Education

Stop Lamenting the “80-hour Rule”

Although internal medicine programs instituted an 80-hour weekly work limit in 1989, the “80-hour” duty hour limit was formally implemented by the ACGME is 2003. The purpose of the limit was to ensure patient safety and reduce medical errors while protecting the safety of residents by preventing burnout and psychological distress.  While there is conflicting data with respect to whether the duty-hour limits have resulted in improved patient safety and decreased medical errors, the duty-hour limit has been blamed for numerous deficiencies in resident education.1 The responsibility for this is often placed on the residents by older generations of surgeons.  The residents are explicitly told, or it is not so subtlety implied, that they are “weak” for abiding by the duty-hour regulations.  Residents are chastised for losing continuity of care and for “choosing shift work” instead of choosing to take care of their patients.  Many surgeons feel that there has been an erosion of the surgical skills and clinical acumen of trainees and that these deficiencies are rooted in residents spending less time in the hospital and performing fewer surgeries with less independence.

Even if the 80-hour duty limit has not improved patient safety or reduced medical errors, it is my belief that the regulations are attracting a higher quality applicant into medicine.  The days of first year trainees being “interned” in the hospital and living on the grounds for an entire year are long gone.  While some may mourn the fact that today’s medical students see their career as part of their life and not their entire life, these students have varied interests and talents that would not have been a fit in medicine 50 years ago.  Their different perspectives and values will hopefully allow for innovative solutions to our most challenging problems.

We must adapt our teaching techniques to optimize surgical education in this new era.  The 80-hour duty limit is not inherently good or bad, it is just different.  Instead of lamenting the lack of hours that residents are in the hospital, we need to make the most of those hours and stop insisting that the education of the pre-80 hour duty limit era is unquestionably superior to education of the post-80-hour duty limit era.  Given the exponential growth of medical knowledge and surgical techniques, it is no longer enough that residents and fellows “learn by osmosis,” simply by being present in the hospital and watching senior mentors perform surgeries.  Medical and surgical education in the post-80-hour era must be more efficient.  Many programs have already instituted bioskills labs, and our understanding of how to measure surgical competence continues to evolve. It is my plea that we stop “lamenting” the 80-hour rule but rather rise to the challenge of improving how we teach the future generations of student, residents and fellows.

  1. Philibert I, Nasca T, Brigham T, Shapiro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med. 2013;64:467-483.

Article written by:

John Fowler is an Assistant Professor in the Department of Orthopaedics at the University of Pittsburgh. He completed his residency in Orthopaedics at Temple University Hospital in Philadelphia and a hand fellowship at the University of Pittsburgh. His research passion is the use of musculoskeletal ultrasound. When not working, he tries to spend as much time as possible with his amazing wife Amy and two children, Alexis and Kyle.

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  1. Paul Guidera MD FACS

    The predictable outcomes of implementation of trainee work hour limitations have been the “hand off” and the sculpting of physician-employees. Those who tell us to “stop lamenting” are in an advanced state of denial or are true believers who have finished training within the last 10 years or so and are therefore victims of this dumbing down of American medical education. Academic medicine is the perp. The patient is the victim.

    Surgical trainees of the 21st century no longer have the opportunity to follow every step of a deathly ill patient from the emergency room entrance to the morgue refrigerator. He (or she) will never have to experience the unpleasant truth of getting to know a family and face with them the soul-shattering reality of the unexpected and imminent loss of a loved parent or spouse….or child. That would be too uncomfortable…get a nurse to do that!…I’m going to my safe place!

    We’ll have much happier residents and therefore much happier ‘providers’ or ‘caregivers’ or whatever it is the emasculated doctors of the near future are called. They will be better rested because they will be employees, with strict limits on the number of hours they will be required to spend being a doctor before punting their problems to the next robodoc coming on shift. They will have the well-deserved luxury of dropping everything and going home and they will of course enjoy preplanned and guaranteed-uninterruptible vacations.

