Residents' Work Schedules

Dr. Val looks to Labor Day as a reason to think of residents and the long hours they work. She's right, some of these folks are ridiculously overworked and it can get dangerous. Over My Med Body finally had his first night on call. It's pretty accurate in its craziness.

But there are arguments on the other side.

It should be noted that the length of time spent in the hospital has important benefits. Originally, the idea was much more than having cheap labor to benefit hospitals and attending physicians. The benefit to the learner was the opportunity to observe a patient's evolution for a continuous and prolonged period of time. A patient with diabetic keto-acidosis usually turns around in about 24 hours. You can see an elderly gentleman with pneumonia get better before your eyes in 2 or 3 days. I'll never forget my frail renal failure patient who presented for the first time in pulmonary edema. I stayed up with her all night and learned more than I ever could have going to bed. An acute appendicitis may take a few hours to diagnose and treat and a couple of days for the patient to recover. It is valuable to watch the process.

In the old days, it took a couple of days; now the patient would be discharged in 18 hours. There was a time when there was sufficient leasure in the medical teaching environment that a resident could stop and think and consider what they have been observing. I believe this process is important. In fact, without it, I would argue very little learning has occurred.

Today things have changed. Admissions are short and care is fragmented as patients are transferred through various service units: ER to ICU to step-down to regular ward... and it was still an "observation, "too short to be considered a full admission by Medicare standards.

It is a rare resident who actually choses to follow the patient past their immediate care responsibilities. When was the last time you saw the ICU resident on a med-surg unit? I know it happens, but it is the exception that confirms the rule.

The head cardiologist at my residency was musing one day that when he was chief resident, the nurses would call to let him know about someone having an MI on the ward. He would usually acknowledge it and go back to bed. There was nothing to be done in those days.

I don't think working forty eight hours straight is the problem. More likely the fact that those 48 hours have become as grueling and punishing as an ultra-marathon. The fact is that medical interventions have become much more intense than ever before and no patient lounges around the hospital waiting to get better. The cost-containment pressures on the health care system have made the job insane. I would rather residents spent the hours, but sharply reduced the number of patients they followed. At least they would realize some of the original benefits of spending long hours in the hospital.