Monday, March 24, 2014

Perchance To Dream

Surgical residencies have been significantly affected by the recently reduced work-hour requirements. People are finishing with inadequate training, and, realizing that, many are seeking subspecialty fellowships before loosing themselves upon the unsuspecting public. And directors of those fellowship programs are commenting that people entering them are disturbingly unskilled, unready to operate unsupervised. Not all of those, one notes, go into fellowships. Some go into you.

Back in my day (he said, like a typical old guy who grows nose hairs nearly as fast as he kills off brain cells) we had essentially no limitations on hours worked. On my easy rotations, I had every other night away from the hospital, although the time out was rarely more than about eight hours. On the harder ones, it was every other weekend off, usually starting mid afternoon Saturday and ending around 5 am Monday. As chief resident on the trauma service I had one short night out of the hospital in two months.

It's not as if I liked working that hard (although there were times I absolutely loved it); but I always believed, because, I'm pretty sure, it was true, that it was what was necessary to become a well-trained surgeon, one who could legitimately ask people to trust him with their lives. The rules changed, I remind the reader, after an incident in NYC a few years ago wherein a young woman died after arrival in an emergency department, and the review concluded (falsely, as it turned out, too late to matter) that the poor care she received was due to lack of sleep by the resident who first saw her.

In that context, I found this recent report interesting (I can't link to it because it's behind a log-in-required wall):

... Does loss of sleep from unscheduled nocturnal surgery have a negative impact on subsequent daytime elective laparoscopic cholecystectomy? The authors used Canadian administrative data to compare the outcome in 2078 cholecystectomies performed by surgeons who operated the preceding night vs 8312 cholecystectomies performed by surgeons with no immediately antecedent nocturnal surgery. The patient characteristics of the 2 groups were nearly identical. The results after cholecystectomy were similar in the 2 groups: the relative risk for conversion to an open procedure was 1.18 (P = .33), iatrogenic injuries were insignificantly lower in the nocturnal surgery group, and overall mortality was low and similar in the 2 groups...
I've thought about this subject a lot. Looking back, I've always believed that lack of sleep never affected my judgement or technical abilities during those training years. The main reason, assuming it's true, is that I was young. In those days, when called from sleep I'd be wide awake and functioning instantly. When I could grab a couple of hours of sleep, I fell asleep right away.

Funny thing is, it was after I was in practice, getting older, that I began to take longer to crank up my brain when the phone rang at two a.m. If I took a call and didn't have to get up, I'd often lie awake, sometimes needed to call back to correct something I'd said. To me, that was scary, and eventually was a factor in my early retirement: although it never happened, I started to worry that I'd talk myself out of the need to come in at 3 a.m. and that disaster would result.

I still think the work-hour restrictions were based on bad evidence, and are but one more example of widely-applied rules imposed based on a single incident, the consequences of which are much worse than the problem being addressed.

He says, reaching for the ear-hair trimmer.

[Image source]

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