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TAKE BACK THE NIGHT...
Mary G. Barry, MD
Louisville Medicine Editor
[email protected]
A
nd at least part of the day after, if
you want to learn surgery. That is
the plea from specialty societies
at the most recent “Resident Duty Hours
in the Learning and Working Environment
Congress” held by the ACGME this March. I
believe it applies to medicine and its branches too; the sick person does not live by some
artificial clock. The broad result of over-limited night call and work hours has been to
destroy learning opportunities and foster a
pass-the-buck mentality in patient care. It
has forced teaching institutions to exhaust
their faculty members to spare 27-yearolds, while robbing the young doctors of
chances to make crucial clinical decisions
and gain operative expertise. The expense
of hiring, on-the job training and benefits
for advanced practice nurses and PA’s who
are substituted for house staff has strained
institutional budgets.
Work-hour restriction has failed to
achieve its overall goal of reduced morbidity
and mortality. Measures of these have improved over time, but there is no convincing
proof that work-hour restriction has had
anything to do with that. Surveys of junior
residents show dissatisfaction with clinical
rotations; surveys of senior residents show
the same, but with increasing worry over
their inability to make progress in autonomy
and responsibility.
The American College of Surgeons has
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LOUISVILLE MEDICINE
published in the NEJM of Feb 25, 2016, its
FIRST study, a head to head trial of more
flexible time schedules v. the current strict
limitations for residents. Data was accrued
over the 2014-2015 academic year, and included 117 residency programs with care
delivered to 138,691 patients. There were
no differences in mortality, morbidity or
secondary postoperative events. Residents
on flexible schedules were more likely to
note positive effects on their education but
less likely to report any change in perceived
effects on patient safety, professionalism or
continuity of care. There were no reported
differences in fatigue. In fact, the ACS position statement to the Work Hours Congress
states, “We know of no physiologic or other
data which indicate that PGY-1 residents are
somehow more physically or intellectually
fragile than their older peers, and therefore
need more rigorous protection.” The ACS
points out that because of their limited presence and intermittent availability, interns
can become “a supernumerary member of
the team.”
This stands in stark contrast to the training programs of the previous decades, when
the intern was the primary doctor of the
patient, guided (yelled at, taught and vetoed as needed) by his ward resident, but
required to make and to defend his clinical
decisions, no matter the hour. We owed our
education to our patients, and we repaid
them with our care. Current housestaff are
actively kept from the bedside by work hour
restrictions, actively pre