Helping surgeons stop lying on their duty hours

Not ready yet to extend the rule loosening, the ACGME is expanding and extending its study of the effects of longer shifts for surgeons. The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) has unsurprisingly shown that occasionally longer shifts and a less stringent rest period did not affect the rate of “surgical fatalities or serious complications.”

I say unsurprisingly because despite being tired making all of us drunkenly stupid, residents under supervision (like those in the OR) are unlikely to be able to make a significant number of extra disastrous mistakes when the additional time periods we’re talking about are usually an hour or two. Conveniently, classic fatigue-related personal disasters weren’t even covered: needle-sticks and post-shift car accidents. They also collected duty hours the normal way, meaning that the “control” group was probably lying on their duty hours just like programs do all the time, further eroding any possible real differences. Lying on duty hours is endemic to residencies nationwide, particularly surgeons. So yeah.

What else did FIRST show?

Residents working longer shifts indicated that their educational experience improved, but at the expense of time with friends and family, extracurricular activities, rest, and health. However, these residents generally were no more dissatisfied with their overall well-being than residents whose shifts conformed to the more lifestyle-friendly ACGME rules, the study shows.

This is what I love the most. What FIRST is studying is the effect of different shift length in the context of an 80-hour workweek. While long shifts can be miserable, the underlying issue affecting burnout, misery, and lack of personal well-being isn’t occasionally working 18 or 20 hours instead of 16 (or 32 instead of 30), it’s working 80 hours a week or more for extended periods of time. You can’t have a life working 80 hours a week. If a person wants to have something consistent and grounding outside of medicine, it’s probably not going to happen. And as the young professional demographic that competes against medicine involves more flexibility, better pay, less debt, more travel, etc, this dichotomy hurts young doctors. Every social metric measured was worse, but the study was promising enough to be expanded because overall dissatisfaction was similar. Of course the real bottom line is that residents—and general surgeons in particular—are burnt out.

You take a pie made out of….an unpalatable ingredient, and then tell someone that they have to eat one every week. They have the option to eat it in 5 big pieces or 6 slightly smaller ones. Do you think they’ll care that much? The bigger pieces are harder to eat, sure, but at the end of the day, it’s still a lot of pie. For most people of normal emotional reserve and professional eagerness, it’s probably too much. The FIRST results just tell us that the 80-hour work week trumps shift length—on the whole, both groups were equally miserable.

Duty hours restrictions may have initially started as a patient safety improvement mechanism, but both anecdotally and scientifically, it’s clear that the sacrifices made in the other direction wash away most if not all of those benefits. What duty hours really have the potential to do is make happier doctors who are less likely to suffer from compassion fatigue and other issues of burnout. But to do that, we either need more residents to make the same amount of work doable with less man hours per person, or we need to design systems that are resilient and flexible enough to not be built on the premise and foundation of overworked residents (or both).

 

The looming GME funding crisis

David Silberswieg, Professor of psychiatry and Academic Dean at Harvard Medical School, writing in the Washington Post about the increasingly underfunded mission of academic medicine:

But while there is a need for oversight, in some political and journalistic quarters there are exaggerated senses of mistrust, attack, mixed messages (if not hypocrisy), and mis-aligned incentives…Ever-increasing regulation brings more and more unfunded mandates and documentation requirements, which while very important to a degree, require extensive amounts of organizational and personnel time, detracting from patient care and increasing professional burn out.

The IOM’s To Err is Human and the resultant quality improvement mandates have done some important things, but fetishizing quality improvement has resulted in countless ways to try to optimize some metrics at the expense of others (as well as other unintended externalities). When you tie reimbursement to a metric, you better be sure that metric is what you really care about. When it’s not, the system suffers (such as the issues that arise with optimizing patient satisfaction).

All of this has resulted in the corporatization of the culture at many teaching hospitals. Endless meetings and initiatives to make processes leaner and to remove waste may be imperative for the responsible, viable running of the teaching hospitals. But the relentless focus on these real concerns increasingly comes up against a point beyond which staffing and funding cuts endanger the academic mission, before endangering patient safety — the point no one wants to reach.

This has been become more and more of an issue during the past four years of my residency. In addition to more documentation, various best practice warnings, mandates, programs, and the unending growth in “vice-presidents” of various manufactured responsibilities, the GME funding dollars are simply getting tighter and tighter. Even our duty hours are now being scrutinized from both directions. A resident still can’t work too much (at least on paper), but the hospitals we work for also want to make sure each is getting their money’s worth for our salary as well. They’re even starting to compete within the system with each other for their share of the pie (if I’m working at hospital A, then why am I call on at hospital B?).

How, then, can we save our academic medical centers, cutting costs and improving efficiency, without compromising the high caliber of care, patient safety, workforce development and discovery? How can we attract, educate, retain and develop our best medical talent, who have spent many years training while incurring crushing debt, and allow them to do their best work on behalf of society?

I’m not sure you can without big changes in the structure and length of medical training from college through residency. With trainees caught within the ever-grinding gears of the bureaucratic machine, the clinical and regulatory missions will absolutely try to kill the academic mission. How can the average trainee learn over a reasonable timespan in an environment of relentless oversight and pseudo-clinical distractors? How can we continue to attract driven and smart people to medicine when the journey and even the destination are becoming more unpalatable? More young physicians want “part time” work (which would often still be considered full time outside of medicine) in order to match the non-medicine lifestyles of their peers. Meanwhile student debt grows unabated. Big things change slowly, and the GME is no exception. But we’re slowly approaching a crossroads.

Approaching the radiologist

Rewind. Time for the Jedi Mind Trick. I held the films out. “This patient isn’t an operative candidate. I don’t know if you could even biopsy this mass. It’s really in there.” I prayed his ego would take the bait. The radiologist turned and snatched the films from me then threw them up on the lighted wall on his left. “Oh yeah, I can hit this, no problem. I’ll do it tomorrow, about 9.” And that, folks, is the Art of Medicine.

From Salvatore Iaquinta’s very funny internship memoir, The Year THEY Tried to Kill Me. The closest thing to a modern The House of God since…The House of God.

Me & Nanoism on NPR

yUFp12rpGot to put on my writer/editor hat and be a guest on WNPR’s Colin McEnroe Show to talk about Twitter Fiction, Nanoism, and read a few tweet-sized tales. This was my very first radio interview (and live is tough, oof!). My part is toward the beginning, with Colin introducing me around the 6:45 mark. But you should at least listen to the very beginning, because their intro sketch bit is the best part of the show.