In the last few years of being an attending, I have certainly pushed far beyond the work hours I served as a resident in training and it begs a question of whether or not restrictions during learning are beneficial when they’re gone in full practice. For those unfamiliar, in 2003 the ACGME (Accreditation Council for Graduate Medical Education) enacted an hour restriction for work of medical residents to be 80 hours per week. Later in 2011, a mandated limited first year residents (also called Interns or PGY1s) to a maximum of 16 hours of consecutive work. Although the latter was later removed, reaffirmation of an 80 hour work week continued in 2017. However, the funny thing about having an “hour restriction” that they don’t tell you as a medical resident, is that after you graduate, that’s not a real thing. The real world doesn’t care how many hours you work, nor do your patients.
Recently I had a long discussion with one of my favorite OBGYNs, also out of Residency in the last 5 years, on this paradox. Many of us that trudge through a long Residency training do so at the hope that when we’re done, we can relax just a tad, and have somewhat of a semblance of a normal life – there’s enough loud discussion these days on burnout that it’s a very common conversation to have, “Ah, the good days down the line when the grass is greener and I’m an, ATTENDING!” However, for many fields of medicine, particularly surgical specialties, becoming an Attending comes with more responsibilities, administrative roles and overall necessity that pushes us far beyond what we trained to do. For myself, as someone that has masochistically designed a rigorous schedule, I have worked many weeks in the last few years of significantly more than 80 hours per work week. So of course, the questions that arise:
- Are we causing a detriment to the clinical ability of future Attendings by not teaching them how to think and survive when work hours are non-existent?
- How do hour limits affect education or does it even matter?
- Should Attending physicians have some sort of hour restriction? Pilots do… And they’re not routinely cutting into people, afterall.
Controversial and not easily answered, I write this as an opinion that should just be considered with medical education going forward. As much as it can sometimes seem condescending, judgmental, and annoying… I do think that some ears should be applied to thinking about, “how it used to be way back when...” As much as I understand that trainees are already prone to mistakes, it was BY working 28 hour shifts every 3 days that I learned to function at the peak of exhaustion. It was by being tasked with minimal sleep that I was able to train my mind and body to re-focus and to re-evaluate each scenario I was in. When I have these talks with providers that have been around way before hour restrictions; there seemed to be so much value to their clinical skills and accumen that I’ve observed, anecdotal experiences shape the way we practice medicine, regardless of the evidence surrounding them. There are studies that look at the results – along with a big systemic review showing decreased Certification Exam skills and case loads for some trainees (https://pubmed.ncbi.nlm.nih.gov/24662409/), but I’m not sure the answer of liberalizing training time is quite that simple; especially since, in the long run it’s difficult to say that those training pre/post hour restrictions have statistically significant differences in outcomes.
I didn’t work often more than 80 hours in residency, but I’m also not a surgeon. However, I did work shifts that seem longer than humanly possible. As an Attending i have now burst that envelope with my longest streak of work being 120 hours in 6 days being in the hospital 24 hours a day. Personally, i wonder if I could have handled it without having done 28 hour shifts in Residency, but it’s obviously impossible to say. As more and more programs for Residency across the country impose these ‘protective hour restrictions,’ I wonder the balance of experience and mental fortitude that may be lost.
Once you’re in the real world after all, there are no hour restrictions, then what? Practice doesn’t make perfect. Perfect practice makes perfect. I am a strong advocate to consider liberalization of hour restrictions for medical residents but to have some guard rails for fatigue when it gets to a level of danger; until, we can offer hour limitations with reasonable back-up and safety to Attendings, we should start preparing our residents for the worst. Maybe one day hospitals will take advice from high reliability industries that limit work hours for Pilots or like the Federal Motor Carrier Safety Administration limiting the work days of truckers… But until then, we should train our Residents with fire, so that they can stand the heat when they’re in a new kitchen.