Working 9 to 5

There are restrictions on work hours in residency that have been in place for about five years.  We are allowed to work eighty hours a week with no more than thirty hours in a row. There are other restrictions, but those are the biggies. Going over the legal hours can get your program in quite a bit of trouble; they can even have their accreditation revoked.

Old timers grumble they worked far longer hours than that when they went through residency.  They are absolutely right.  They did work longer hours.  

However, the patient population has stayed the same or increased since then.  The surgeries and treatments have become far more complex.  Back in the day, we only had aspirin to treat a heart attack.  Now we have an entire protocol of medications and interventions and guidelines that require we have a door to catheterization time of less than 90 minutes.  In essence, the amount of work a resident does now has easily doubled and probably tripled since the 1950s while the amount of time we have available to get that work done in has shrank.

This puts current residents in a tricky position.  We have to get the work done.  It is difficult to darn near impossible to get the work done in 80 hours sometimes.  There are times when we might be quite a bit closer to 100 hours than to 80.  We are told that we have to be honest on the hour logs.  Then in the next breath we are told that we have to make sure we are under 80 hours on the log.  We don't want to get our program in trouble.  We don't want to break the rules. We are stuck in a situation where there is no clear solution that ends well for us.

So what is a resident to do?

Lying about hours is unethical.  Residents know it is wrong.  It reflects poorly on our profession and our integrity.  We don't feel good about it.  We don't want to do it, but no aegis is being offered.  Something must change in the culture of medicine, particularly in the culture of surgery.  We are under an obligation to our patients to provide them the safest care within our capabilities.  Operating with slowed reflexes and blunted decision making is unconscionable.  Getting a program suspended by refusing to lie about  hours is unacceptable to superiors.  The blame will immediately fall on the shoulders of the resident who was honest about their hours - not on the superiors who are responsible for getting the resident out on time and the culture that caused the resident to be stuck in the hospital long past the deadlines.  The resident takes the fall.  

Take for instance this cautionary tale told to me.  The person in the story has asked me not to identify him/her.  He or she is currently trying to find a program willing to accept damaged goods.

This resident in a surgical program in the west got tired of lying about his or her hours. He or she decided to truthfully record every hour he/she was working.  He/she turned in the Medicare time card to his/her superiors at the end of the month.  He/she was immediately called in and accused of lying about the hours.  The superiors insisted that he/she could not possibly be working that many hours since the other residents were reporting right at 80 hours.  He/she told the superiors that the other residents were lying, just like he/she had been before. He/she also explained to the superiors that they could look at the charts and records to verify that he/she was in the hospital writing orders, admitting patients, operating, and writing notes during the times he/she had reported. The superiors got blustery.  They got upset and told him/her that he/she was a danger to the program not being on probation.

Then they fired him/her for falsifying records.

So I ask you all - what's a resident to do?