Thursday, October 15, 2009

Post call: resident duty hour regs in perspective

"Post call" is shorthand for being at work the day after having spent the entire previous day and night working. While this sort of situation isn't unique to medicine (for example, attorneys in some specialities pull similar sleep-deprived work shifts early in their careers), it's probably the best known, thanks to medical-themed television shows such as "ER." In the days when medical interns lived at the hospital and were almost exclusively unmarried men, being post call every other day and regularly working more than 100 hours per week was not at all unusual.

Fortunately, by the time I did my family medicine residency (2001-04), matters had improved significantly. Although the Accreditation Council for Graduate Medical Education didn't mandate that programs limit residents to 30-hour shifts and an 80-hour work week until 2003, my program made the change in my second year. We all got more sleep, and I don't feel that quality of care suffered - what experiences I may have missed out on by not stumbling around the wards on a post call afternoon, I made up for by being awake to read more about the patients I was managing. So it strikes me as odd that serious physicians are still debating whether enacting the regulations was the right move - as if the benefits of more sleep to residents can be measured scientifically in any complete and objective way.

In 1997, Vancouver resident Rachel Rose, the author of two books of poetry (most recently, 2005's Notes on Arrival and Departure) published in JAMA what has long been my favorite evocative description of caring for a soul mate who's post call.

**

Postcall

Postcall you come home diminished, wan, your hands
Faltering at the lock. You feel a need to tell me
Each patient’s history before you sleep,
The progress of each malignancy, the way the family
Spoke to you, the suffering that makes death a release.
I understand. But I wait for you, Isabelle,
Not your stories of the progress of the dying.
I lead you to bed like a child, almost crying
With fatigue and despair these anaemic mornings
When you have donated all your strength
And then come home to me, stricken, empty
And grateful for the smallest gesture of tenderness,
My easing your heel from your boot as you undress,
Holding you while you try to reclaim your membership
As one who sleeps. Your limbs twitch
Like a dog’s, hurrying into dreams, your lips
Part with sighs. I soothe you with my weight,
Whisper about the snow piling up outside.
Your eyes close, it’s late afternoon, slow repose
Beckons. But even in dreams your fingers pleat the quilt
As if gathering the flesh of an arm before a shot.
I understand. Accountability never leaves your hands.

– Rachel Rose

4 comments:

  1. Hm. I tried to post a comment but seem to have lost it. Well, not that critical. See my Dec 3, 2008 post the topic on Medicine and Social Justice, http://medicinesocialjustice.blogspot.com/2008/12/medical-resident-work-hours.html

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  2. Thanks for the link to your blog. I agree that adequate "handoffs" are important to ensuring patient safety no matter what hours residents (or attending physicians, for that matter) are working. These days, service sign-out sheets are usually computerized - permitting much greater detail than in my residency days, but also challenging to keep updated (which paradoxically, increases the chance of an error occuring).

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  3. I did my residency in internal medicine from 2000-2003. Our program in theory had regulations but they took an average over the year. While on service I may have easily had to do 100 or more hours. Some days post call after being up all night doing blood draws etc i then would have to drive 20 mins in rush hour to clinic til 6pm then back to the hospital to complete notes. Our program rationalized this saying that on ambulatory rotations you had less hours and so the time averaged out. Hopefully some changes have been made. I am glad that ACGME mandated these changes, but how well are programs monitored?

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  4. These days, service sign-out sheets are usually computerized - permitting much greater detail than in my residency days, but also challenging to keep updated (which paradoxically, increases the chance of an error occuring).

    ReplyDelete