Residents and Patient Care

Residency is the time in a physician's life when he or she has graduated from medical school, but is not yet fully licensed. It can range from three years up to thirteen years (depending on specialty and subspecialty), and is often the most intensive time in a physician's life. During this time, the physician works in a hospital, and is often in the first line of doctors that the patient will see. They are responsible for the day-to-day care, while their supervisor, the attending physician, just makes sure that they aren't endangering the patient.

In the past, residents have been expected to work 120 hours a week (to give you an idea of how much this really is, there are only 168 hours in a week, so this schedule leaves 48 hours for time away from the hospital). Of course, there was a great deal of concern that the exhaustion faced by residents was endangering the lives of patients.

So, standards were introduced to stop this. After patient safety was called into question, reforms were instituted, limiting work weeks to 80 hours (usually 10 hours a day for 5 days, plus every fourth night on call), and shifts to 30 hours. Of course, these reforms were often not enforced, and residents still suffered burnout and made fatigue-related mistakes.

So, the Institute of Medicine has recently released a report that calls for a limit on shifts to 16 hours, with a mandatory 5-hour nap following the shift. Also, they suggest, let other people do the non-educational aspect of medicine, such as wheeling the patients around to get X-rays, or draw blood.

Is this a good thing?

Well, there are many opinions on this matter. First of all, there is the concern of patient safety when the same physician is not attending to the patient. Dr. Sandeep Jauhar, in his book Intern: A Doctor's Initiation, describes a situation where he is the 'hand-off' physician, the one who takes care of the patients at night while their regular residents go home. Due to the residents wanting to get out as soon as possible, he is left with little knowledge of the patient's condition and needs, and thus has difficulty making choices about the patient's care. This lack of continuity of care can lead to some serious mistakes, especially when patients are hospitalized.

There's also the concern of lack of experience when going into the field. The physicians who worked 120 hours a week are going to experience more in the long run than those who only work 80 hours a week. It's just simple math. So, are those restricted by the work cap going to be as good of doctors as those who were left unrestricted? Another, similar concern is that the residents will suffer burnout sooner, because they are being forced to do the same amount of work in a smaller amount of time.

There is also evidence to suggest that allowing residents more sleep really doesn't stop the errors that they're making in the first place, though burnout did decrease.

In response, some have suggested reworking the way residency is done. For instance, spending more time in clinics, focusing on patient care, rather than in the hospital setting, may prepare physicians more for a career.

So, are work hour limits really the solution to the problem of patient safety in residency? Maybe. But I think it's safe to just say the more research needs to be done on the negative aspects of residency, before we try to propose solutions to fix it, especially considering the cost of the Institute of Medicine's suggestion is something like $1.7 billion per year.