On Hours

A Book of Hours is a kind of medieval prayer book.  They are often quite beautiful, as some of the existing versions were owned by affluent persons and families, such that the pages or cover may be gilded, or inscribed with beautiful artwork and filigree.

For somewhat unfortunate reasons, I was thinking of prayer in context of moral luck when reading Carey Cuprisin's post on the difficulty of satisfying on-call requirements.  Though he is primarily focused on such requirements for ER physicians, the problem, as he touches on, goes beyond ER physicians to residents in general.

Cuprisin says:

Everyone who knows me knows that I hate call -- give me the power to change one thing in medical training and it would be this. Residents are on-duty without sleep for far many hours in a row. The threat of federal legislation a few years back led the ACGME to implement an 80-hour work week rule, but this rule is often violated, and the rule itself isn't strong enough. Believe me, you can be worked beyond physiological reason under the current 80-hour rule.

Watching my older brother go through a surgical residency convinced me of the serious deficiencies in the way residents are trained.  About six years ago, I was excited to learn that several antitrust suits had been filed against the ACGME.  These suits were all settled fairly quietly, with no large-scale change in the way the residency programs are administered by the ACGME.

Whether the ACGME is guilty of antitrust violations is a complicated inquiry, but I continue to believe that some of the problems that residents face -- including the problem of hours that Cuprisin mentions -- are connected to the specific employment features of the residency programs.  How, after all, does one become a resident? By applying through the ACGME for certain residencies, and then being matched, primarily.  How else could a medical student become a resident? Virtually no other way.  Hospitals need residents, for a variety of different reasons.  The idea here is that the ACGME is the administrative body that controls access in a bidirectional manner -- both for the medical students seeking residencies, and for the hospitals seeking residents.

Arguably, if the residency system were immediately scrapped, hospitals would have some other options for filling the needed positions.  This is not to suggest that doing so would be easy; quite the contrary, it might darn well be impossible.  But at least in theory, the hospitals have other options -- they can hire more physicians, increase their recruitment of qualified foreign physicians, utilize allied health professionals (like nurse practitioners or physician assistants) more, etc, etc.

But the medical students have only one path open to them for their required training: the ACGME's medical residency program.  This means that they have virtually no bargaining power whatsoever.  The labor market for medical students who wish to become practicing physicians is decidedly non-competitive.  It is not a free and open market.  Medical students seeking residencies cannot bargain for better pay, more enhanced benefits, or, and here is the kicker, better hours. 

I remain convinced that a systemic part of the problems in the on-call system that attends many medical residencies in the U.S. can be traced to this fundamental inequality in bargaining power that medical students have.  Indeed, unequal power dynamics have a long history in medical training, and I think it would be unwise to dismiss such influences out of hand as contributing to the problems Cuprisin writes of.

Now, this is not to suggest, in any way, that the ACGME program is violating or has ever violated antitrust law.  Antitrust law is tricky stuff.  But I do think there are some competitive imbalances facilitated by the residency system, and that these imbalances may contribute something to the problems some residents face in terms of hours.  And of course, hospitals have economic incentives that create friction against residents' obtaining higher pay and less hours.

There are myriad other factors contributing to this problem, of course, not least of which is the culture of medical training, one in which both attendings and residents participate, as Cuprisin notes:

The most fascinating thing to me about the whole thing is the seeming complicity of the residents. Panda Bear describes it thusly: "their thinking is cluttered with duckspeak from the medical establishment which not only hides the reality of the situation but sets the conditions of any potential debate to preclude anything but the party orthodoxy." Even if you don't agree that the residents are brainwashed, it's clear that they aren't the ones pushing for a more rational and physiologically sound schedule.

Finally, I'd like to suggest that the stakes of this discourse are quite high.  The more we learn about medical error, the more we discover that such errors occur with alarming frequency and higher-than-suspected severity.  There are numerous articles assessing the correlation between lack of sleep, fatigue, and medical errors, the majority of which unsurprisingly find a statistically significant positive correlation.  A 2004 report of the National Institute for Occupational Safety and Health found that medical errors were decreased when work schedules for interns were limited.  However, as Cuprisin suggests, restricting the hours is an important step, yet if unaccompanied by an assessment of the cultural practices that animate the grueling schedule, may not work the needed changes.  He concludes: "we should be asking: what kind of evidence must we have before we take action to solve the problem?"       

UPDATE: More dialogue from Cuprisin here.  I'm not going to excerpt anything, but he makes a number of excellent points with which I agree.  Go read the whole thing.