Ever since the ACGME regulations came out that strictly limit working hours for residents to 80 hours a week, there has been much discussion and protesting about these regulations. Strangely, there has been very little discussion about work hours or work schedules for attending physicians, nurses, and other health professionals. Work schedules for attending physicians require a lot of attention, because in many institutions such physicians work long hours without a break and continue to work even when obviously fatigued. I’ve known surgeons who worked over 100 hours a week – some of them were over 60 years old and they would be obviously tired – slow in their speech, unsteady on their feet, delayed in their reactions, and often cranky from exhaustion. Working when in such an unsafe state probably leads to more medical errors and harms patients, although I am not aware of specific studies to prove this. Why do attending physicians continue to work under such arduous schedules, and increase risk to patients? From what I’ve observed, there are several reasons:
1) For physicians to work in optimal schedules requires many more physicians than are currently employed in most hospitals. In most hospitals there are not enough attending physicians available to staff a unit optimally. Hiring attending physicians is expensive, and hospitals may not be willing to spend the money to hire more physicians. In private practices, the revenue and profits have to be split between all the physician partners. The fewer such physician partners, the higher each one’s income is. Therefore existing partners may decide to spread themselves thinner rather than hiring additional physicians and lowering their income.
2) Even if enough attending physicians are available, they may not wish to work in an optimal schedule because they may prefer a schedule that gives them the maximum time away from clinical work. Working a schedule that is optimal for patient care might require them to perform clinical work for shorter durations more frequently, thus interrupting their non-clinical time. Physicians value their non-clinical time, which may be spent on academic activities (research, teaching, traveling to conferences), or with their families, or engaging in recreational activities. They often want their non-clinical time to consist of long blocks uninterrupted by clinical work. Thus, an emergency room physician may choose to work, in a week, two shifts of 24 hours each rather than four shifts of 12 hours each. In doing this, if physicians voluntarily are cramming clinical work into long periods to maximize their non-clinical time, they are putting their own needs first and the needs of patients second.
3) Physicians may think that working in long stretches is better for continuity of patient care. While this is well-intentioned, in reality, continuity of care results from consistent information about the patient and plans of care being available when required. It is not a result of the same person being present all the time. Ensuring good communication between well-rested physicians as they hand off patients to each other, and using good sign-out tools can lead to as much or more consistency of patient care as having the same tired physician present throughout. Although well-intentioned, schedules in which physicians work long hours and thereby become unsafe for patients probably result in more hazards for patients than benefits.
4) Finally, there has been profound neglect of this issue by researchers and regulators. There aren’t many studies about fatigue and work schedules in attending physicians. There is no regulatory organization that recommends or mandates work-hour limits and optimal schedules for such physicians.
It’s time for conditions to change. We need to shine a
spotlight on the problem of fatigue in senior doctors, and ensure that work
schedules for attending physicians are designed in such a way that patient care
is not compromised, while ensuring that such physicians still have time for
their research, other scholarly pursuits, personal development, and their
families.
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