During my post-graduate medical education, I learned to enjoy quiet times in evenings with patients and families. Going home wasn’t an option when I was on call.

I learned how to function with a sort of ongoing sleep deprivation. I discovered that a few hours of full-court basketball after working 36 hours can be therapeutic, especially when followed by pizza and beer.

Then process began all over again the next day.

Despite the memories, my first thought was, “Where was this law when I needed it,” when Congress adopted legislation a few years ago limiting the work week for medical interns and residents to 80 hours.

It was passed with the best of intentions — to reduce the fatigue factor in training programs in hopes that mistakes would be minimized and patient care improved.

Studies on medical mistakes seemed to indicate that some of them were directly attributable to long hours, poor communication among staff and exhaustion.

A wrinkle to the 80-hour work week was proposed last week.

In the latest issue of the New England Journal of Medicine, a proposal from the Accreditation Council for Graduate Medical Education was published that would mandate that first-year residents work no longer than a 16-hour shift and have constant supervision, and that more senior residents work no longer than a 24-hour shift.

All of this sounds reasonable and good on paper, and certainly patient safety should be paramount.

There is only one problem. Data after the first regulation was passed haven’t supported claims that shorter work weeks translate to improved patient care.

There has been no meaningful reduction in medical errors made since the 80-hour week was mandated. Some even claim that mistakes may be slightly higher.

A noble objective has led to a system where errors remain a major problem.

One reason is that the more we become “shift” doctors, a greater likelihood exists for communication mistakes to develop between staff who “inherit” the patients from their colleagues who are rotating off duty.

Medicine is unpredictable. People seem to have this infuriating habit of getting deathly sick at any hour. The body doesn’t recognize holidays, work schedules or outside commitments.

The more we divide patient care and continuity among smaller and smaller parcels of physicians and specialists, none of whom communicate with each other as well they should, more errors probably will happen.

One other unintended consequence of the latest proposal is that we succeeded in training a generation of physicians who have little experience in crisis medicine.

By functioning primarily as “shift” physicians, they have less experience when a patient crisis erupts.

Our system of care seems to be moving to an outpatient “wellness” model of delivery and an inpatient “sick” model.

And the two skill sets that are required are fundamentally different.

Is it asking too much that when patients become sick enough to require hospitalization that they have someone attend to them who knows their case?

Perhaps it is asking too much of young physicians to hone their skill sets so that when crisis comes, they can respond appropriately.

But our current system is fundamentally flawed and limiting work shifts doesn’t seem to get to the heart of the matter.

Until we address these deeper systemic issues it seems that focusing on the work schedules of physicians-in-training is a bit like plugging a dike with a pinkie finger and expecting the leaking water to stop.

 

Michael Attas is a local doctor, a medical humanities professor and an Episcopal priest. Contact him via e-mail at Michael_Attas@baylor.edu.