“When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians.

 

This article was written by a Pulmonary, Critical Care Fellow who completed residency after recent resident duty hour restrictions went into effect.

During my internal medicine residency, we were allowed to work  a maximum of 30 hours per shift.  You would do a 24 hour call in the hospital , then round on your patients post-call and go home by noon.  This was the norm.  I completed 5-6 of these shifts per month during my entire 3 years of residency.  Even then, when timidly telling my attending physicians that it was time for me to go home after fulfilling my 30 hours of duty and barely being able to keep my eyes open, they would respond with the old clichéd phrase “Well, when I was a resident……”  The sentence would usually end with something about how they used to work for 3 days straight with no sleep, no shower, and on and on.  Just like your Dad telling you “When I was a kid, I would walk to school, barefoot, in 6 feet of snow…..uphill.” At least that’s what my Dad would say, and I would sigh and roll my eyes.    I never thought I would agree with such a cliché.  But now, as a 2nd year Pulmonary and Critical Care fellow, I frequently find myself repeating these same exact words:  “When I was a resident..” and let’s face it, that was only 2 years ago.

 I completed my residency  prior to the “new” duty hour limitations that went into effect in 2011.  The new regulations limit residents from working more than 16 hours straight; after 16 hours, they must have a mandatory “nap” time.   This has forced many institutions to change the call schedule to so-called “block nights”.  Residents are only allowed to work 12 hours during a call shift.  They work 12 hours and may stay for an additional 1-2 hours after for educational lectures and sign-out, but otherwise, they are off duty.  I have even found that many resident physicians will not even return a page after 7 am because apparently that would be a violation of duty hours.

 Shortening duty hours to a maximum of 16 hours at a time has not, in my opinion, improved resident physicians experience in any surmountable way.  It seems detrimental if anything.  Studies including the one recently published in JAMA, would seem to support the view that shortened hours may not in fact be beneficial to residents or their patients.

Because of the changes in work hours, residents are becoming less educated, less experienced, and more apt to push work off onto someone else or to leave it altogether.  They have a decreasing sense of patient responsibility and motivation.   I frequently hear, “Oh, I have to leave, can’t go over my duty hours,” even when there is still patient care to be done.  I’m not asking that residents be asked to stay beyond what’s reasonable (and I know “reasonable” is still the big debate), but I do think these increased restrictions on allotted time in the hospital are molding a generation of residents who are less than motivated. Many are being  instilling with bad habits and a poor work ethic.

Now, I know, maybe I am just one of those people. The overachiever who expects a lot from myself, and from others.  I am, after all, a pulmonary/critical care fellow, so I do have that type of personality.  But I know the majority of my colleagues agree with me:  the general consensus is that these duty hour restrictions are instilling a lackadaisical apathy in many of the underclassman.  Not all, but many.  We are teaching them that it’s OK to do the minimum, and that there’s not a need to go above and beyond.  It’s OK that you weren’t able to put that arterial line in because you put in your 12 hours, and I know you were busy.

In my opinion, this is not acceptable.

“When I was a resident”, we completed caring for a sick patient, even if it meant working a little longer.  We took pride in caring for our patients and made sure they were “tucked in” prior to leaving the hospital.  We didn’t frequently leave tasks unfinished or patients unseen; it was not in our nature to leave work for the next person.  Unfortunately, it seems this is becoming more common among the trainees.  Because it would be a violation of duty hours, there are frequently tasks left undone at the end of a shift, putting an extra workload on the next shift. I foresee this only growing worse in the future.  Patients will be left unseen, labs unchecked and procedures delayed.  What is the incentive for residents to complete duties within their 12 hours?  There really aren’t any.  They know that at the end of 12 hours, they are going home.  It doesn’t matter what tasks were left undone because if they stay, it’s considered a violation.  This mindset is not creating great physicians or teaching those in training how to live up to their potential.  It’s sending the message that being mediocre is allowed.  As long as you put in your time (even if you left the next team to finish work undone), you’re golden.

