It is a common sense (I realize that this is not "common") given that less long hours is a satisfier for trainees. I cannot blame them. While I trained in the halcyon days of 48 hour shifts and minimal supervision, I consider myself wise enough to see the error in those ways. I do not remember enjoying any part of that experience.
I think that there is adequate evidence that less sleep to less cognition. Poorer quality of cognition leads to gaps in patients' care. Patient care gaps are bad.
I am also a pragmatist and realize that duty hours rules are not going away. I also am aware that there are those who feel that they do not go far enough.
Given this reality, what are some of the other unintended consequences of this paradigm shift? Here are a few:
1. If the current residents are not going to be around to care for the patients, who will? This is a significant policy question. The call for 24/7 coverage of hospitals compounds this reality. A recent blog post by Brad Flansbaum, DO for the Society of Hospital Medicine elucidates more issues on this topic.
2. While the QUALITY of education rises with a higher level of cognition, the decrease in hours (and in many instances census) decreases the QUANTITY of education. This may not be all bad as there is some evidence that our current quantity paradigms are flawed. In a competency-based world it is outcomes that matter, not time served. The problem is that we are “not there” yet. There is also a suggestion, both anecdotal and some evidence that time (likely maturity) may matter.
3. See #1 and #2…If we need more physicians to care for the patients and if those physicians are trained in a paradigm of decreasing workload (hours and volume), then we will need even more physicians. It is a self-perpetuating cycle.
While I do not have the answers to solve this problem, we need to look at #2 for answers. What is the needed education? What does the physician of the future need to know and how to we train this in the new paradigm? Who are our partners on the healthcare team and how can they help solve this dilemma?
Some of solutions are beginning to be developed. We have discussed some of them in past posts. We need to change what, when and how we teach.
We need to train thought not facts.
We need to train leaders not managers.
We need to communicators not commanders.
The solutions will require open minds and innovation.
Rest assured there is no turning back!
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