Attending work hours?!
Rahul K. Shah, MD, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC Over two decades ago, the concept of intern and resident work hours was novel and in many circles met with disbelief and impetuousness. Fast forward to 2014 and our interns, residents, and fellows have work hours. This begs the question—what do we all anticipate will happen in the next two decades? Academy member Scott Schoem co-authored a provocative and perhaps prescient article on what the future holds for attendings, our work hours, and our associated liability. What is great about Dr. Schoem’s perspective is the reality in the clinical scenarios he describes and the financial implications and pressures that attending surgeons face. This is all too well known to many of us; however probably not as well known to our patients, regulators, and insurers. Many countries and even here in the United States, some jurisdictions, have limits on the age that a physician can take call and some even limit the age an individual can be on the medical staff. The legalities of such are beyond my expertise, but we all know that a physical decline does come with aging. As such, the points raised by our colleagues about the inevitable examination of attending work hours is well stated. As they note in their article, there are work hour regulations for anesthesiologists after an on-call night, but not specifically for surgeons or other attendings. The concomitant reduction in resident work hours has resulted in a huge administrative burden being placed and transferred to the surgeon; furthermore the electronic medical record has reduced potentially the need for some administrative staff, with the attending surgeon completing “everything”electronically. That may sound great for a policy-maker, but for the surgeon—it is not great, having to document and chart the entire care delivery spectrum from office visit to billing is a large task that has been shifted over to the attending surgeon in the guise of efficient electronic documentation. As such, we are seeing the same number of patients, but taking almost twice as long! Whereas previously there was availability of trainees to assist in such duties, they are often times post-call or cross-covering. The concept of surgeon fatigue is magnified for the vast majority of our Academy members who are in private practice. In areas not served by academic medical centers or large community-based hospital systems, the emergency department or patients most likely depend on their surgeon to take the urgent cases to the operating room the next day and cannot afford to not have such occur (for the safety of the patient and the finances of the institution). Dr. Schoem and Dr. Christine Finck his co-author astutely note that what is needed is a cultural or paradigm shift towards an understanding of the limits of attending surgeons in practice. They certainly postulate some potential ways to handle the situation of surgeon fatigue when operating post-call with a long surgical list/case. However, until there is a broad cultural shift and acceptance of such a paradigm, real change will be elusive. We must implore our hospitals, state societies, and national organizations to recognize surgeon fatigue from the vantage point of an affected patient. The Joint Commission and others are very focused on the issue of sleep deprivation and there are many courses that help explain to surgeons the factors to look for and how to plow through sleep deprivation. Therein lies the problem, why are we accepting sleep deprivation and surgeon fatigue as a closed issue? As Dr. Schoem and Dr. Finck indicate, we need to think of novel solutions to this unique problem; the problem is magnified in the current era of trainee work hours and a huge increasing burden on attending surgeons in both private practice and academics. References Schoem SR & Finck C. Time Out For Surgeons: When is the Attending Surgeon Too Tired? Volume 76(3) We encourage members to write us with any topic of interest and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
Rahul K. Shah, MD, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC
Over two decades ago, the concept of intern and resident work hours was novel and in many circles met with disbelief and impetuousness. Fast forward to 2014 and our interns, residents, and fellows have work hours. This begs the question—what do we all anticipate will happen in the next two decades?
Academy member Scott Schoem co-authored a provocative and perhaps prescient article on what the future holds for attendings, our work hours, and our associated liability. What is great about Dr. Schoem’s perspective is the reality in the clinical scenarios he describes and the financial implications and pressures that attending surgeons face. This is all too well known to many of us; however probably not as well known to our patients, regulators, and insurers.
Many countries and even here in the United States, some jurisdictions, have limits on the age that a physician can take call and some even limit the age an individual can be on the medical staff. The legalities of such are beyond my expertise, but we all know that a physical decline does come with aging. As such, the points raised by our colleagues about the inevitable examination of attending work hours is well stated. As they note in their article, there are work hour regulations for anesthesiologists after an on-call night, but not specifically for surgeons or other attendings.
The concomitant reduction in resident work hours has resulted in a huge administrative burden being placed and transferred to the surgeon; furthermore the electronic medical record has reduced potentially the need for some administrative staff, with the attending surgeon completing “everything”electronically. That may sound great for a policy-maker, but for the surgeon—it is not great, having to document and chart the entire care delivery spectrum from office visit to billing is a large task that has been shifted over to the attending surgeon in the guise of efficient electronic documentation. As such, we are seeing the same number of patients, but taking almost twice as long! Whereas previously there was availability of trainees to assist in such duties, they are often times post-call or cross-covering.
The concept of surgeon fatigue is magnified for the vast majority of our Academy members who are in private practice. In areas not served by academic medical centers or large community-based hospital systems, the emergency department or patients most likely depend on their surgeon to take the urgent cases to the operating room the next day and cannot afford to not have such occur (for the safety of the patient and the finances of the institution).
Dr. Schoem and Dr. Christine Finck his co-author astutely note that what is needed is a cultural or paradigm shift towards an understanding of the limits of attending surgeons in practice. They certainly postulate some potential ways to handle the situation of surgeon fatigue when operating post-call with a long surgical list/case. However, until there is a broad cultural shift and acceptance of such a paradigm, real change will be elusive.
We must implore our hospitals, state societies, and national organizations to recognize surgeon fatigue from the vantage point of an affected patient. The Joint Commission and others are very focused on the issue of sleep deprivation and there are many courses that help explain to surgeons the factors to look for and how to plow through sleep deprivation.
Therein lies the problem, why are we accepting sleep deprivation and surgeon fatigue as a closed issue? As Dr. Schoem and Dr. Finck indicate, we need to think of novel solutions to this unique problem; the problem is magnified in the current era of trainee work hours and a huge increasing burden on attending surgeons in both private practice and academics.
References
Schoem SR & Finck C. Time Out For Surgeons: When is the Attending Surgeon Too Tired? Volume 76(3)