Fischer, Josef E. MD
Dr. Fischer is chairman, Department of Surgery, surgeon-in-chief, and Mallinckrodt Professor of Surgery, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts. He is a former chair of the American Board of Surgery, a current member of the Residency Review Committee for Surgery of the Accreditation Council for Graduate Medical Education, and a regent of the American College of Surgeons.
Correspondence and requests for reprints should be addressed to Dr. Fischer, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite 3A, Boston, MA 02215.
For articles on related topics, see pp. 379–380, 384–385, 394–406, 407–416, and 447–452.
The controversy concerning the limit of residents’ work time to 80 hours a week has generated unprecedented dismay for many involved in graduate medical education, particularly surgeons. The author maintains that 80 hours a week is too short a time for surgery residents to provide excellent care and that this new rule undercuts the importance of continuity of care, a principle highly valued by surgeons. General surgeons and those specialty surgeons most closely associated with them think of themselves as the last “compleat physicians,” who should and can take care of the entire patient, and that when difficulties arise, they should not transfer the patient to another physician but instead ask someone else to help them continue to care for the patient.
The author traces the arbitrary choice of an 80-hour work week (instead of a 92-hour one) to several sources, including the leadership of internal medicine, which he feels has largely de-emphasized patient contact for many years and has become focused on research and/or administration. He also maintains that the issue of moonlighting has also driven the push for an 80-hour work week, and that the view of moonlighting by surgical residencies (i.e., that it is almost always counterproductive) is different from that of other residencies.
He concludes by acknowledging that the 80-hour work week and the abandonment of the principle of continuity of care are societal decisions, and have occurred because surgeons and other physicians did not make their case strongly enough or in time.
The past years have not been happy ones for U.S. surgery. We have grown accustomed to the fact that physicians have not been in control of health care in this country for two or three decades. But until recently the mythology has persisted that we are in control of medical care. This, too, is no longer evident, and for the first time in the history of medicine, surgeons and other physicians are in control of neither health care nor medical care. Add to this the hassles of dealing with health maintenance organizations; the retroactive disallowances; the petty and costly failure to pay for services already delivered; the hassles of attempting to plan for patients’ care and being overridden for economic reasons; the absence of tort reform; and the ever-present and increasing specter of ruinous litigation and one has a group of fairly unhappy campers.
But as an observer of this scene for over 40 years, seldom have I seen such an outpouring of pain and genuine angst as I have witnessed in the controversy concerning the 80-hour work week. One would have thought that other aspects of unhappiness to surgery, such as those named earlier, would have been much more divisive and would have created as much or more unhappiness. Yet, the 80 hours and the other new work rules of the Accreditation Council for Graduate Medical Education (ACGME) have been widely seen as a loss, particularly for surgery, and have generated unprecedented dismay. It is difficult to watch, and it is more difficult to comprehend. So, one must ask the question, What is this about?
After all, most of us who have been in the business of educating residents and, to a lesser extent, medical students believe that it is possible to carry out the process of excellent, detailed care and provide continuity of care with a 90-hour or at most a 92-hour work week. Yet, as a final outcome of the ACGME rules we may end up with an 88-hour work week, with the additional 10% of time required to have a strong educational content. And 88 hours is four hours short of the 92 hours that many believe is essential for continuity of care. Also, the ACGME rules have certain strictures, of which the most difficult to deal with are (1) the six-hour transitional period, which cannot be altered even by the addition of the eight hours weekly, and (2) not being able to change the fixed intervals of 24 hours of continuous duty, 10 hours complete rest, and 6 hours of the transition, although the 10-hour rule at present is highly desirable but not mandatory. Even so, most surgical programs have adapted in a way in which this is manageable, not ideal, and while there have been some disasters, overall care has suffered only slightly. Mind you, most programs have continued problems of compliance with the chief residents and the fourth-year residents. Despite the fact that the difference between 88 hours and 92 hours is statistically insignificant (and I have gone on record to say that if you cannot train residents within 92 hours you should probably get out of the business), the reaction to the ACGME rules of the surgical community, young and old, trainer and trainee alike, has been devastating. Why is this the case?
I believe that the reason for this extraordinary response is that the imposition, from without, of the 80-hour work week is seen as damaging to the essence of surgery's being. It is the denial of the foundation of one of the most closely guarded and almost religiously regarded axioms of surgical care: the concept of continuity of care, at least in general surgery and those aspects of surgery which are most closely related to it. Whether complaining of their lot or not, general surgeons and those specialty surgeons most closely associated with them think of themselves as the last “compleat physicians,” the last generalists. They all believe that they should and can take care of the entire patient, and that when limitations in knowledge base or nonsurgical complications occur, they should not transfer the patient to another physician or surgeon but instead ask someone else to help them care for the patient so that they can continue to participate in that patient's care. Continuity of care is the basic lifeblood of general surgery and related specialties.
Indeed, the 80-hour work week has revealed a schism in U.S. medicine that has long been apparent to the thoughtful observer of the scene. It involves at its heart responsibility to patients. It is evident at many levels, particularly in academic medical centers, where many of these work hours battles were fought and many of the individuals who make the rules that govern U.S. medicine have matured. The following comment may seem harsh, but at least to this observer, most academic medical center's internal medicine departments have long since lost interest in continuity of care as a basic principle. Night floats appeared years ago and then afternoon floats and then other floats, and, as our residents joke, the morning float and the “float-float,” with the result that if one consults on a patient on the medical service it is difficult to determine who of the housestaff actually is caring for the patient.
