I’ve done 16hr calls, 24hr calls, and 28hr calls… here’s my take on duty hours!

Duty hours – the word doesn’t mean much to me anymore as a PGY4. I’ve done my fair share of shifts through the years ranging from 16-28hours straight. As a senior anesthesia resident, my schedule now only occasionally comes close to the 80hr/week limit, even with occasional moonlighting shifts thrown in. Many of the best paid attendings I know get that way because they work MORE as an attending than they ever did as a resident. It’s an obvious point, but there are no duty hour rules once you graduate (though equally obvious is you have greater control over your schedule at that point).

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But while a resident, the ACGME governs how much you can work and when. In the news now is that the ACGME wants to change the guidelines for interns (First-Year Residents Could Be Allowed To Work 28 Hours Straight) – originally set in 2011 – from 16 hours maximum in a row to 24 hours (with 4 additional hours allowed for transition of care).  There will still be an 80hr/week maximum and a 1 day off in 7 policy (both averaged over 4 weeks) that is unchanged.

It’s a rule change, not a culture change. Unless you change the culture, you don’t change what actually happens in a hospital. And I suspect (and have seen) that what actually happens in the hospital is not uncommonly different from what happens on some rule-book paper.

I’m lucky, in the specialty of anesthesia there is often a culture of shift work and sharp end times. When my 24 hour call is up, I go home. I can probably count the number of times I’ve stayed longer than even 15min to “transition care” on 1 hand. I have colleagues in surgical residencies across the country, however, who quietly admit that duty hours are simply what you write down on a piece of paper.

Do longer shifts make a difference in patient care? The research (Study Suggests Surgical Residents Can Safely Work Longer Shifts) suggests no. Though like one commenter mentioned in the article, with all the nurses, attendings, techs, consultants, etc. – residents are unlikely to have a statistically measurable effect on patient care. BUT, it is important to remember if a few residents made a very small number of very serious mistakes due to fatigue – it might not be statistically significant – which would be of little comfort to the patient who was severely harmed.

I say all that, to lead to this point. I actually have no problem with the change of 16->24 hours. It makes very little difference in my mind and while not vigorously studied, it seems residents don’t express any more dissatisfaction with the 24 hour shift compared to the 16 hour shift. I actually think 24 hours leads to an easier/more predictable schedule for most people and at the same time does not really increase fatigue. With a 24hour schedule, it’s often 7am-7am. With the 16 hours, it usually becomes some weird hybrid of 7p-11a, or similar.

The aspect I DO have an objection to is the 24 hours “plus-4” that is allowed. It’s that plus-4 that changes the dynamic and I tend to think has the most potential for abuse. In theory, you should be assigned no additional work in that 4 hour period – but that definition can be very subject to interpretation. Is being asked to fully round on patients you already have been taking care of new work? Or continuation of previous work you have? What about when the team is rounding on other patients while waiting to get to yours? Is that new or old work? I don’t think there is an easy answer there. My thought and solution is that a shift should be 24 hours at maximum, and that there should be minimal flexibility in “transition of care” time. The reason for that isn’t for patient care but for the benefit of resident lifestyle.

The difference between going home after a 24 hour shift knowing you leave at 7 am vs. knowing you’ll leave sometime around 11am is quite different. Your day is set up different. If you want a mid day nap, it’s harder to get that done, plus do all the real life things you want to accomplish on your post call day. And in residency, those post call days are about the only chance you have to get done anything that follows a traditional 9a-5p pattern (dentist/doctor apt, post office, etc.).

At many large academic centers, residents are relied on so heavily that the work likely would barely get done in their absence. But while residents as a whole may be nearly irreplaceable at many centers, there is no reason it should take 4 hours to relieve an individual resident. So when it comes to the change from 16 hours to 24 hours I say this: 24 hours is fine, but keep it AT 24 HOURS!

 

Update March 17:

The ACGME went ahead and adopted the above rules. The first year doctor will now be allowed to work the 24+4 style call shifts, giving them occasional periods of 28hr work – starting July 2017.


 

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