by Allan Joseph
Let’s start here: I’m only a first-year medical student. I don’t claim to have inside knowledge into how residency works. But when I saw this widely-shared New Yorker article by cardiologist Lisa Rosenbaum decrying restrictions on resident work-hours, I was struck by how many in the medical field took Dr. Rosenbaum’s argument at face value. I think she makes some valid points, but I worry that in blaming new regulations for every problem, the medical profession misses a critical opportunity to examine its own weaknesses.
Take the article’s opening anecdote, about a mistake made by “Resident B,” who had taken responsibility for a colon-cancer patient from “Resident A.” Dr. Rosenbaum attributes the error to the fact that Resident A was forced to leave the hospital due to work restrictions — but as we see in the article’s own words, the error came from somewhere different (emphasis added):
So when [Resident B] arrived, [Resident A] handed her a fresh list, which now included an instruction to pull the abdominal drain.
A few hours later, [Resident B] entered the patient’s room, saw the kidney drain coming from the patient’s back, and assumed it was the one to pull.
This error was absolutely preventable within the context of the work-hour restrictions. Sure, Resident A wouldn’t have made the mistake if he had been there, but Resident B had to make a faulty assumption to make that error. That’s not the regulations’ fault — it’s due to a problem in coordinating care. The patient was going to be in the hospital for several days, perhaps even weeks. Unless you wanted Resident A to be in the hospital for the duration of the patient’s care, the handoff was going to happen somewhere. And if that’s the case, the handoff had to be better.
I’m not saying that work-hour restrictions don’t contribute to poor handoffs. They almost certainly do. But they can’t be the only cause. The American healthcare system is rife with care-coordination problems, due in no small part to physicians’ historical role as “their own bosses” and resulting distrust of administrative solutions. It doesn’t help that paperwork issues with nascent electronic-health-record (EHR) systems add roadblocks to effective coordination, but again, that doesn’t mean we need to get rid of restrictions, it means we need to get better EHR systems.
There are issues with the work restrictions that do need to be addressed. For the physician-in-training, residency is supposed to be learning experience: see as many cases as you can and learn from each and every one of them. Work-hour limitations do reduce your caseload over a typical three- or four-year residency program, but perhaps physicians could improve their training through longer residency programs. Morning rounds should be a sacred time, and there should be enough flexibility in the system to allow residents to complete proper handoffs. But none of those issues require a wholesale repeal of the regulations. They simply require improvement of that which exists. If patients really are more comfortable with rested physicians, and we can improve the system to the point that education and care are at least as good as they were before, then why shouldn’t we put patients’ wishes first?
There are always solutions to the problems brought about by changes like new regulations, new EHR systems, and new reimbursement systems. But instead of looking to move forward and lead a new generation of innovation, physicians tend to look backwards and bemoan the loss of what once was. Rather than training in an environment that sees and addresses the flaws in the practice of medicine, a new generation of physicians is training in a culture that would simply rather blame new regulations and cruel administrators for all of its issues. We can analyze work hour restrictions’ effects on clinical and educational outcomes, but we can’t use them as a scapegoat for all that ails academic medicine.
Our profession is not perfect, and neither are residency work restrictions. But instead of blaming external factors for all of our problems, why can’t we improve the regulations and our own care? We’d produce better physicians in the process — and that’s an outcome we can all agree on.
Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.