    And that’s just great for the entitled new generations of children America is now producing. We don’t want our new state-of-the-art doctors to have to fret about a patient after hours, or to experience anxiety because that they might miss their evening or weekend plans when a patient is circling the drain.

    We don’t want our young doctors to worry…at all. After all, they are our children! We just want them to be happy, well rested, polite and nicely scented.

    Tragically, they will never know what they don’t know, because they missed 67% of the clinical material they could have managed while in training…because they were resting. They simply can not and never will have the depth of experience that battle-hardened surgeons had who were fortunate enough to have trained before we placed more emphasis on our trainees’ comfort than on the learning potential inherent in staying awake past 8 pm.

    In addition to the astonishing volume of difficult cases that I managed as a resident on shifts that were often 36 hours, and the invaluable intuition that I gained from 8 years of staying awake, an enduring quality that I gained, and consider a gift from my attendings, remains, after 22 years of practice. It’s my own personal WWJD: trust no one, check everything yourself.

    That mantra doesn’t exist in medical education now. It’s already all gone. Instead, they “hand off”. Our new surgeons will go from coddled residency to hospital or large group employment where they will have corporate shields protecting them from accountability that they never knew they should have. Made a mistake? Corporate counsel will manage that, Doctor. Don’t you worry. It was probably the patient’s fault anyway.

    In the unfortunate 6 years that I spent recently in a large orthopedic group, I do not recall attending a single meeting in which patient care was discussed. The only issues on the agenda were…
    money,
    contracts,
    upcoding strategies,
    CMS and…
    of course…
    more money.

    Let’s not kid ourselves: Medicine is no longer a healing profession. It’s a for-profit industry and our rested but sadly lobotomized new doctors are being trained to be subservient to those interests. They want those guaranteed hours and bonuses, even if means that they will inevitably be pitched out of the company after a couple of years to make room for cheaper talent.

    I’m not judging of course. That would be bullying.
    I’m just appalled.
    And my flight is about to land.

    • John Fowler

      Paul,

      Thank you for your comments. I am glad that my post generated some discussion!

      Your comments are a perfect example of the “we walked uphill both ways to school every day, in the snow” phenomenon. Everyone always feels that their training was harder than every one else’s training. You state at the end of your post that you “aren’t judging”, but you clearly are doing just that. Today’s residents are “weak” and “aren’t good doctors anymore.” Your comments are just flat wrong. I did complete my training within the last 10 years and I can guarantee you that I am “not in denial” as you have suggested.

      It is not the absolute number of hours that we work, it is what we do with those hours. My intern year, we had to print x-rays every morning (taking 1-2 hours) and draw all of our own blood for patients on our service (1-2 hours). The following year we had digital x-rays and a phlebotomy team. That saved 4 hours a day right there! Surgery is more efficient now than ever. Surgeries that once took 2 hours to complete are now routinely performed in 1 hour or less. We are completing more surgeries in less time. ER’s are more efficient and get patients in and out and/or admitted quickly. I would argue that today’s residents have as many or more patient encounters than your generation.

      Your comments about the 36 hour shifts are simply misguided. Numerous sleep experts will tell you that you can’t really “train” yourself to “work tired”. It is probably an increase in knowledge and efficiency that gives the illusion of “getting better at working while tired”, but the evidence would show you clearly make worse decisions when tired, regardless of how many hours you worked 30 years ago as a resident. I could counter your 36 hours argument with, “why didn’t you work 40 hour shifts”? It is an empty argument. The hours themselves don’t matter as much as what you do with those hours. It would make more sense to learn efficiently in less time than to learn inefficiently and take twice as long.

      The other comment I would like to make is that while service is a large part of residency, the purpose of residency is to learn. Your comments drip with the sentiment that residents are merely a means an end to get all the work done.

