Sign Out: Time for an 80-hour workweek for attendings?

April 1, 2007

We need to define shift mentality simply as a time commitment, not as a measure of our level of care.

OK, those were the days of the giants, and I am quite glad it's time for those days to end. I don't think I made any major errors in that 106-hour marathon, and I am grateful to the multiple shifts of residents who made sure I got a few hours of uninterrupted sleep each night. Still, in the light of what we are now taught about fatigue, it's hard to think that this was a good idea.

Like many of you, I grew up in the era of solo practi tioners and multiple nights on call even in groups. We took whole weekends on call, driving back and forth to the hospital numerous times in the night for deliveries. I was never aware of problems with my patient management or my driving.

The pattern of practices that I've seen since starting residency in 1979 is for fewer solo practitioners and more groups, and the groups are, for the most part, assigning one partner to the labor floor for 24 hours, some with a backup built into their schedules. But I still see some practices covering L&D for whole weekends, and I know that in rural areas where practices are smaller the idea of taking a day off after being on call doesn't seem possible.

It's time for us to admit the truth

If we give twentysomething residents the day off after a 24-hour shift, shouldn't we require the same for older attending physicians as well? I don't find the counter-arguments persuasive. Sure, too many hand-offs could lead to errors, but there are lots of high-stress, intense situations that utilize hand-offs smoothly (air traffic control for one, emergency medicine for another closer to our own environment), and the risk of errors due to fatigue is greater. We can and must develop systems to ensure smooth, accurate hand-offs. Sure, patients like having their doctor around for the whole labor, but if we explain the safety aspect of our work to them early and often, they'll agree. And, maybe there aren't enough doctors in some communities to support real work hour limitations. If so, we'll need to get more comfortable with midwives or other options.

The term "shift mentality" is often used to decry a general problem of less engagement in care on the part of residents. But today, we need to define shift mentality simply as a time commitment, not as a measure of our level of care. Once our patients understand we are changing our ways to improve their safety, they'll thank us for it.