One of the reasons why I believe that surgical chairs should take call in the emergency room, take calls on the consult service, and participate in the operating room is that the reality of the practice that staff and residents alike encounter should also be part of the chief's experience. A well-known and highly respected dean of long standing once told me that in academic medical centers the standard of care is set by the Department of Surgery and the intellectual standard is set by the Department of Medicine. While I would argue with the absence of participation of surgery in his view of the intellectual standard's source, I find it particularly unfortunate that whatever intellectual tone is being set by the Department of Internal Medicine is often research centered, with little room and fewer rewards for excellent patient care. It is completely devoid of the social contract that physicians have with patients and their responsibility to patients, since the reward system is not set up in that fashion. While the economics may dictate the one-out-of-12 (monthly) on-service concept, the research-oriented physician (who is often a very narrowly based specialist) takes call, as it were, and serves as the physician of record for a complex patient. This physician is often acting merely as a traffic director, getting one consult after another but not himself or herself trying to define what is really wrong with the patient. The problem-oriented systems and history cover every single aspect of the patient except one and that is: Is this patient getting better or worse? Morning report with the absence of someone actually making rounds on that patient, “laying on the hands,” and taking a look to see whether that patient is doing better or worse—something that an experienced clinician can do from the end of the bed in 15 seconds—is not the way young people should be trained. The emergence of the hospitalist, while useful for the primary care physician who is distant from the medical center, also has the unfortunate effect of farther distancing the research-oriented specialist from any responsible contact with patients.
This is not true in all medical centers or in the real world, where there are some genuinely skillful internal medicine physicians who take excellent care of their patients. But the leaders of internal medicine in this country have largely ignored or de-emphasized patient contact for many years. They have busied themselves with research and/or administration, without connection to the leavening and balancing that active patient care brings to one's experience. This absence of patient care has too often become accepted, and few of those who lead internal medicine are now highly regarded clinicians. Thus, to the academic internal medicine community, continuity of care is a disembodied concept. The arbitrary work-week figures of 92 hours, 80 hours, 60 hours, 70 hours, 75 hours, or 84 hours have no meaning to them, and so the actual number decided upon is merely an exercise in the politics of what is possible.
The surgical community does understand that residency programs are under pressure and that there were bills being prepared in the House and Senate that would have imposed standards had we not acted ourselves. What is really bothering the surgical community is the lack of emphasis in the discussion over what continuity of care means to the patient and to the physician, in this case, the surgeon. That is the reason for the political angst that is felt so intensely by surgical faculty and surgical residents alike.
The arbitrary choice of adopting 80 hours was picked out of a hat, whereas if anyone had asked, 90 hours or 92 hours would have been sufficient and might have enabled surgery to continue to deal within its cherished tenets concerning continuity of care. Eighty hours became a foxhole to be defended against all onslaughts. So, in the real world, the 80-hour work week represents a complete denial of the value system of U.S. surgery, denial of continuity of care as a basic tenet, and denial of professionalism, coming cynically at a time when professionalism is one of the six competencies that the “competency movement” has busied itself with. A professional is a person who gets the job done no matter what the temporal restraints. Temporal restraints have no place in the definition of the profession. But, alas, it appears that they do.
One of the most interesting aspects of this arbitrary 80-hour figure is how it has upset senior surgical residents, who understand their responsibility to patients and who acknowledge that the privilege afforded to surgeons by society to assault (in a very real way) a patient carries with it a responsibility as part of the following unspoken contract: If I assault a patient I have a responsibility to that patient and their family to see him or her through 24 hours a day, seven days a week. Only I know how pleased I was with the anastomosis, so if on the sixth postoperative day, the patient complains of sudden abdominal pain and a high fever, I know the anastomosis has blown and what I must do. Until recently, the system had evolved to the point where one could fulfill that responsibility, absent extraordinary circumstances, with a team of well-trained residents, within 92 hours weekly. I do not know whether future senior surgical residents, having trained in an 80-hour week, will feel the same upset at being deprived of the ability to care for a patient in continual fashion. Will they miss this type of care? Or will they not even think that it is abnormal or unusual to not be allowed to give it?
Another aspect of the schism in medicine, one that has influenced the decision for an 80-hour work week, is about moonlighting. We all know about medical school debt. We all know that in some cases medical school debt is so crushing that it interferes with the ability of individual residents to pursue further training in subspecialties of their choosing. In a surgical program, the two years in the laboratory enable residents in an academic program to put a real dent in repaying medical school and college debts and even enable them to purchase a home for the last three to five years of training. However, moonlighting's role in the schism concerns the time that residents spend on the clinical service. The purpose of a residency is the training of a professional. It is education. It is not moonlighting. One can't be blind to the fact that moonlighting has also driven the push for an 80-hour work week. It is also clear that the view of moonlighting by surgical residencies is fundamentally different from that of other residencies. Independent of residents’ contracts it is clearly understood on most surgical services that while a resident is in the clinical years, moonlighting, except under very special circumstances, and with the approval of the program director and the chair, is counterproductive. This is not the case in most other residency programs in medical centers that I am familiar with. There may be exceptions, but I think I have described the general rule.
However, one should not lose sight of the fact that the 80-hour work week, moonlighting, and any of the other ills that lay at our feet are basically decisions that have been imposed on us by society. Continuity of care is a principle disposed of by our increasingly disposable society. If we surgeons and other physicians had a case to make, we have not made it effectively. Whatever the reason, we have not insisted that continuity of care is important, that it is the basic tenet of care, particularly surgical care, and that it is essential for patient care. I don't know why we did not make this case, but we didn't. The fact remains that the members of the surgical community feel great angst because their perceived role—as the last compleat physicians devoted to patients without regard to time—has been denied. They have been defeated by the temporalism that has unfortunately crept into medicine over the past 30 years.
Will society finally realize the loss of continuity of care and perhaps regret it? I do not know. But if society does realize the loss, it may blame physicians. And if it does, for once it will be correct.