 They are also missing out on important educational opportunities and experiences that are imperative to improving their knowledge and skills. I have found that with duty hour changes  increasing numbers of residents have not had adequate opportunity to become skilled in central line placement.   Many do not have experience in basic critical care principles because they have yet to deal with very sick patients.  How can you gain necessary experience when you are working such limited hours?   And the majority of these residents are complaining about being tired and fatigued after working a 12 hour call shift.  They complain about being too tired to handle a 30 minute post-call lecture necessary for their overall education.   They are not learning how to deal with real life as a physician and I fear they will not be capable of handling it.  Not only do these restrictions seem to have a deleterious effect on their education, it has, as importantly, not improved their morale or their sense of well-being according to recent research.

 As a fellow, we provide care just as an attending physician would.   We take 24 hour home call, sometimes 3 or 4 days in a row.  My attending physicians do 5-7 days straight, sometimes more.  Many physicians frequently do 1-2 weeks at a time.  Are we all tired?  Absolutely.  But residency prepared me well for this.  The long, grueling days and nights during residency prepared me for dealing with fatigue.  I can, without a doubt, answer my pager all night long and still function the next day.   I can go in at 3am to place that dialysis catheter for emergent hemodialysis and still round on my 25 patients the next day.

Residency prepared me for this and I would not take back even one call shift.

It taught me not only how to manage fatigue and still make important life-saving decisions, but also that I needed to be responsible and take ownership of problems that I encountered. One of my biggest fears is that the new generation of residents will have no coping skills.  They do not and will not be able to handle fatigue and stress related to fatigue because they do not have to experience it now.  Instead, it feels like a precedent is being set that after fulfilling required hours, it is someone else’s responsibility to pick up the slack.

 Fatigue is part of being a physician.  We all knew that when we signed up for this job.  Maybe we didn’t realize, at least I know I didn’t, the extent of the fatigue or what real exhaustion feels like, but we all knew being a physician was not going to be easy.  Not mentally, emotionally, spiritually, or physically.  When residents go out into the “real” world, there are no limitations on duty hours.  Patients are not going to stop coming to the hospital, or stop coming into your office just because you are tired.  There is not going to be the threat of program dissolution or joyous scheduled nap time if you continue working after your allotted 16 hours.  And let’s face it, this will happen.  You will frequently put in more than 16 hours at one time.  Restricting duty hours so significantly during training is not going to change this fact.  Instead, it is creating physicians who are ill-equipped to handle it.

 When I look at my mentors and my attending physicians, I know my duty hour limitations were significantly better than what most of them experienced.  But when I look at the massive amount of experience they attained during their residencies and fellowships, I ask myself, “Who would I rather be?  An extremely experienced, well-rounded physician who endured a difficult but rewarding residency, or an inexperienced physician who spent residency more worried about how many hours I worked rather than how many patients I encountered or procedures I performed?”  I don’t know about you, but I choose the former.  I want to be the best physician I can be, and that requires experience.  Even then, I know I will never be able to encounter every disease process and every clinical scenario over the course of my training, but, at least allow young physicians the opportunity to experience all they can during these crucial years in training.

 Adding an extra year of residency, which already feels like an eternity (not only to residents, but their spouses and families as well), will not fix this issue of teaching residents how to deal with fatigue.   It may allow young physicians to gain more experience prior to practicing on their own and I realize this is the most important topic in this continued debate.  However, it is necessary to force residents to complete another year to gain the necessary experience?  The opportunity to experience life as a physician is attainable in the already allotted time for residency, if residents are allowed to spend their time in training wisely.  Just look at our predecessors.   They were able to become amazing physicians within that time period; however, they did not have such strict regulations on time allowed to learn during this time period.  Residency is not supposed to be a walk in the park.  It is supposed to be difficult.  It is supposed to test us.  It is supposed to teach us to deal with all aspects of medicine.  Instead, it seems as if it is teaching the new generation of physicians how to merely get by and be less efficient.

 “When I was a resident…” used to feel like a cliché.  But now it feels more like a way of life, like an attitude.  One that I hope changes in the near future.  Sometimes change is good, sometimes great; but sometimes, the old way proves to be better.  In this instance, I think change has been detrimental for education and I hope the phrase “When I was a resident…” continues to be a phrase my attending physicians use; but not one that I find necessary.

