Saturday, September 3, 2011

Hours of work

"The problem with one in two call is that you miss half the interesting cases."


This article caught my eye.

To summarize, an arbitrator in Quebec has ruled that the 24+ hours shifts some residents still have to work are unfair and have to stop. This ruling of course only applies to Quebec but will no doubt reverberate across Canada. There is no question that long hours and lack of sleep affect performance and judgement. We all know that, we just haven't figured out how to deal with it.

This debate has been seriously brewing for at least 10 years. In our program junior housestaff are allowed to go home after 1200 when they have been on call. Peer pressure usually prevents them from doing this. The innevitability of reduced work hours for trainees has been extensively discussed in academic forums and the conclusion has been that in order to allow residents to work shorter shifts it would be necessary to add 1-2 years onto their 5 year residency.

Anaesthesia on the other hand has allowed residents to go home post-call since before I started training. Some programs now even have 12 hours shifts. Anaesthesiology trainees do 3 years of anaesthesia during their 5 year residency getting their post call days off. They also do 6 months of ICU which also allows them to go home after call. Assuming anaesthesia trainees when they are working work as hard as other residents (judging from the condition of the patients coming to the OR they work way harder than surgery residents), this means that anaesthesia residents get about 20% less clinical exposure during their residency than do surgery or medical residents. That is one whole year.

Consider this however:

If your life depended on the skills of either a newly qualified surgeon, a newly qualified internist or a newly qualified anaesthesiologist who would you pick?

Any anaesthesiologist would of course pick the anaesthesiologist. I suspect however a significant amount of surgeons and internists would also pick the anaesthesiologist. It is quality of training not quantity of training that matters.

When I was a resident I got involved with what was called the Interns and Residents Association and what I called the Residents Union. We negotiated things like salaries and work conditions with the hospitals and the government. Late in my residency our contract was up for renewal. We realized that because of the economy we were not going to get any more money so we decided to negotiate terms of work. At that time we were required to come in for 4 hours on Saturday morning so getting rid of that was a no-brainer. We then moved on to call frequency. At the time we were restricted to maximum of 10 days in 30 (1 in 3) call. We decided to go to maximum of 1 in 4 call. Most services at that time actually did less call than that, the surgical and some internal medicine services being the exception. I sat on the University's Residency Training Committee and attended a meeting where that proposal was discussed. At that meeting there were dire predictions of the collapse of patient care and loss of training opportunities from the staff physicians there. There were also a few threats. The Head of Orthopedics said and I quote, "Any resident who won't do 1 in 3 doesn't get to pick up the knife." We eventually backed down and only got rid of the Saturday mornings.

It was as they said however a fait accompli and now residents only do 1 in 4 call, the collapse of the medical training system has not yet happened.

We do learn a lot of medicine at the bedside. We also have to deal with emergencies some of which happen after normal working hours. Unfortunately forcing trainees to deal with patient care when they are tired is not educational, it teaches them a lot of shortcuts to deal with the problem now in a way that you can get back to bed or watching TV. A lot of advice I got from kindly residents as a student intern dealt with just that, how to defer or patch up the problem until someone else can take care of it. It also makes patients the enemy for destroying your sleep and your sanity. It took me a few years to get over that.

Another issue often raised is the issue of hand-over and continuity of care. It is felt that if residents work shorter shifts patients will suffer as information is not passed on. Nobody has ever commented on what happens now in the evenings when residents go home, leaving everything to the on call resident or on weekends when only the on call staff show up. In most services there is no sign out. When I did general internal medicine for 3 soul destroying months, I recognized quite early that around 1900, I would start getting pages about patients on other services with fairly significant and complex medical problems; patients I knew nothing about. I also learned that if I phoned the attending physician I would get yelled at. Therefore I approached the head of medicine and suggested that around 1600 the housestaff have a signover rounds where these complex patients could be discussed. This was of course rejected as the 30 or so minutes required would take the housestaff away from more important work.

Fortunately nurses who actually do sign over patients between shifts knew something about the patient, something which probably saved my, and more importantly the patient's butt, more times than I can think of.

In retrospect a big part of the opposition to sign over was the whole concept that you shouldn't leave a complex patient which meant you were often expected to stay well into the evening if you had somebody in trouble, rather than signing the patient over to the physician who was eventually going to have to look after your patient anyway because sooner or later you were going to go home and the patient was not going to suddenly get better. Of course the person you were signing over to would have worked as long as you had already that day, probably a little bit harder and wouldn't it have been nice to be able to sign over to someone who was just coming in relatively fresh. What a concept.

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