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Hospital Resident Awareness

Written by: Attorney Micheal Gunzburg

No one knows when an injury or illness will strike. But for anyone planning surgery, it might be prudent to steer clear of any teaching hospitals in July. That’s when hospitals start training their new medical students. In mid-summer, hospitals are filled with residents, who are basically new doctors characterized by their years of experience. First years are known as interns, and second through fourth years are residents. After completing their internship and residency programs, some residents go on to become chief residents who supervise other residents, prepare their schedules and get the benefit of attending and participating in more complex surgeries. Some residents are licensed medical doctors; some are not.

In order to attract and retain good residents, hospitals encourage attending physicians (doctors who use the hospital for their patients) to permit residents to actively participate in surgeries and get as much hands-on experience as possible. Hospitals want residents to develop sufficient skills to perform these procedures without supervision by the time they finish their residencies.

Though attending physicians, who are known as attendings, are alongside residents during surgery, many things can still go wrong. Residents handle surgical instruments and perform critical procedures that have taken skilled attendings years to perfect. Hospitals require attendings who want to operate in their hospitals to submit applications for review by a credentialing committee. The committee grants privileges to attendings with the necessary skills and experience. The only way for residents to gain experience and enhance their skills is to perform surgery under the supervision of more experienced physicians.

The problem lies in the fact that when a surgeon speaks to a patient before surgery, the patient is under the assumption that his doctor will be performing the entire surgery. Unfortunately, the reality is that the attending will most likely have a resident with limited experience and skill “assisting” during surgery. But since the hospital encourages attendings to give residents hands-on experience, the resident will likely be actively participating in that surgery. If something goes wrong, the operative record rarely describes what really happened and who was responsible.

Most often, patients have no idea who is in the operating room while they’re on the table. Though residents may not have operating privileges, they frequently work alongside the attending doctors. The attendings are supposed to supervise the residents. But doctors delegate and residents relish the opportunity to perform major aspects of surgery, including making initial incisions, suturing and performing dissections.

Patients not only lack awareness of the degree to which a resident may be participating in their surgical care but are also usually unaware of how many consecutive hours this resident has been working. Under earlier guidelines, residents often found themselves working 120 out of a total 168 hours per week. The Accreditation Council for Graduate Medical Education (ACGME) determined that residents are more likely to make medical mistakes while functioning under such a grueling schedule and, in 2003, implemented restrictions limiting workweeks to 80 hours and allowing for no more than a consecutive 30-hour shift. However, according to a study conducted by Dr. Charles Czeisler, director of Harvard Medical School’s Division of Sleep Medicine, residents and their supervisors rarely follow these limits.

Even within the new guidelines, operating under these conditions can lead to major medical mistakes. A national survey of 2,737 first-year residents found that when residents worked more than five 24-hour shifts in a month, their risk of making fatal errors increased by 300 percent. Dr. Christopher Landrigan, an assistant professor at Harvard Medical School, has stated that “staying awake for 24 consecutive hours induces decrements in human performance similar to blood alcohol level of 0.1 percent.”

If 24 sleepless hours can have this effect on residents, working even longer shifts can only worsen their mental and physical condition. Yet nearly 84 percent of residents surveyed reported that they continued to work longer than permitted. Despite the rule changes, residents are still being pushed passed their natural limits and consequently endangering patients. Czeisler’s study concludes that tens of thousands of preventable injuries can be attributed to sleep-deprived residents working long hours.

As these exhausted residents gain valuable experience, they take over many of the tasks normally performed by attending physicians – unbeknownst to the patients. Moreover, the surgeon may not even know who the resident will be until the day of the surgery. None of the standard forms the patient signs mentions the fact that a resident will be performing critical aspects of the surgery. Though residents are supervised by attending physicians, attendings are not able to watch and catch everything a resident does during a surgical procedure. In fact, sometimes they react too late.

The problem is that procedures that typically expose the patient to low risk when performed by an experienced surgeon can become more dangerous when a tired resident with limited experience scrubs up. Patients tend to be unaware of this heightened risk and if a serious injury occurs, are surprised to find that a resident is at fault. It’s not until a lawsuit is commenced and the parties are forced to testify at an examination before trial that those present and the roles they played may be disclosed. More frequently, what occurs is that the hospital and attendings try to protect the residents by claiming the attendings performed the procedures, or that they don’t recall who did what during surgery. The standard operative note rarely specifies which procedures were performed by attending or resident physicians.

The bottom line is that patients have a right to know who will be taking care of them and what state of mind this person is in. Patients, already feeling frightened and vulnerable in a hospital setting, should be able to trust that there will be few surprises down the line when in comes to their surgery, recovery and overall well-being. The National Sleep Foundation found that 86 percent of potential patients nationwide would fear for their safety if they learned that their doctor had been on duty for 24 hours straight. Of those polled, more than two-thirds said they would most likely request a different physician. Yet patients don’t have this choice in the real world.

Sources: DOME: “Residency Rules” By Mary Ellen Miller

Harvard University Gazette: “Interns continue to work overly long shifts, study finds” By William J. Cromie

Harvard University Gazette: “Doctor fatigue hurting patients” By William J. Cromie

Medical News Today: “Long Hours For Medical Residents Can Result In Errors, Study Finds” By Kathleen Fackelmann, USA Today

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