Doctors fear work caps for residents may be bad medicine

By Ian Shapira
Washington Post Staff Writer
Thursday, March 18, 2010; B01

A few months ago, Glen Silas, 40, an obstetrics and gynecology doctor at George Washington University Hospital, wanted a young resident to observe a sophisticated procedure in which a renowned laparoscopic surgeon was operating on a uterine tumor. Silas was certain the resident would eagerly embrace the opportunity.

But as doctors gathered in the staging area, the resident declined, telling Silas, "I am at the end of my shift anyhow, so I will see it another time."

"Even those at the attending level still learn from this surgeon, so for a resident to say that . . . is a special thing," Silas said. "I just told the resident, 'Wow. That is disappointing that the restrictions on your hours keep you from participating.' I don't even think I got a response."

Since 2003, when an 80-hour-a-week cap was placed on the nation's medical residents, many older physicians have worried that the next generation of doctors won't have seen enough patients and done enough procedures, even as residents continue to complain that working so many hours without sleep diminishes their ability to absorb lessons and avoid errors.

Now, the group that governs residency programs is considering even tighter limits, possibly down to 60 hours a week, leading some older doctors to argue that constant baton-passing by shifts of residents can disrupt patient care.

The changing shape of medicine's boot camp has fostered a generational tension between baby boomers and Generation-Xers, who trained in an era of 36-hour shifts and 120-hour workweeks, and millennials, the young doctors who have come up in a time of heightened concern about the impact of marathon work shifts.

"We hear about it all the time from attending physicians," said Xiaomang Ba, 29, an OB-GYN resident at George Washington. "They just say, 'Ignore your family for the entire weekend.' It sounded like people didn't really have a life [under the old rules]. It's all joking, 'Oh, you guys have it so cush. . . . I can stay awake for 40 hours straight, can you?' But once you go past a certain number of hours, you stop learning."

Under the existing work limits, some residents say they feel as if they are sneaking around if they stay late to observe an interesting operation. Rachel Seay, 29, a George Washington first-year resident, said she usually works 70 to 75 hours a week but sometimes stays beyond her shift to take part in procedures involving fetal abnormalities.

Someone will ask, " 'Aren't you supposed to go home?' and you say, 'I am not here,' " Seay said.

The issue of work hours can be so sensitive for fourth-year medical students, who find out in Thursday's annual "Match Day" ritual where they will serve their residencies, that they can be reluctant to ask about it in job interviews. Not one of the 90 candidates for George Washington's OB-GYN residency this year dared to mention duty hour limits, said Nancy Gaba, the school's OB-GYN residency program director.

Gaba said young doctors seem hesitant about diving in to the intense life of a resident. "You used to work 120 hours a week," she said. "Now you get a different kind of person. They're somewhat protected; the lifestyle has changed. These poor residents are in the middle of two competing [realities]: If you're fatigued, you're not taking good care of patients, but you're also not learning anything."

Doctors and patients also worry that shorter hours mean that patients will see a longer procession of doctors and, thus, that there will be more opportunity for errors. On Friday morning inside GWU's labor and delivery unit, Elizabeth Gray walked the halls with her husband, nervously hoping that her baby would be delivered by Seay, the first-year OB-GYN whose shift was to end Saturday morning.

Down the hallway, Seay was not optimistic that Gray, herself a resident in internal medicine, would deliver during her shift. "Sometime tomorrow," she said, guzzling the first of eight cups of coffee she requires to survive a 27-hour shift. "She's, like, at one centimeter."

Three hours into her shift, Seay had already taught a medical student how to take a sonogram, assessed various patients' drug needs and was preparing to perform a circumcision, adding to her tally of more than 40 such procedures in her nine months as a resident.

"It's the 1 a.m. to 4-ish range when I hit a wall," she said. "Eat when you can; sleep when you can."

John W. Larsen, 67, GWU's OB-GYN department chairman, said he worries that reduced hours have diminished new doctors' training. Residents who stay with one patient from their arrival at the hospital all the way through to delivery have the advantage of detecting and recalling tiny but important clues that might not be written down when a case is handed to the doctor on the next shift.

"You could remember things," he said, recalling how abdominal infections have been found in women who have just delivered. "Did the patient have three wrinkles on her forehead when you pressed her tummy?"

Still, he has trouble persuading younger audiences that his war stories amount to a better way of training doctors. "The kids, they don't want to hear it," said Larsen, who was a resident in the early 1970s at Yale-New Haven Hospital.

At the end of April, the Accreditation Council for Graduate Medical Education , which determines work rules for residents, will unveil a proposal that could further shorten workweeks. If approved, the new rules would take effect in July 2011.

Thomas Nasca, the council's chief executive, said he is not certain what the new rules will be. At George Washington, some officials who run the residency programs are so sure the new limit will be 60 hours a week that they are setting up a pilot program to test the impact of a lower cap.

"What's being discussed is 60 hours a week and that no shift would be more than 16 hours," said Gigi El-Bayoumi, director of GW's internal medicine residency program. Best-selling author "Malcolm Gladwell talks about the whole idea of 10,000 hours as a way of mastering a topic. So with that in mind, I actually looked at how many hours I did as a resident versus the current rules and the proposed rules. In my training, it was 15,000 hours. Now, it's about 8,000 to 9,000. And if [the new limit is] 60 hours, it'll be close to 6,000."

The result, she fears, could be that residents finish their programs with a sense that they need more training, leading them to pursue fellowships in more esoteric specialties and exacerbating the shortage of doctors in internal medicine. Alternatively, hospitals might extend residency programs by a year or two.

At 1:09 a.m. Saturday, Gray surprised Seay by giving birth while the resident was on duty. Gray was relieved that it was Seay who delivered Oliver Leith Kovel, at 7 pounds and 12 ounces.

"It was nice because we had met before," Gray said several hours after the delivery. "She had advocated for me to get an epidural, and I wasn't sure, because I thought it would slow me down. I felt like she was on our side. I got lucky because I delivered in her window."

Around 8 a.m., with about an hour left on her shift, Seay looked weary. She had had about 90 minutes of sleep overnight. Having downed all eight cups of her homemade coffee, she resorted to a Starbucks latte. "Elizabeth did really well," she said. "I didn't think she was going to deliver."

She sped on to her next patient. "If I don't move, I'm going to sleep or die. Gotta move, gotta move."

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