Recently, Rebecca Ulep wrote a rebuke of recent resident duty hour restrictions and their potential negative effects on physician education in a post entitled “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. Many practicing physicians agreed with these sentiments, while most residents did not. Our expanding #PulmCC community brought me into the acquaintance of one the latter, who agreed to write a post taking the other side of the argument. Scroll down for the article, and hit the link above to read the original post. And follow the #PulmCC hashtag on twitter to keep up with relevant material and participate in future #PulmCC twitter chats.
I argue with my father a lot. He works as an intensivist at a community hospital in Indianapolis while I am about to graduate from a highly academic internal medicine program in Chicago. Needless to say, we have very different perspectives.
He sometimes expresses views similar to those written in a previous article, “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. I started residency the first year that the new intern duty-hour regulations were put into effect. After explaining these rules to my father, he asked me: “How do you guys learn? When I was a resident, we did not have limits to how many patients we saw. I would be working until five or six in the evening on my post-call day and then stay to work a moonlighting shift.” I, then, delightfully asked him if that was before or after penicillin was discovered.
The field of medicine has undergone many changes (yet we still carry pagers…that’s for another rant), some for better and some for worse. There has been much debate over potential benefits and detriments that come with the changes in duty-hour regulations. I can only speak to the culture at my own institution, but in my experience, there is one thing that has not changed: the pride we take in our work. This is why I take particular issue with the overly dramatized notions brought up in the aforementioned article.
Now to be clear, this should not be taken as praise for the duty-hour regulations; I am not convinced that they are necessarily beneficial. Instead, this is meant to argue, on behalf of the duty-hour generation of doctors, that we are just as capable as the graduates from before these regulations were implemented. This is a look at my own “When I was a resident” short list, once I graduate at the end of June.
“When I was a resident,” we (also) took pride in caring for our patients. Because we were restricted by shift-work, we learned to become efficient and prioritize our tasks. Yes, many times we had to pass on duties to our colleagues who came in to relieve us at the end of our shift, but usually the most important things were taken care of. We especially took pride knowing that even once we left the hospital, our patients were being looked after by our trusted colleagues.
“When I was a resident,” we were taught that medicine is a team sport. We felt personally responsible for our patients and felt a personal responsibility towards each other. We frequently assured our colleagues that we would act on any critical labs, perform any critical procedures, and make any remaining assessments on their patients, because they were not just their patients; they were also our patients. We could go home because our colleagues picked us up. Our colleagues could go home because we picked them up.
“When I was a resident,” our program prioritized our education. With the re-structuring of the program to comply with duty-hour regulations came a re-structuring of conference schedules to allow maximum attendance. We were afforded increased opportunities for meaningful participation, as we were not burdened by excessive service requirements or post-call fatigue when we attended.
Duty-hour regulations have not made us unmotivated. Duty-hour regulations have not instilled bad habits. Duty-hour regulations have not given us poor work ethic. Most importantly, duty-hours have not made us less educated. What duty-hours have done is change our approach to how we handle our responsibilities, and with repetition, we will become good at caring for our patients in this manner.
On a personal note, I will be starting my Pulmonary and Critical Care fellowship in July after I graduate. I am confident that, despite all these concerns regarding the duty-hour rules I trained under, that I am prepared for this role. I am confident that I have seen and cared for an adequate number of critically ill patients. I am confident that I have acquired sufficient procedural experience during my time in residency.
Maybe I am wrong. Maybe I will start fellowship and realize that I am tired. Maybe I won’t function well after answering my pager all night or maybe I will be have a hard time rounding on all the patients the morning after having to emergently come to the hospital in the middle of the night. I suppose the next question is should I care? While some attendings have home call for a week at a time, other attendings work on a periodic night-block schedule just like I have trained under. Why should I have to work fatigued when I have a team of people to help me?
Now the truth is, I do care, as I am going into a field where making critical decisions while dealing with fatigue is a common occurrence. I feel confident in my ability to handle this as I myself focused on honing this skill during residency (or because I spent all my mandated time off partying instead of resting). That doesn’t mean, however, that it’s a necessary experience for everybody. For another resident, with career aspirations of a primarily office based specialty such as endocrinology, I see no reason why they need to develop this skill. Similarly, I probably shouldn’t admit this before I graduate, but I am ill experienced with knee injections. Does this make me unmotivated? Maybe, but to be fair, I probably wouldn’t have bothered learning it even before the duty-hour regulations.
We all have mentors and role models that we look up to and strive to become. Here is the dirty little secret: we are not done learning once we exit residency. These mentors did not learn the skills we admire over the 3-6 years of residency, rather, they have developed via their experience over 15-25 year careers. We all have access to the same journals and resources. We all see the same pathologies when we encounter patients. We will all work with senior doctors to help guide our path as we develop over the course of our careers. Life-long learning is a competency championed, not only by the medical school I attended, but also by medical schools all over the country. Short of being brilliant, it’s impossible to survive medical school without having the appropriate motivation and work ethic. The graduates of medical school, in general, are passionate people with a sense of duty and responsibility. It seems unlikely to me that a single year of duty-hour regulations will ruin that foundation.
-Rohit Devnani is an Internal Medicine Resident, he is on twitter at @RoRo_Nani