      John

      • Paul M Guidera MD

        Dr. John,

        With all due respect to your many outstanding accomplishments , you sound like the predictable end result of exactly the dumbed down medical education that you are defending. Medicine is dumbed down. It’s not your fault, necessarily. Of course you can’t see it. You cannot see it because you don’t know what you don’t know. Is that too obtuse?

        Trivializing the opinions of better trained and far more experienced senior surgeons is nothing more than petulant arrogance. Again, it’s just you not knowing what you don’t, and never will, know.

        Getting the work done? John, the learning is in the work and those are hard lessons. Perhaps shocking to you, we had to perform many trivial tasks like drawing blood from NICU babies, working up a fever in a combative patient at 2 am and doing our own Gram’s stains, but those exercises were lessons in humanity and humility, qualities that you evidently successfully dodged by getting some rest instead.

        Your argument again hard work is circular and self serving. The logical response to it is simple: You can’t learn if you are not there. Even you cannot argue that basic truth.

        I understand that being spoon fed is easier, it’s just that the gains are minimal. Arrogant arguments against hard work as a means to expertise is exactly what one would expect from the unfortunate generations of doctors hitting the streets now. It’s no different than handing a child a trophy for every soccer goal scored. We just want everyone to feel good about themselves, even if the end result is a self-absorbed and minimally competent adult who whines about working too hard and denigrates those who disagree.

        A few years ago I watched an orthopedic resident (perhaps it was you) walk out of an osteochondral knee reconstruction being performed by one of the best surgeons I know because…

        …his shift was over at 2 pm. Following your arguments to their logical conclusion, the opportunity to experience technical virtuosity for an hour or two was no reason to delay getting home to…snapchat…Netflix…rest?

  2. Anonymous

    Those of us who were in the middle of the discussions about the 80-hour rule knew exactly what would happen if instituted. The comments by Dr. Guidera are harsh, but correct. When I interact with residents now, 23 years since my fellowship, the “hand-off” is the most dreaded time of the day. A consult is called of me, and there is no one with whom to discuss my findings; they have left for the day, even if my findings dramatically alter the course of the patient’s course or status. Its when patient care becomes secondary to ones supposed tiredness and the clock ticks 80. Its an attitudinal shift from taking care of what needs to be done despite the long hours that propels the work day. The emphasis therefore becomes me. Its not the Hippocratic Oath anymore. Nowhere is there any comment about taking care of the sick, if you have enough time. In fact, it is only after we take care of the sick patient that: “If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter.”

    • John Fowler

      Thanks for your comments.

      I disagree that Dr. Guidera’s comments are “harsh, but correct.” I think they are ignorant to the current training environment.

      I am confused about your “hand-off” comments. Why could you not make a mental note and follow-up the next day with that trainee.

      The current generation of trainees are not trying to break the Hippocratic Oath as you have suggested. The vast majority would work 120 hours a week if we asked them to. The point is that there should be a system in place that when they leave, there is another person there to take care of the patient. Just like when you leave for the day, the resident is there to take care of things …..

  3. DWT, MD

    Dr Fowler,

    Why did you actively solicit opinions about your topic and then personally attack each physician who responded? That’s really inappropriate. You should consider apologizing to the respondents and then reboot your ego to something approaching civility.

    I think it is an example of a “snowflake” mentality on your part. As far as your personal attack on Dr. Guidera, it is deplorable and unwelcome in a setting such as this.
    As he put it, you REALLY don’t know what you don’t know…about a lot of things.

    Shame!

    • John Fowler

      Disagreement does not equal “attack”. In any discussion/debate, there can/should be a certain level of disagreement. I respectfully disagree that I personally “attacked” either of the posters above. I assume that by posting comments to the opinion piece, those physicians were interested in having a dialogue and I would argue that nothing that I posted was in any way an attack or uncivil as you have suggested.

      Name calling (“snowflake”), however, does seem “deplorable and unwelcome” in a setting such as this and perhaps you are the one who “should reboot your ego” and apologize.

      John

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