A few weeks ago, SERMO members created their own memes out of the Willy Wonka template with the prompt, “Oh, you’ve never been to med school? Please, tell me more about….” We requested some assistance from GomerBlog, “Earth’s Finest Medical News Site”, to help narrow the hundreds of submissions to the top 10. Today, one of our doctors is sharing their opinion on why they submitted this hilarious meme, and why it’s actually a very important topic. If you are a physician, join SERMO to participate in the conversation.
I could still remember that most awful feeling when I had to work 36 hours straight with a bad cold during an SICU rotation as a fourth year medical student. I was so miserable that I wished I were dead because being dead would have been a welcomed relief. A surgeon with the last name Kill told me that he was so frequently tired that he fell asleep on the weight bench at the gym as he was trying to exercise. I have heard of one who fell asleep in the parking lot in his car for hours with the motor running. What could we do? We had to work the required hours. We shrugged our shoulders and soldiered on because the only thing which stood between us and a bed was the drive home.
At stop signs, I couldn’t help but fall asleep until an angry driver from behind startled me with his car horn. I guess jaded doctors would roll their eyes that a study from Mayo showed that near misses or car accidents in residents are linked to fatigue and sleepiness. In 2005, a study from the NEJM called medical interns who completed their marathon shifts and drove home a road hazard. Some of us may have even known a fellow resident who died post-call while driving home from a single car crash.
We all love sleep but as physicians we care more about competency and the ability and the confidence to care for patients independently after residencies. An inside joke among us is missing 50 percent of the good cases by not being on call. A recent study examined resident work hours and Orthopedic In-training Examination (OITE) scores. A large variation in duty hours exists between resident-logged duty hours and no correlation exists between in-training scores and duty hours; however, there is a positive correlation between senior resident operating room hours and technical skill scores.
Survey of graduates from a Family Medicine program before and after implementation of duty-hour restriction showed that implementation of resident duty hours appears to have little overall association with self-reported preparedness for practice. With the mid-levels laying siege the gate of primary care, I personally don’t think duty hours matter much in primary care.
The surgeons, on the other hand, are quite vocal about duty-hour restriction. They examined mortality and length of stay in the ICU in the pre and post periods of the 80-hour work week for interns. The post period was not a predictor for mortality but it’s an independent predictor of increased length of stay in the ICU.
For general surgeons, work-hour limits pose an even larger issue with the ever-expanding array of new techniques and technologies young surgeons must master, which now must be accomplished in an even smaller training window. Fellowship directors feel that 40% of new fellows could not “perform 30 minutes of a major procedure independently on arrival to fellowship” while 30% of programs directors said new fellows could not independently and safely perform basic operations, such as a laparoscopic cholecystectomy. Additionally, 32% reported new fellows lacked proficiency in a variety of technical skills, most notably in laparoscopic suturing.
It’s hard to deny the link between a surgeon’s operative skill, the volume of procedures performed and patient outcomes. With the work hour restrictions, it is estimated that training surgeons may participate in just two or three operations a week, as opposed to one per day, as was the case a decade ago, and that trainees now lose about a year’s worth of experience according to an article in generalsurgerynews.com
Medical training is exceptionally demanding and complex. Work-hour limits required multifaceted approaches to educating competent and confident physicians and surgeons.