner:
Question: I'm curious as to what the experience has been, not in terms of the workhour restrictions to which we as cardiology trainees are subject, but rather, do you think that the workhour restrictions on residents has had an effect on what you are expected to do as fellows? Is work flowing uphill? Is it flowing over fellows' heads to attendings? Is it being shifted over the physician extenders? And perhaps most important, do you think that we're at steady state, or are shifts going to continue?

Work hours restrictions have definitely changed the nature of training. The hierarchical 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.
The conversation is shifting. Traditional hierarchical patient management is giving way to the need for "scut management" as work hours, thrown in amongst teaching sessions, draw short. Divide-and-conquer. No time for supervision. Hurry up! We've got to get done!

More surprisingly, trainees are now perceiving a tectonic shift in patient care responsibilities as attendings "manage every single patient" and rely less and less on their presence. Housestaff are becoming fearful that they will be marginalized members of the patient care team. Meanwhile, they witness the change in their attending's quality of life. Suddenly, the lure of the title "senior attending" is losing its luster.

And home life for the attending? Well... Oh, geez, I better call home!

"Sorry for calling so late dear. Yes, dear, I should be home soon."

"What's that dear? Why can't the residents finish up? Well, you know, they've left. They can only work so many hours..."

"Say what? Who made those rules? It really doesn't matter... (Holding phone away from ear)... I know you don't give a damn about those residents, dear. But someone has to manage the patients, dear."

"Birthday, whose birthday? You're kidding, right. (Looks at calendar and thinks, "Oh no! I'm so screwed!") I'm so sorry dear. Er, uh, I'll come back later to finish up, dear. No problem, I'll get changed and get home right away..."



James said...

"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"
Part of the mission of my blog is going to be to actively combat this kind of thinking. I think that you learn by learn by learning, not by doing and then hoping that after you've done it you've learned how to do it correctly. The less scut work you have, the more time you have to learn and, as a consequence, the better you will be at managing patients.

Anonymous said...

It seems like much of the resistance to the work-hour restrictions is a function of the "culture" of medicine, which tends to value tradition over change. This seems odd considering that the science of medicine is constantly changing. Instead of bemoaning the restrictions on work hours, why not seek out new ways to train physicians? We wouldn't want pilots or truckers to work 120 hours a week because if they fall asleep at the yolk or at the wheel, they can kill people. Which is worse, an alert resident who can work a problem on an unfamiliar patient, or an exhausted resident who knows the hx but is so impaired that he or she writes the wrong orders or falls asleep during a procedure? I, for one, wouldn't want an attending in that condition working me up either. Also, as a med student, I'm already up to my ears in loans; I don't want to shell out north of a hundred grand on such a high-powered education only to do phlebotomy after I graduate. I did phlebotomy before med school, and it doesn't require an MD. There are some traditions that need to be discarded. I'm happy to work hard and put in long hours, but not to the point that it compromises patient care. Sure, there are all kinds of errors in hand-offs, but why not improve hand-off procedures instead of subjecting patients to a sleep-deprived resident who has been working for 36 hours straight and can't read an EKG? Why not train more physicians? (We all know the an$wer to that already)

DrWes said...

Anony 10:14-

Thanks for your comments.

As you know, the work-hour restriction change has happened and has been embraced for many of the reasons you mention. But the commentary is interesting here for several reasons. First, what is "scut?" Is not "scut" caring for the patient and all that that entails? Or is "scut" just those things that no one else wants to do because of poor economic incentives - like primary care? We should define the term better.

I am fortunate to work in a facility with remarkable IT support. The "scut" of the old days used to be running to the microbiology lab to find the micro results in a stack of chits - now the results appear instantly on my computer screen. Retrieving the information used to be the domain of med students. Technology has greatly replaced the "scut" of the old days with a new scut: documentation or stuff that computers can't do - like phlebotomy or obtaining an EKG. But there, too, hospitals have recognized that IV and EKG teams are a more efficient means to assure tests get done when they're ordered (and therefore help decrease the all-dreaded length-of-stay), so med students there have become marginalized. What's been lost? Maybe little. But facetime with patients is now relegated to others as med students seem to sit more and more behind a computer screen. It seems to this old fart that another skill and opportunity to check on your patient has been diminished.

Secondly, to suggest that others on the "team" are not affected when residents work hours are limited is ludicrous: the work still has to be done. Certainly, practice patterns have evolved with the advances in knowledge and technology. But many groups have had to resort to employing larger legions of ancillary providers to address the challenge of trying to remain income-neutral at a time when increase numbers of patients must be seen due to declining Medicare payment rates, often at personal cost to themselves. There can be no denying that patient communication and "access" are improved by these personnel acquisistions: but again, housestaff are marginalized from the day-to-day patient care interactions that occur. Is this a good thing for training?

Finally, what "new ways" to train might you propose? Using mannequins? Spending more time in classrooms and not at the bedside? Prolonging the years of clinical training? Certainly, with the advent of "nurse-doctors" and the like, the medical school (and hence physician-directed care) paradigm is being challenged like never before. Even the need for "organic chemistry" in the curriculum has been questioned now that automation makes it all look so easy.

But as you and I know - it ain't easy - or pretty - but the much of the challenge of creating the solutions necessary to assure great healthcare delivery will require an ongoing dialog about the compromises inherent to any option proposed for ALL involved.

Michael D. Miller, MD said...

I was a surgical intern the year the Libby Zion case happened - which is what led to the new rules. I was in a different city from where the Zion case occurred, but as an intern, the best shift of the year was the ER and the ICU which were essentially 24 on/24 off. On other rotations it was every 3rd night call, and one week I worked 136 waking hours (there are 168 total hours in a week.) Those types of hours aren't good for learning (it teaches survival rather than training), and it can't be good for patients when the residents are walking wounded, and the "fresh" residents and attendings have to watch over the "fried" residents.

So the new hour rules may be hard for some to adapt to, but they certainly can be implemented to improve quality of patient care and quality of physician training. I think that emphasizing more broad team approaches to both inpatient and inpatient care will improve both - and have benefits when the residents carry them out into their post-residency practices.

Michael D. Miller, MD said...

Sorry that should have been "inpatient and outpatient care"

Theresa said...

I entered residency as the work-hour restrictions were being implemented. I think they saved me from undue punishment, as did a team Night Float system.

Dr. Wes makes an excellent post that we should define "scut" more carefully. If the promise of EMR is fulfilled and patient records are automatically updated with status changes and lab/radiology results, then some of the traditional scut burden will fall away from the health care team. This will be a good thing. However, some "scut" will never go away--interpreting EKGs, making sure labs get done and are reviewed, documenting multiple follow-up visits--and it remains a question how this work will be redistributed.

I have no quarrel with the need for work-hour restrictions, but I also agree with the "old farts" when they worry about the loss of rigor in medical training. There must be a middle ground between old and new somewhere.

Anonymous said...

Dr. Wes, I'm at a loss to understand how your (or any student) chasing after slips of paper was a meaningful exercise of everyone's valuable time in a learning situation.

It's great that technology has been implemented to make those old ways and days antiques, but yearning for them, or claiming that it made better doctors, requires something along the lines of ... I don't know, EVIDENCE?

Survival in a disfunctional system isn't what makes good doctors, and while it is good that the house staff was there to save patients lives (PRN) is laudable, the fact that their lives could be saved by such process-oriented 'scut' is a condemnation of the training system.

These days we have (or better have) a clue about why we do things, be constantly looking for objectively better ways of doing them, and not inflict stupidity on anyone - student, resident, or patient.