There is an interesting article in the New York Times (found here) about sleep deprivation and physicians-in-training. A new set of work rules for doctors in training (residents) took effect on July 1st of this year. There was one rather odd requirements where the 1st year resident can work up to 16 hours but must then get 10 hours off, causing those of us involved with training to do a little head scratching about how to make that work. Did that mean residents come in 2 hours later every day? Talk about a screwed up circadian rhythm.
The article in the Times pointed out that despite severe reductions in work hours over the past 10 years, care related errors have not decreased and have in fact increased. The implication was that perhaps the hours, themselves, were not to blame. The comments accompanying the article were predictable. Many were from older doctors (likely my age) relating how they were able to resurrect folks from the dead but only after working for 35 hours straight. Some were from physicians who are currently in training (and thus only know the work-limited training model) talking either talking about how they would never learn resurrection without being allowed to work 30 hours straight or conversely how they disbelieved the older doctors stories. I trained in a time and setting where the hours were unlimited. I do not recall any specific abilities granted me by virtue of working long hours. I do recall being bone-tired after a day in the office, a night of working to fix some very sick people, followed by a day in the office. I certainly never felt I was doing my best at hour number 36.
The real story is not about one young woman (Libby Zion) who died in New York and her dad’s efforts to affix blame and correct a common sense problem (working for 36 hours straight can never be good). It is about system change:
But all of these hospital reforms ignore what may be the biggest problem in physician training today: the yawning chasm between what most doctors learn during the 80 hours a week they spend training in hospitals and what they actually do after leaving their residencies. Defenders of the old-school way argue that the demands of medical practice justify the brutal hours. But after their residencies, most doctors practice in outpatient settings and work regular daytime hours as members of large groups. They treat chronic problems that need weeks or months of periodic outpatient follow-up, not high-intensity hospital-based care lasting only a few days.
The old method of physician training is dead. We used to think we could put physicians in training and really sick poor people in the same building, and poor people would get at least some care and learners would get training. It was this model that Medicare put money into in the 1960s. This evolved into a different model. In the current model some (if not all in some teaching hospitals) of the inexpensive trainee labor is re-purposed to provide help for physicians providing complex care for paying patients. As we ratchet back the inexpensive labor, changes are going to have to happen.
As I have discussed here and here and as Dr Sanghavi discusses much more eloquently, the current training system does not prepare learners for practice and now is shown to contribute to fragmented, error prone care. It is time to re-think the entire process. In the words of the man who sets policy:
“For people who came out of the old training system, it may be hard to imagine one that works better,” says Donald Berwick, the director of the Centers for Medicare and Medicaid Services and former president of the Institute for Healthcare Improvement. “The point is, it’s all about design and coming up with optimizing models.”
Poor people need care other than in the hospital provided by over-tired trainees. Trainees need to learn about care delivery in settings that prepare them for a future of error free practice. Hospitals need to wean themselves from cheap labor provided in the name of training.
Also, I kind of think the resurrection stories were exaggerated.