Friday, March 24, 2006

Dilemmas, dilemmas

Work hour restrictions for residents have created a conundrum for everyone involved. Some educators worry that the residents they are responsible for teaching have too little clinical time to get all of the training they need, and often worry that we are creating a generation of trainees that do not have the necessary dedication to patient care that is required in many clinical settings. Some residents worry that they are not getting enough clinical experience to be competent upon completion of training. Patients ---- they probably should worry the most ---- have fears about being cared for by exhausted residents; they may also fear that their newly minted physicians don't have enough clinical expertise by the time they hang up their shingles.

There have been a series of articles relating to the implementation of the 80 hour work restrictions for residents ---- I would say that the majority of the articles that have been published have been favorable towards the regulations, which is 180 degrees opposite the opinion of the physicians I speak with (both academic and non-academic). Two that were not so positive that were in the surgical literature were reviewed by myself and by my colleague to the east, Dr. Bard Parker.

This month's American Journal of Surgery contains yet another take on the work hour restriction debate. Work-hour restrictions as an ethical dilemma for residents comes from the Dept. of Surgery at Vanderbilt (subscription required for entire article). The authors basically approached the problem from what they described as an ethical dilemma --- are residents reporting their work hours honestly? If not, why?

The results were interesting. Of the eighty-one percent of responders to the survey, eighty percent reported exceeding their work hour restrictions, against policy and without reporting the transgression. The reason most commonly cited for this was concern for patient care (80%); junior level residents were more likely to exceed work hour restrictions than their senior level counterparts (86% vs. 63%), and surgical residents were more likely to exceed work hour restrictions than non-surgeons (89% vs. 74%).

Actually, I have to confess that the numbers were higher than I suspected -- being an older, curmudgeonly surgeon, I have a tendency to believe the next generation of surgeons will be lazier than an NBC reporter chasing down good news about Pres. Bush. And, actually, I am greatly encouraged to see that concern for patient care trumped the artificiality of the work hour restrictions. The authors of the study, however, don't necessarily share my enthusiasm. They feel that there is a conflict that has arisen between the work hour requirements and a culture in residency training that equates professionalism with, well, working longer hours rather than "passing off" one's patient care responsibilities to another resident. Some of this is attributable to differences between surgeons and non-surgeons (see the statistics above):

Medicine resident teams enter and exit daily patient care as a unit. Passing on responsibility for longitudinal patient care to an oncoming team has been their operational norm for many years. The tradition and dogma of surgical resident education continues to emphasize individual responsibility and a sense of personal patient "ownership". Although, in the past, such sense of duty has been promoted as professional conduct, this paradigm may further suppress team development and hinder actual work hour compliance within surgical training programs.
In the eyes of the authors, the desire of these residents to provide some continuity of care to their patients --- which has been traditionally emphasized as paramount in physician training --- creates an ethical dilemma for the residents, and it "hinders" the development of team building solutions to the work hour constraints.

I empathize with the program directors' plight in this difficult situation, which is I think reflected in the tone of this article. They have no choice. It's not as if they can say "piss off" to the Residency Review Committee and set their own work hour rules to suit the educational needs of their residents. Having spoken with a number of surgery program directors, I suspect the majority of them feel that the rules are really not in the best interests of resident education. But, what are they to do?

IMHO, both the residents and the faculty are faced with a different dilemma than the one proposed by this paper. It is the dilemma presented by the desire to teach/learn what is required to take the best possible care of one's patients when faced with an arbitrary rule that occasionally prevents the same. It is the dilemma faced by those who understand that the idea of "ownership" of patients is a better model for patient care than "shiftwork" provided by rotating teams of residents. It is the dilemma faced by the surgeon who is tired but at 6PM finds that one of his postop patients is not doing as well as expected --- who else knows what occurred during that surgery? Who did the preop evaluation, and understands that the patient has some underlying coronary disease/history of thromboembolism/anxiety disorder/etc.? The "team" that gets a verbal handoff? Not. Very. Likely.

I cannot speak for any professional occupation other than general surgery, but I will throw in my two cents about this topic as often as possible. It is not advisable to develop a system that encourages a shiftwork mentality amongst surgeons. The "ownership" mentality that was damned with faint praise in this article provides, once again IMHO, the best possible, most cost effective, and most error-free care for surgical patients. As somebody who might resemble an aggravated surgeon once wrote:
I have always felt that continuity of care is one of the most important hallmarks of general surgery; basically, the surgeon shoulders the responsibility to see his or her patient through the perioperative period, and be the one responsible for returning the patient to the OR in the case of an adverse event if at all possible. In fact, the surgeon's ability to deal with postoperative complications is perhaps his/her most important asset.
Contrast that with the conclusion of the article:
Ongoing clarification of this proposed social model would better enable program directors and their residents to attain compliance at their particular program through precise intervention. True compliance would relieve residents of the ethical dilemma associated with hours reporting. This level of intervention will likely require both education and system changes.
I don't see much there that reflects the ideals of continuity of patient care, education, and preparation for the difficult times when surgeons must get out of bed in the middle of the night to make sure a patient receives the appropriate level of attention and care.