Miércoles 28 de Septiembre de 2005, Ip nº 128

Your Intern Today Is Both Sleepy and Bored. Feel Better?
Por Peter C. Beller

Josh Bedwell was deep into his third year at Mount Sinai School of Medicine before he got up the nerve to ask a resident for permission to go home. After 7 a.m. rounds and a lunchtime class, Mr. Bedwell often found himself stuck at the hospital with nothing to do.

"You sit there until the resident is like 'Oh, you're still here? You should go home.' That gets really old," said Dr. Bedwell, 25, now a surgical intern at Beth Israel Medical Center.

While sleep deprivation and long workdays are deemed rites of passage for medical students, there is growing concern among medical educators that students may be spending excessive hours in hospitals doing work of little educational value, to the detriment of their education and health.

In a recent survey by the American Medical Association, one in four students said lack of sleep had put them in physical danger and one in six reported having or nearly having a car accident because of sleep deprivation. Two-thirds said fatigue might have affected their learning.

As a result, medical schools and the bodies that set policy for medical education are debating whether medical students should have strict guidelines similar to those that limit the hours medical residents can work.

Many schools have started to monitor how much time students spend in the hospital and what they do while they are there, and some have instituted formal policies.

At the University of Chicago's Pritzker School of Medicine, policies enacted last year require that third-year students' on-call duties end at midnight, so they have time to do patient write-ups, discuss their observations with residents and still get home to study and sleep before morning rounds.

"There was a lot of anxiety on the part of students as to when they could go," said Dr. Holly Humphrey, dean for medical education at Pritzker.

Faculty members were also confused about when to send students home, and sometimes had trouble keeping track of them, resulting in "dramatic stories of students being in the operating room and no one realizing how long the students had actually been in the hospital," Dr. Humphrey said.

The rules also recommend against assigning new patients to students after 10 p.m., and they also grant holidays off.

Under a policy adopted several years ago, surgical faculty members at Northwestern University's Feinberg School of Medicine are told not to ask students to arrive before 5:30 a.m. or stay later than 7 p.m., except when on call, which is at most one night a week, said Dr. Raymond Curry, executive associate dean for education.

The school monitors compliance by asking students on evaluation forms if they were kept beyond those hours.

Responding to concerns, the Liaison Committee on Education, which accredits the nation's medical schools, amended its standard last year to state that in general, students should not work longer than residents.

This year the committee began asking institutions for information on their work-hour policies, an indication that formal rules will probably become a requirement, said several school administrators, including Lynn J. Romrell of the University of Florida College of Medicine.

The questionnaire was enough to convince Dr. Romrell, associate dean for education, and his colleagues to adopt a policy in May that, among other things, guarantees students an eight-hour break between clinical shifts.

Although concern over long workdays is not new, the adoption of nationwide rules in 2002 limiting residents to 80 hours a week on average and 24 hours consecutively raised fears that students might be asked to pick up some of the slack.

There is evidence that, with their teachers' hours severely restricted, students are sometimes being asked to perform duties previously handled by residents during the clinical rotations that usually make up the third year of medical school.

"Programs have responded to guidelines by making changes to residents' schedules without appropriate staffing, so some of the work has been put onto medical students," said Dr. Brian Palmer, who was president of the American Medical Student Association until his term expired in May.

A study by the association found that nearly half of all students said they finished paperwork for residents who were bound by work-hour regulations, and a quarter reported finishing clinical work for the same reason.

"If they're being used as ancillary staff to finish the work, that's not a meaningful educational experience," Dr. Palmer said.

The responsibilities of medical students and medical residents differ significantly, since students' main objective is to learn while residents are practicing doctors on salary. While students generally spend the second half of their four years in school doing clinical work, they have not earned degrees and cannot order treatments, prescribe medicine or perform procedures on their own.

Among students, the menial but necessary tasks commonly referred to as "scut work" are a favorite gripe. Scut work ranges from writing up charts and retrieving lab results to getting coffee or dinner for residents.

"The thing about scut work is it's highly, highly resident-dependent," said Dr. Bedwell, the Mount Sinai graduate. Although he was rarely saddled with scut work, he said "certain residents were known to scut out their students a lot."

Seth Krantz, a fourth-year student at Northwestern, said scut work bothered him more than long hours. He contrasted Northwestern's surgical rotation, where close attention is paid to keeping students involved, with obstetrics.

"The hours are similar, but I feel people are just more exhausted on obstetrics, said Mr. Krantz, 24. "All it is is just writing notes. There's really not a lot of time where patients are discussed."

A third-year student at Duke University Medical School, who asked that her name be withheld, said she was commonly asked by surgical residents to carry books, buy coffee or fetch keys.

"Most people will have no problems doing scut work for their own patient," she said. "The question comes in when you have to do all that stuff for patients you're not taking care of."

Duke has no written policy limiting student work hours, and Dr. Edward Buckley, an associate dean at Duke, said surveys of students leaving their clinical year did not indicate a problem.

Even at schools with formal policies, students are often unaware of them and reluctant to report being overworked because of peer pressure and the fact they are graded by their residents.

In the A.M.A. study, three-fourths of students said they would not be comfortable reporting excessive hours.

"I think students are very conflicted about that," said Dr. Peter J. Katsufrakis, associate dean for student affairs at the Keck School of Medicine at the University of Southern California, which began surveying students about their hours this year. "I think sometimes they might assume, well, this is part of just being a professional, when it's not, it's abusive."

There is resistance, though, to imposing tougher restrictions. Several doctors, including some who favor tighter rules, expressed a common fear that students could be deprived of valuable experiences. A common hypothetical offered was a student attending to a woman in labor only to be sent home just before the baby is born.

Dr. J. James Rohack, who was American Medical Association chairman until May, said that concerns about student fatigue were valid but that evidence of a problem was needed before the organization should recommend specific restrictions.

"Medicine is a service industry, a profession that is not 8 to 5," said Dr. Rohack, a cardiologist. "Patients get sick on Christmas Day. Ditto 2 o'clock in the morning, and as a physician you need to be able to take care of them. Do physicians put in long hours? Yeah, they do."


  14/09/2005. The New York Times.