By Kiran Gupta
The number of hours that we doctors can safely spend on the job has long been debated. Many first-year physicians bear the brunt of the 30-hour call shifts, admitting patients over 24 hours followed by six additional hours to finish notes and rounds. Concern over our schedules makes sense: we all know that chronic exhaustion contributes to medical error. But the pendulum may be swinging too far in the opposite direction. New guidelines, which come into effect this month, may compromise the education of my generation of trainees.
The debate over work hours began with the tragic story of 19-year-old Libby Zion, who died at a New York hospital in 1984. The two resident doctors who admitted her prescribed a medication and left to attend to the many other patients. Zion continued to worsen. Later in the day, reportedly without examining her, the overworked residents prescribed additional medication over the phone. By evening, Zion had developed a high fever, then suffered a massive heart attack. A drug she was taking, combined with the medications given to her by the residents, had led to “serotonin syndrome,” which is fatal if not treated immediately. Her symptoms might have been recognised earlier had the residents been well-rested.
The ensuing controversy led to recommendations that residents work no more than 80 hours per week, or admit patients for more than 24 consecutive hours. Overnight call was limited to once every third night, shifts could not exceed 30 hours, and each trainee had to receive at least 10 hours off between shifts. I saw those long shifts as integral to my learning.
But things have now changed. First-year doctors will only be allowed to work 16 hours at a time. Programs now have to try to use the same number of residents to cover the same number of patients while creating new shifts. This will undoubtedly have an impact on how many residents are present on morning rounds, and on the continuity of patient care.
Limiting doctor hours has already caused issues elsewhere. In England, where an EU directive has limited doctors’ work hours to 48 per week, there are concerns that patient care is compromised because doctors are required to take breaks at crucial moments.
Yes, our schedules may be exhausting but, at the completion of my intern year, I am more convinced than ever that the most valuable learning takes place in the hospital. Managing chest pain, respiratory distress and septic shock on the wards is different from reading about it in textbooks. I think of the many nights I spent in the hospital. Sometimes staring at the walls of my call-room, pager lying next to my head; other times running from patient to patient, the call-room bed remaining untouched. Those were the nights I owned my patients. They were mine from dawn of one day until noon the next. I knew them inside and out – their families, their smoking habits and their potassium levels.
We are now entering an era in which the sign-out, the pass-off, and the hand-off will become the focus of patient care. These times, at which one doctor gives over the care of patients to another, present an opportunity for error. Crucial information is sometimes not relayed. What one doctor thinks is important may seem trivial to another. The more numerous the shift changes, the more time we devote to preparing documentation and the less available for learning. Sleep is important and we must be rested to do our jobs well, but we must also know our patients if we are to learn from them.