The best work schedule for residents… Dr. Marshall Wolf outlines his vision and challenges
How to balance sleep and work schedule for medical (and surgical) residents in intense work environment of a modern academic hospital? Eminent physician and medical educator, Dr. Marshall Wolf:
In modern medicine, what is the best schedule for physicians in training to make sure that they are both happy and perform the best? Well, I have a lot of problems about schedule. And part of it is that I think the boards that tell training programs what they should and shouldn’t do in terms of their schedule, often do that in a data-free zone. So they haven’t studied the situation, and so they set up programs, which, in my mind, don’t make sense. I’ll go back to the sleep business. What we were trying to find out was how many hours of sleep do you need, so that you perform well the next day. There was data in the literature, and data in the literature was quite interesting. It turned out 2 hours of sleep was enough for people to perform well the next day – unless they were on call. So it’s what’s called a “fireman effect”. If you get 2 hours of sleep and you’re not going to be called, that’s enough. If there’s a chance you’re going to be called, like a fireman, you need 4 hours of sleep. So we redesigned a [training] program, even when the people were “not supposed to be on call”, they would get at least four hours of sleep. Because that’s what should be enough to let them perform well the next day. It is interesting and is a tribute to the young people I trained and their energy level, they often arrived on an every fourth night schedule sleep-deprived from their joyous activities on their nights off. So they weren’t getting enough sleep at that time. In terms of the schedule, I am concerned about the new schedules. And in that, two things: I think sometimes the new schedules leave young physicians with poor coverage. That is, you would like a young physician to do his thing, but to also have a chance to discuss the patient with a more experienced resident or staff physician. And some of the new programs don’t do that, and I also think that some of the schedules send people home when they are sleep-deprived and when we know they are twice as likely to have a car accident. So I have a lot of problems with the schedules. And it was interesting when my youngest son was an intern and I saw what he was going through – by that time I stopped running our program – I came up with a new schedule for our program, which I thought would deal with a lot of these issues. And the board refused to let us try it, even though we were going to measure the effect on sleep and clinical outcomes, patient satisfaction, nursing satisfaction. We were really prepared to do a definitive study and the board would not let us do that. So I am a little discouraged. They are now beginning to look at some of these issues, but in a less restricted way than I think they should. It bothers me that people who made their career doing research and testing hypotheses, in the field of schedule make a declarative statement and then they don’t test it. What I wanted to do was on a four-day schedule, on the first day, you come to the hospital at 7 AM, that’s your admitting day. You admit [patients] till ten o’clock [22:00] and then you get to bed at 12AM, at midnight, and you would sleep in the hospital. You didn’t go home when you were sleeping. And the next day you’d get up and you’d spend the day in the hospital from, say, 7:00 AM to 5:00 PM, and the third day, you’d spend the day in the hospital again from 7:00 AM to 5:00 PM, and on the fourth day you would be completely off. You wouldn’t come to the hospital. Now the length of stay in our hospitals now averages about three days. So if you’re there for the first three days, you’re there when most of the exciting things happen with your patients. So you have a chance to be there for your patient, and to see their illness and their therapy evolve. But the number of hours was less than the 80 hours that was then suggested. And you did not have any nights where you were not given sleep time. I thought it was terrific schedule, and they would not let us test it. – Do you think it’s possible to test it somewhere? – They are beginning to do some of those things here, but I just thought… It really bothered me, because, I had a lot of wonderful ideas to make our program better, I would ask the young people who were training with me – What’s broken? How do you fix it? And then we would discuss the new suggestions, and then we’d try it. We’d always keep track of whether experiment worked, and having done very careful planning. About half or two-thirds of the time what we tried worked. A 1/3 of the time it didn’t – even though we were sure it would. It bothers me that the people who are looking at hours for house staff, don’t have the same sort of rigorous look at what they’re suggesting, and whether it really does make things better. Now, the other thing I worry about is with the new training schedules, the young people don’t have quite enough time to be taught. It’s sort of an interesting problem that I have not anticipated. But the workday is so busy, especially now, they spend a lot of time on their computers, I was shocked to learn it. There’s been three or four studies now. The average medical resident spends about five hours per day on a computer, and 1,5 hours per day face to face with patients. So I think they’re so busy with all the things they do, they don’t have time to be taught! We have to figure out how to address it. I am thinking about it but I don’t have a solution.