 

-Rebecca Hastings, D.O is Pulmonary, Critical Care Fellow, she is on twitter @RR_Hastings

 

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  • Jessica McFarlin

    “residents are becoming less educated, less experienced, and more apt to push work off onto someone else or to leave it altogether.” This article unfairly characterizes many, many current residents. They did not create their current work environment any more than those of us who worked under the first round of duty hour restrictions created ours. As an attending I work daily with motivated residents in the ICU who lament that they turn over their patients on a too frequent basis. Rather than having a “decreasing sense of patient responsibility and motivation” they worry that the patient they took care to admit and work up will be left in hands that do not know their case as well as themselves. Current residents recognize the boundaries they have been forced to work in. As an attending I am also called to ensure they follow the duty hours or face penalties to our own program. None of us like the system. Rather than mischaracterizes our residents, as leaders and educators we have to work within the system to design learning environments than ensure the continuing creation of quality physicians. This is a much harder task than blaming residents.

  • Lauren

    “I completed my residency prior to the “new” duty hour limitations that went into effect in 2011. The new regulations limit residents from working more than 16 hours straight; after 16 hours, they must have a mandatory “nap” time. This has forced many institutions to change the call schedule to so-called “block nights”. Residents are only allowed to work 12 hours during a call shift. They work 12 hours and may stay for an additional 1-2 hours after for educational lectures and sign-out, but otherwise, they are off duty. I have even found that many resident physicians will not even return a page after 7 am because apparently that would be a violation of duty hours.”

    One small thing- the 16 hr work hour restriction, and the 12 hour call restrictions? Those only apply to interns- at least in my husband’s residency, which I assume is following the same standard as everyone else. PGY2s and 3s are more similar to the hours back in your day. As I write this, my husband has finished a 24hr call and is still finishing up work at the hospital and while he will be home before noon, it will still be long past the 24 hr mark.

    I’m not disagreeing with the point. In fact, I can’t say much at all about the point seeing as how I’m just a spectator to the residency experience, but I did want to point out that the hours restrictions you’ve given here only apply to one year of residency as far as I understand it. : )

  • Lauren

    From the ACGME website:

    “Duty periods of PGY-1 residents must not exceed 16 hours in duration.

    Duty periods of PGY-2 residents and above may be scheduled to
    a maximum of 24 hours of continuous duty in the hospital.
    Programs must encourage residents to use alertness
    management strategies in the context of patient care
    responsibilities. Strategic napping, especially after 16 hours of
    continuous duty and between the hours of 10:00 p.m. and 8:00
    a.m., is strongly suggested.” (note they don’t say mandatory. Emphasis mine.)

    Also from ACGME:

    “In unusual circumstances, residents, on their own initiative,
    may remain beyond their scheduled period of duty to
    continue to provide care to a single patient. Justifications
    for such extensions of duty are limited to reasons of
    required continuity for a severely ill or unstable patient,
    academic importance of the events transpiring, or
    humanistic attention to the needs of a patient or family.”

    Here is the link to the requirements set forth in July 2011. The above mentioned sections, as well as all things pertaining to duty hours, are on pages 16 and 17. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/Common_Program_Requirements_070120111.pdf

  • Guest

    If a residency program is responsible for instilling work ethic in its residents, it chose the wrong people. The ethic should already be there, these are not adolescents. It seems that there are real, systemic problems in medicine–across the professional lifespan–and that a number of shifts must occur (i.e. both in ways of thinking about and doing medical education). Your piece has a deficit view of residents, to say the least. Why do you imply residents leave slack behind? If there is a resident who’s ready to leave at the end of his/her shift, it does not mean that patient care was compromised, things were left undone, etc. I mostly wonder about your family. I wonder about your friends. I wonder if you have children. A spouse. I wonder how many of those people are also physicians. How many work in the medical field. I wonder, if they are medical folk, is that the primary reason they are in your life: you created no boundaries and work hemorrhaged into home life.