The interview trail and duty hours

So the interview trail has been a busy one for me. I have been trotting all over the midwest, and I'll share a few thoughts on the strengths of the various programs that I've been to:
Mayo: Amazing physical facilities. Dozens of different kinds of marble in the waiting rooms alone. Also, the truly bizarre cases come to Mayo
Michigan: A lot like Mayo from a pedagogical standpoint, Ann Arbor has a little more going on than Rochester
Case Western Reserve: Sweet moonlighting possibilities where you can make $65/hr doing anesthesia after hours. Level 1 for children's trauma.
Cleveland Clinic: Very strong in hearts, lots of pump cases and congenital cases. Very strong ICU
University of Wisconsin: national leader in transplant, very livable town.
Medical College of Wisconsin: Strong peds rotation
Washington University: Has everything, knife and gun club.
SLU: lots of penetrating and blunt trauma.

I have two more anesthesia interviews and three more prelim or transitional year interviews before I'm all done in January.

So, now my rant about duty hours. Residents are currently able to work no more than 80 hours a week, averaged over a month, with no shift lasting longer than 30 hours. They must also have 8 hours off between shifts. I think this is reasonable and allows for sufficient exposure to ensure a balanced and adequate post-graduate education. The Institute of Medicine, a think-tank (if they in fact think there) which makes recommendations to the ACGME, which is the accreditation body for residencies, recommended that interns not be allowed to work more than 16 hours at a time. This recommendation becomes codified into regulation next summer, when I become an intern. Great! I hear you cry. Interns won't be as tired and will be alert and less prone to make errors. Right? Wrong.

Here are the problems with that line of reasoning. Yes, there will probably be fewer fatigue related errors. The flip side of having shorter shifts is that there will now be more hand-offs of patient care between residents. Would you rather have your ailing father be cared for by someone who had seen and monitored his care continuously for the first day he was admitted? Or would you rather have 3 different hand-offs?
Remember playing Telephone as a kid? the same problems with garbled messages and discontinuity will now exist in medicine. In essence we're trading fatigue for the problems engendered by frequent pass-offs of care. I think it will also turn the newest generation of physicians into clock-punchers who will be ill-prepared for the real world where doctors don't have duty hour restrictions. I would rather work hard as a resident and emerge a well trained physician who is competent and has seen and cared for a wide variety of illnesses than emerge a well-rested but half-trained doctor.

There are also changes for upper level residents, who will only be able to work for 24 hours straight. This will not be any change for anesthesia residents who only work 24 hours at a stretch when on call anyway, but will be devastating to surgical residents. If you shorten the amount of time a resident can be at work, you limit the number of procedures he does. Would you like to have your knee replaced by new surgeon who has done it 350 times in training? 200 times? 100? 50? 10? It is a mathematical necessity that in order to be competent in a procedure, you have to have a baseline minimum number of repetitions to be good at it. Surgical residents are going to be doing fewer cases and emerging from training with less experience than their predecessors.

Bravo, institute of medicine. That's some strong work.