Resident Work Limits: Solving the Wrong Problem
Many practicing physicians perceive a major disconnect with the academic community over this issue. In the rarefied atmosphere of academic medicine there is frequently an abundance of physicians. Many patients have multiple caregivers with medical students, interns, residents, and staff physicians assigned to them. Also, in a few large urban areas there is an oversupply of physicians. But in most of the United States there is a chronic physician shortage, which is compensated for by the available physicians working long hours.
Residency training offers the opportunity to learn to condition yourself to combat fatigue and improve performance under stress. Many perceive the training period to be the ultimate boot camp preparing physicians to serve under the most adverse conditions. To adapt a phrase from the military, practice like you train, and train like you practice. For most physicians, artificially limiting work hours is not a realistic simulation of the real world. You can’t train for a marathon by limiting training sessions to a couple of miles.
In the real world, much of medicine operates in the crisis mode. There is no obstetrician who has not worked over 30 continuous hours doing multiple complicated and unpredictable deliveries. There are not many trauma surgeons who have not worked over 30 hours treating mass causalities from sequential or large accidents. Limiting work hours in training seems like a good idea, but until it translates to an adequate physician supply to staff real world challenges it will be largely meaningless and counterproductive.
Everyone would agree that under ideal circumstances a physician should be completely rested and alert. We would also agree that in a crisis, physicians should not abandon patients because of arbitrary work rules. The problem with work limit rules is that much of medicine is practiced in the crisis mode. Until the physician manpower shortage is solved, physician work limits are an empty promise.