Sunday, November 11, 2007

80-Hour Work Week Revisited.....
Going "back to school" as it were has placed me squarely in the sights of the 80 hour limitations. My program director maintains a firm line, based largely on a wrist-slapping by the RRC. I am regularly kicked out of the hospital post-call by about 11:00. While I find that enjoyable on some occasions, there is a downside to it. They are, IMHO, and in no particular order:

Work remains Constant: While the hours have been reduced, the work load has not. Unless a training program has the funds to employ some extenders or midlevels, your workload in the hospital will increase, leading to...

Loss of Downtime: When I was a resident (especially a midlevel) there were times, mainly during the afternoon on non-clinic days where there wouldn't be that much to do. Even as an intern this could occur. Why, because the services were at their full strength of residents every day. Some services even had "off-service" interns to share in the workload. But those are gone, having been pulled back to the night float of the "mother ship". Your time in the hospital is almost always spent in some sort of work, with little time to eat or sit down.

Loss of the "Teachable Moment": As stated previously a surgical residency is five years of "shame based motivation". In olden times if you made some jackass decision when on call you were still around to catch hell from your chief resident at the end of your post-call day. It was embarrassing but it had the added benefit that you learned quickly to avoid that mistake again. Nowadays if the offender has left the hospital before the crime is uncovered the lesson loses some of its relevance when you are not there to see the consequences of your actions (for the patients and you), or defend yourself

Loss of Continuity:In my former life I would provide follow-up to the ED physician who called me in to see an interesting case or just to tell them that yes, the patient had appendicitis. But now I find myself giving similar reports to the "night float" team of surgical residents.

Loss of Procedures:Because the interns have to go home, they are losing out on some of the simpler cases the they would often do, such as abscess drainage or breast biopsies. These are left to the attendings and upper levels to do. This has the effect of making programs more "top heavy" than they already are.

Loss of Dedication: When a chief resident, who thanks to the night float does only two nights of call a month, leaves his attending to do an appendectomy with a medical student, something is wrong. Back before the limits, you had to be very dedicated or very crazy to go into surgery. You knew that you would give up a large part of your life, possibly sacrificing your marriage and sanity. You knew that and still chose to do it. Now it becomes just another specialty, made attractive by the hour limits. The true story will be told in 5-10 years when the "baby boomer" surgeons begin to retire.

Now I agree that the system is now more humane, and that is a good thing. But the workweek limits have had a greater impact on the training of surgeons than any other physicians.
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