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September 06, 2007

More on Trainees' Hours

The wonderful Health Care Renewal blog has been closely tracking some of the issues relating to interns and residents' ungodly work hours.  I have touched on this issue before:

But . . . 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 . . .

Apparently, two new studies have been released that found only a limited reduction in mortality resulting from reducing the number of hours interns and residents worked.  Both Roy Poses and MedInformaticsMD have excellent criticisms of the study.  Poses notes:

While mortality is obviously an extremely important outcome of hospitalization, it is not the only one. Fatigue is likely to cause many errors that lead to bad outcomes short of mortality. Yet the current studies were not designed to determine if the reduction in work hours could have improved patient outcomes other than survival.

This is a significant limitation in the study.  The consequences of medical error extend far beyond mortality, and as there is reason to believe that trainees' overwork increases the likelihood of such errors, then the mere fact that reduction of hours is weakly correlated with reduction in mortality is really only one part of the overall story.

Poses also notes that the "reformed" work schedule still

allow 24 hours of continuous, intense work, and then another 6 hours of "education" and for hand-off. Then imagine, after such a 30-hour experience, having all of 10 hours to sleep, eat, catch up on life, before it starts all over again....

So another obvious explanation for the failure of these two studies to find much effect of house-staff work hour reforms were that these reforms were woefully insufficient to prevent major sleep-deprivation and fatigue.

That is absolutely correct, and a serious confounder if I have ever seen one.

He goes on to note several other conceivable confounders, and also demonstrates the importance of narrative in health policy:

Because of extreme sleep deprivation and fatigue, my internship year was the worst year of my life so far. One reason I went into academic medicine was the hope that I could help reform the system to make it more humane for house-staff, and hence provide them better education, and patients better quality of care.

MedInformaticsMD shares a similar story:

Not included in the calculus of the author's articles is the effect of the work hours and work environment on the health and well-being of the trainees themselves.

Like Roy, my internship in the early 1980's was the worst year of my life, bar none. The psychological abuse, delivered under conditions of serious sleep deprivation, was, in retrospect, simply shocking.

This is extremely important.  Even outside of the increased risks of medical error that patients are subjected to from sleep-deprived and exhausted trainees, one really needs to examine the effects of such training on the interns and residents themselves.  I continue to believe there are more humane ways of training physicians that sacrifice relatively little of great importance as to training.  But what's more, even if I am wrong and a significant sacrifice in training is required, it still remains crucial to query whether the costs of such training on the trainees and the increased risks of error patients are subjected to outweighs the training advantages.

MedInformaticsMD fears that

studies showing little benefit from work hour reduction will increase the pressure from reactionary educators and those addicted to cheap labor to reverse the "changes" (as ineffective as they may be in preventing fatigue).

Indeed; reversing even the marginal progress that has been made on this issue would be ethically suboptimal, IMO.

No matter one's view of collective bargaining in general, the history of occupational health in the U.S. shows quite clearly that deleterious health consequences frequently follow employment relationships in which there exists a wide disparity in bargaining power between employee and employer.  Whatever their faults, unions have demonstrated some effectiveness in correcting or at least ameliorating this power imbalance.  This is certainly not to suggest that trainees should unionize, but simply to note that the existence of the significant disparity in power between institution, mentor, and medical trainee can have profound consequences.



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