Something peculiar happened during my first inpatient oncology rotation as a senior resident. At exactly 6 p.m., the on-call intern stopped admitting patients. She stopped receiving pages about new patients in the emergency department, patients being moved out of the medical intensive care unit and patients being transferred to our team from outside hospitals. A short while later, after she “signed out” her patients to a peer, she stopped receiving pages altogether. Instead, she went home and had dinner.
In July 2011, medical internship changed in a profound way. Driven in part by the 2008 Institute of Medicine report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, the Accreditation Council for Graduate Medical Education (ACGME) implemented new duty-hour regulations for residency programs across the country. Under the new rules, interns are no longer able to stay at the hospital for more than 16 hours at a stretch, thereby eliminating the lengthy overnight call shifts that many physicians had considered the sine qua non of medical internship. The regulations are an extension of sweeping changes introduced in 2003, when the ACGME enacted duty-hour standards limiting overnight call shifts to 30 continuous hours and the resident work week to 80 total hours.
While aspects of the ACGME proposal were well received when first unveiled in July 2010, the specific restrictions on intern shift duration were not as popular. In a nationwide survey of residency program directors published in the New England Journal of Medicine, 79 percent of respondents disagreed with the proposed 16 hour limitation for interns. A survey of house officers across medical specialities suggested that residents similarly shared concerns about the new restriction, with many “expressing alarm that education and experience will be severely limited by the lack of traditional 24-hour call periods.” Nearly half of responding residents doubted that the changes would have a positive effect on their education.
Why the skepticism? I suspect that anyone who was an intern prior to 2011 could readily answer this question. On a typical day/night at the hospital as the on-call intern, I observed the often unpredictable course of unstable angina and acute leukemia. I was there to see the normal results of the ultrasound I had ordered for my patient with suspected cholecystitis and reconsider my differential diagnosis for her abdominal pain. At the bedside of a patient with congestive heart failure, I assessed whether any of my interventions eased his breathing. Although physically and mentally challenging, the long call shifts were my chance to learn, experiment and struggle – the sort of critical, immersive experience I needed to build my basic competency as a physician.
Unfortunately, the extended call shifts of internship have been replaced by shorter day and night shifts and more frequent sign-outs among interns. Certainly sign-outs are an integral part of medicine for trained physicians—no one can or should stay at the hospital long enough to provide patient care from admission to discharge. However, increased sign-outs among trainees may come at a significant cost. For the on-call intern, does hearing about what happened to a patient overnight have the same educational value as actually being at the bedside? For the night intern, is it possible to glean the deeper meaning behind the list of seemingly mundane checkboxes on the sign-out for a patient he or she has never met? Can medicine really be learned from the completion of tasks such as “diuresis goal: two liters negative” and “follow-up midnight electrolytes”? Beyond the educational compromises, I fear that increased sign-outs could also adversely influence the culture of medicine. Rather than being a necessary evil that allows interns to go home and rest when they are not on call, will the sign-out become an end in and of itself, a daily ritual that symbolizes the endless passing of responsibility for patients back and forth between physicians, none of whom can truly call themselves a patient’s doctor?
In place of making on-call interns sign out and go home, perhaps we should let them stay at the hospital but ensure that they have the support they need to effectively take care of their patients over long stretches of time. This is what I found so valuable as an intern physician, and I was reminded this year of its importance when I became the backup as a senior resident. Otherwise, the new ACGME regulations run the risk of unintentionally withholding from interns those invaluable, formative experiences that are the building blocks for a career in clinical medicine.
Sameer Chopra, MD PhD, is a third-year resident in internal medicine and genetics at Brigham and Women’s Hospital. The opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions or Harvard University.
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