Midsummer Night Dreaming

July 23, 2017

Hi everyone,

One evening during internship, I returned to our apartment on Pine Street after a 36 hour shift. Maybe I'd slept a little on call, but not much. Heide served a delicious dinner, followed by a bowl of pistachio ice cream. Hallucinating from fatigue, I asked her why she'd put peas in the dessert, after which she pulled the bowl away and marched me to bed, appalled that an hour earlier, I'd been writing orders. I badly needed some midsummer night dreaming.

During the nightmare era before work hour limits, my co-interns and I accepted 36-hour shifts as a rite of passage dating back to ancient history, when "residents" lived in the hospital. It didn't occur to us that sleeplessness was dangerous, or that asking us to work extended shifts saved hospitals money. We had no days off the first two months of the year, or during ICU rotations, and questioning those policies would just expose our defective attitudes.

My contemporaries sometimes scoff at today's 80-hour work week limit as if modern residents have it easy. Never mind that residents have less downtime now or that an 80-hour week is still twice the length of most normal jobs. Although the ACGME recently relaxed some restrictions,* the 80-hour rule remains in effect. Even with the new standard, we need to ensure that residents get enough time off between shifts and don't stay too long. The new rules allow some discretion about shift length and give residents more freedom to use judgment about leaving, but the spirit remains the same- you have to go home and care for yourself.

Fortunately, information shared on MedHub helps us structure rotations so most trainees log fewer than 80 hours per week (and usually fewer than 60). Some rotations still push us to the edge, though, so we need everyone to report their hours honestly and consistently every week. Honest reporting identifies structural issues that we can only fix if we know about them- whether we need to change how the day is run, ask the hospital for more support, or change how we design schedules.

Let's dispel two work-hour myths. First, working excess hours (so-called "violations") rarely reflects inefficiency. Although interns become steadily more efficient over the year, we design rotations so everyone can get out on time, even in July. If we're failing, please tell us. Second, reporting excess hours won't get the program in trouble. The ACGME understands that most residencies have work-hour challenges. Their expectation is that residents will log hours consistently and accurately, and that programs will respond appropriately to the information provided.

Even though the ACGME’s new rules should decrease the amount of documentation required, we still need you to log your hours every week. If you do exceed work hour limits, please explain in detail so we can respond effectively. MedHub still flags some pseudo-violations, the most common being the absence of a day off during a seven day stretch, which we address by scheduling extra days off before and after- so just explain. Occasionally you may decide to stay late for emergencies—for example a patient crashing during sign out—which is fine. Other times you'll identify problems with the way the day is structured, the number of tasks you’ve been assigned, the way the schedule is put together, or the way the rotation is staffed; please explain so we can fix it. When you report work hour issues, you'll usually get an email from me thanking you for the information or asking you to elaborate. So here’s my gratitude in advance.

We've come a long way from the bad old days when sleeping, eating, taking a shower, and even going to the bathroom seemed like a luxury. We’re better now, but we still have work to do to get you home and to bed. Your wellness and our patients' well-being depend on it.

Enjoy the rest of your weekend everyone.

Warmly,

Mark

* “Background and Intent: The revised requirements are intended to provide greater flexibility within an established framework, allowing programs and residents more discretion to structure clinical education in a way that best supports the above principles of professional development. With this increased flexibility comes the responsibility for programs and residents to adhere to the 80-hour maximum weekly limit (unless a rotation-specific exception is granted by a Review Committee), and to utilize flexibility in a manner that optimizes patient safety, resident education, and resident well-being. The requirements are intended to support the development of a sense of professionalism by encouraging residents to make decisions based on patient needs and their own well-being, without fear of jeopardizing their program’s accreditation status. In addition, the proposed requirements eliminate the burdensome documentation requirement for residents to justify clinical and educational work hour variations.

“Clinical and educational work hours represent only one part of the larger issue of conditions of the learning and working environment, and Section VI has now been expanded to include greater attention to patient safety and resident and faculty member well-being. The requirements are intended to support programs and residents as they strive for excellence, while also ensuring ethical, humanistic training. Ensuring that flexibility is used in an appropriate manner is a shared responsibility of the program and residents. With this flexibility comes a responsibility for residents and faculty members to recognize the need to hand off care of a patient to another provider when a resident is too fatigued to provide safe, high quality care and for programs to ensure that residents remain within the 80-hour maximum weekly limit.”

-ACGME Major Revision to Common Program Requirements, effective July 2017

Submitted by Mark David Siegel on July 23, 2017