It only took me thirty years to connect the dots. As a resident, I was returning to the hospital to enter orders. Repeating exams I’d already done. Pausing a thoracentesis because I couldn’t remember which side the effusion was on. Word finding difficulties. Checking the same labs repeatedly. Was I losing my mind?
I didn’t realize then that these were symptoms of exhaustion. We were doing 36-hour shifts every fourth night. We had no days off during the summer, or on ICU rotations. During electives, we covered the MICU at night. Our seniors mocked us because we were the first class to have call every fourth night instead of every third.
I assumed exhaustion was a rite of passage. So what if I fell asleep at the nurse’s station, or spilled coffee on my shirt again? So what if I went another week without a haircut or had no time to shave? Didn’t everyone hallucinate at the dinner table sometimes? Fatigue was sapping my mind, and I was too naïve to realize it. We all were. It didn’t occur to us that we could change the system.
Decades later, I’m a sleep evangelist. Residents still work too many hours, even if fewer than before. If we could end 28-hour call tomorrow, I’d do it. If we could decrease weekly work hour limits, I’d do that too. But for reasons deserving their own PD Note, we face roadblocks. But these rules are sacrosanct: all post-call residents should leave before 28 hours elapse, everyone should get a day off a week (at least), and no resident should work more than 80 hours a week, no matter how demanding the rotation. The ACGME mandates these rules but, more importantly, it’s our duty to enforce them.
Thankfully, the number of “duty hour violations” in our residency has decreased substantially over the years, but the goal is zero. Duty hour violations are almost never a resident’s fault. You can’t just work faster or become more efficient. Rather, violations almost always reflect a systems problem- too much work in the time allotted.
We can only fix problems we know about, and that’s why we need you to report your duty hours in MedHub every week and explain what happened if you went over. Are rounds too long? Are there too many tasks? Is sign-out delayed? Is the census too high? Are the patients too sick and complicated?
As most of you know, I get an email from MedHub* whenever you exceed duty hour limits (so-called “noncompliance”). Usually, when I get these reports, I’ll send you a “thank you note” to show our appreciation and to let you know we’re paying attention. Sometimes, I’ll ask you for more information so we can fully understand why you couldn’t get out on time. With your help, we can adjust rotation structures, change caps, and ask the hospital for more support.
Exhaustion is not a rite of passage; it’s a problem that needs fixing. You all deserve to rest, relax, and recharge. And you shouldn’t have to worry, like I did 30 years ago, that you’re losing your mind.
Have a great Sunday, everyone,
*Some of MedHub’s noncompliance reports are “pseudo noncompliance.” For example, if you don’t have a day off one week but have two the next, the average is compliant with ACGME rules. Similarly if you go over 80 hours one week (common in those weeks without a day off), there’s no problem- as long as the average over 4 weeks remains under 80. Unfortunately, MedHub can’t distinguish true noncompliance from pseudo-noncompliance. If we could teach the program to tell them apart we would. But we can’t (we’ve tried). If you think it’s a case of pseudo noncompliance, just enter a brief explanation such as “will average out,” “two days off next week,” etc.