In recent weeks the media have abounded with expressions of joy at the victorious conclusion of the house staffs’ battle to achieve a shortening of duty-on-call hours. Their battle has received almost universal support from the public. It is claimed that the outcome of the struggle represented not only significant improvement in the physicians’ working hours, but also a general improvement of patient care.
I do not begrudge the impressive improvement in the residents’ working conditions. I am not of the older generation that claims a decline in the quality and commitment of today’s residents and supports the view that if we did 15-night duties per month (as, indeed, I did for more than two years in my training) the present generation should do no less. I support the shortening of the work hours and congratulate the residents on their “victory.” But if we do not examine carefully the “side effects” of such a victory, we may discover that the negative outcomes may exceed the benefits.
First, it is important to correct the general impression, as proposed by the leaders of the battle, that the reduction of house staff hours on night duty would result in fewer errors in patient care. Several studies have shown that the errors resulting from house staff exhaustion may be replaced by errors resulting from mistakes in the process of information transfer from shift to shift.
But I want to address another issue that needs serious attention. Let us remember the purpose of residency activity. It is not just a job for young physicians earning a salary. It is true, of course, that the residents provide the bulk of the medical workforce which, with great devotion and personal sacrifice, carries most of the patient care workload. But the major function of residencies is the preparation and education of the house staff to become specialists and consultants who can provide guidance to physicians in other specialties, and training to interns, residents and students.
How much experience and how much exposure to how many patients are required for a medical school graduate to become a qualified consultant? In surgical residencies, it is relatively easy to decide on the number of procedures a resident must perform under supervision during his/her training in order to qualify for the given specialty. The opposition to the changes on the part of surgical training programs is therefore no surprise. I read of an academic orthopedic surgery program in the United States in which they simply extended the residency by another year to make up for the loss of training hours caused by the reduction in the residents’ working hours. But even in the non-surgical specialties, such as internal medicine, it is obvious and essential for residents to acquire exposure to a sufficient number of patients and to a variety of illnesses during the course of training. Night duties are not merely work hours, they provide learning opportunities to function as a relatively independent physician on some of the sickest patients. Reduction of the number of night duties during the years of training means a serious reduction in obtaining the needed experience.
One of the most important and central manners of obtaining experience in managing patients is by following the progress of patients daily and noting the results of the treatment. The shortening of the duty hours and having frequent days off after night duty makes it very difficult for the resident to experience directly the effects of his/her treatment. One resident admits the patient; another sees the patient on rounds the next morning; and still,, but tttt another discharges the patient with instructions for follow-up care on the third day. The system by which patients are transferred frequently from one physician to the next one does not only increase the number of errors, but interferes greatly in quality of training.
In order to achieve maximal benefits from the “victory” with minimal ill effects, it is essential to reexamine most carefully and thoughtfully the entire training process and to introduce drastic and essential changes.
First, the physician staffing of the hospital departments desperately needs to increase from the standards that were set decades ago. The patient population is now much older and sicker and the number of procedures and activities to which the patients are subjected has increased greatly. All this is aside from the new changes introduced by the reduction of working hours. It should be obvious that a reduction of staff hours requires the addition of more staff as well.
It is essential also to provide more ancillary help for the residents to reduce the non-medical workload so that at least the hours on duty are fully utilized for direct patient care and education and not “wasted” on secretarial and administrative activities. It is essential to change the work schedules to permit continuity of care given by each resident to the patients under his/her care. There are such schedules in existence which, for example, provide periods of the year in which a resident has just night duty without simultaneously carrying out daytime rounds as well. Such systems enable the residents to provide continuity of care during the day most of the year.
Also long overdue is the introduction of what has been proposed by almost all world experts in medical education, moving major parts of the residency training into the ambulatory sector both in subspecialty clinics and into the community clinics. In this way, the residents will gain critical training in follow-up of their patients for extended periods of time, an essential skill not provided by exclusive in-patient training.
All the above steps and others could convert the present “victory” into a really major positive change in medical training. Otherwise, the victory will be a Pyrrhic one, and will seriously damage specialty training in Israel.
It is essential that the enthusiasm and effectiveness that led to the revolution in working hours be applied no less to the creation of a revolution in the improvement of residency training.