Work Hours I

In 1984, the inadvertent death of Libby Zion at New York Hospital caused the public to put pressure on hospitals to restrict resident work hours. She died of serotonin syndrome from an interaction between meperidine and phenelzine, and it was determined that her death was due to long unsupervised resident work hours.

In 2003 the ACGME, a governing body that accredits training programs, limited resident work hours to 80 hours a week with no shifts longer than 30 hours. There was no evidence for this decision; the parameters of the restrictions were "made up" in an attempt to preserve the nature of medical training and appease the public. Research has not shown that restricting work hours improves hospital outcomes or decreases mistakes. But intuitively, we think it helps. How clearly and quickly can one think, working at their 30th hour straight? Should someone that sleep-deprived have the charge and responsibility of patient lives? Recently, the Institute of Medicine put out another report suggesting that residents take an uninterrupted 5 hour nap in a shift longer than 24 hours.

Now that I've worked in an inpatient setting for 8 months, I wanted to reflect a little on work hour restrictions. I'm torn in how I feel about them. I recognize their utility; I know what it's like to be on for over 24 hours; thinking, reflexes, motivation, and clarity are obscured. But introducing work-hour restrictions comes at a large cost.

The main cost everyone talks about is hand-offs, when information is passed from provider to provider. UCSF has worked incredibly hard to improve this process and prevent critical information from being lost. Indeed, nurses do it incredibly well. But I've seen a lot of problems come about because information was not transferred properly from an exhausted outgoing team to a naive incoming day float (a resident who takes care of the patients while the on-call team sleeps). The post-call day is when the most happens for patients admitted overnight. The important decisions are made, the family meetings are held, the consults are called. Instead of the provider who knows the patient best, a day float has to manage these important decisions. Some are anticipated by the team, some are fielded by the attending, but most are simply deferred another day until the team gets back. I feel that some continuity of care is lost at this critical junction.

I also think that there's a strong educational value in longer work hours. The old school thought is that you work until the work is done, that patient care is paramount, and that there is a pride in finishing everything you start. Surgeons really have this belief. But the general feeling is swaying away from this idea with introduction of shift work in emergency departments and intensive care units. I like the old school mentality about medicine. I don't know whether it's justifiable, practical, or better, but I don't feel that inpatient medicine is or should ever be a 9-to-5 job. I learn an incredible amount on call and staying through the post-call day. That's when all the good stuff happens. I love hearing about all the new admissions each post-call morning because that's when a lot of the medicine thinking happens. But we're always rushed, racing to get out of the hospital. I would hate to be forced to go home without seeing the resolution of my patients. But I'm still a student and perhaps still too idealistic.