I just finished an internal medicine residency where we had night float on the weekday calls but still had 30-hour shifts for weekend calls. The beauty of night float is that you do get to go home and sleep in your own bed. However, as the primary team inheriting patients from the night float team the next day, there is often either duplicate work or overlooked details, even with a good hand-off. You never know the patient better than if you were the one doing the admitting. Thus, accomplishing tasks on patients after hand-off is much less efficient than if those tasks are done by the admitting team.
During residency, I quickly learned that I do not like being sleep-deprived (who does?). I become cranky and mean and also become prone to illness (I caught influenza twice—A and B—during my inpatient months last spring). While the idea of decreasing the sleep deprivation of a 30-hour shift with either a 5-hour nap or a 16-hour shift is appealing, I think the logistics of accomplishing this without dangerously compromising various aspects of care will require a great deal of creativity. The obvious ways of bringing this requirement on-line have obvious flaws: Is there a team that only works for a 5-hour shift? Will interns and residents take turns napping? What if the intern needs the resident while he or she is taking a 5-hour nap? Will there be 2 more episodes of hand-offs during the 30 hours? How realistic is to expect people to sleep on command in the middle of a shift? What if your bunkmate's pager keeps beeping away?
While discussion and recommendations for more duty hour restrictions may be good, what we really need is more money and support devoted to “scut.” As patients become more complicated, and there is pressure to discharge people faster and earlier, there is more work to do, but less time to do it. Decreasing non-educational, non-physician level scut by paying more than lip-service to acquiring additional ancillary services would go a long way towards successfully getting residents home sooner. There are a few problems that money can solve. More social workers for discharge planning, more phlebotomists for blood draws, more translators available quickly, and more people available to transport patients to tests on short notice would dramatically relieve residents of time-consuming burdens. The new-found time could be used to sleep, teach, be taught or go home a little more. Of course, knowing where to find the money to pay for these ancillary services is above my pay grade.
There are going to be times when not violating the duty hour restrictions will be unsafe. In these settings, there should be no penalty for a violation. For instance, I would not want to be penalized if I am spending hour #31 helping transition a complicated, sick patient to the MICU, but I would be unhappy spending that hour waiting on the phone making a hospital follow-up appointment or trying arrange home oxygen delivery. As postgraduate education systems increasingly embrace duty hour restrictions, I believe that some flexibility must be built in.
DISCLOSURE STATEMENT
The author has indicated no conflict of interest.