In modern medicine, what is the best schedule for physicians in training? Dr. Anton Titov, MD. How to make sure that young doctors are both happy and perform the best? Dr. Anton Titov, MD. Well, I have a lot of problems about schedule. Part of it is the medical boards. They tell training programs what they should and shouldn’t do in terms of their schedule. Medical bureaucrats often do that in a data-free zone. They haven’t studied the situation. So they set up training programs that don’t make sense. At least, in my mind. I’ll go back to the resident’s sleep business. What we were trying to find out was how many hours of sleep does a young physician need. So that a trainee physician performs 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 trainee physicians to perform well the next day. Unless they were on call. It is what’s called a “fireman effect”. You may get 2 hours of sleep and you are not going to be called, that is enough. But there may be a chance you are going to be called in emergency, like a fireman. Then you need 4 hours of sleep. Dr. Marshall Wolf, MD. 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 is what should be enough to let them perform well the next day. It is interesting. It is a tribute to the young people I trained and their energy level. They often arrived on an every fourth night schedule sleep-deprived. They were sleep-deprived from their joyous activities on their nights off. They weren’t getting enough sleep at that time. In terms of the schedule, I am concerned about the new schedules. Because of two things. Dr. Marshall Wolf, MD. The new hospital schedules leave young physicians with poor coverage. That is, you would like a young physician to get some sleep. But a trainee physician also should have a chance to discuss the patient with a more experienced resident or staff physician. Some of the new programs don’t do that. I also think that some of the schedules send people home when they are sleep-deprived. Dr. Marshall Wolf, MD. We know that sleep-deprived physicians are twice as likely to have a car accident. I have a lot of problems with the medical residency training program schedules. 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 medical residency program. I came up with a new schedule for our medical residency program. I thought my schedule would deal with a lot of these issues. Dr. Marshall Wolf, MD. The medical board refused to let us try the schedule for residents that I designed. Even though we were going to measure the effect on sleep and clinical outcomes, patient satisfaction, nursing satisfaction. Dr. Marshall Wolf, MD. We were prepared to do a definitive study. But the medical board would not let us do that. I am a little discouraged. They are now beginning to look at some of these issues. But in a less restricted way than they should. It bothers me that people made their career doing research and testing hypotheses. But in the field of medical residency scheduling they only make a declarative statement. Then they don’t test it. What I wanted to do was on a four-day schedule is this. On the first day, you come to the hospital at 7 AM, that is your admitting day. You admit patients till ten o’clock [22:00]. Then you get to bed at 12AM, at midnight. You would sleep in the hospital. You didn’t go home when you were sleeping. Dr. Marshall Wolf, MD. The next day you’d get up and you’d spend the day in the hospital from 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. On the fourth day you would be completely off. You wouldn’t come to the hospital. Now the length of stay in American hospitals now averages about three days. If trainee physicians are there for the first three days, trainee physicians are there when most of the exciting things happen with your patients. Trainee physicians have a chance to be there for their patients. They see their illness and their therapy evolve. But the number of hours was less than the 80 hours that was then suggested. You did not have any nights where you were not given sleep time. I thought it was terrific schedule. But they would not let us test it. Do you think it is possible to test it somewhere? Dr. Anton Titov, MD. They are beginning to do some of those things here. But I just thought we should test this schedule for residents in our medical train program. It 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? Dr. Anton Titov, MD. How do you fix it? Dr. Anton Titov, MD. Then we would discuss the new suggestions. Then we’d try it. Dr. Marshall Wolf, MD. We’d always keep track of whether experiment worked or not. Dr. Marshall Wolf, MD. We have 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. They don’t have the same sort of rigorous look at what they are suggesting. Whether a proposed schedule does make things better for trainee physicians. Now, the other thing I worry about with the new training schedules is this. Dr. Marshall Wolf, MD. The young physicians don’t have quite enough time to be taught. It is sort of an interesting problem that I have not anticipated. But the workday is so busy. Especially now, trainee physicians spend a lot of time on their computers. I was shocked to learn it. There has been three or four studies now about how physicians spend their time. Dr. Marshall Wolf, MD. The average medical resident spends about five hours per day on a computer. Trainee physician spends 1,5 hours per day face to face with patients. They are so busy with all the things they do. Trainee physicians don’t have time to be taught! Dr. Marshall Wolf, MD. We have to figure out how to address it. I am thinking about it but I don’t have a solution. 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.
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