The New England Journal of Medicine published a piece this past week entitled “An Elusive Balance — Residents’ Work Hours and the Continuity of Care“. The author discusses the tension between adequate learning for physicians in training and the challenges of abiding by the current 80-hour work week (driven by the hope to reduce medical errors due to fatigue).

The article discusses the multiple “hand-offs” of patients that occur between residents. This “handing off” ritual is also known as “sign out” and is arguably one of the more difficult aspects of training.

By the time I became an intern, the 80-hour work week was in effect and thus, I am not familiar with the era when Giants Roamed the Earth, when Residents Plodded Uphill Both To and From the Hospital During Monstrous Blizzards Wearing Only Thin Scrubs and Worm-Eaten Clogs After Spending 137 Consecutive Hours in the Hospital.

As a member of the Younger Generation, I find the 80-hour work week frustrating because of “side effects” like the ridiculous amount of signing out we do. (This is not to say that I want to work 80-hour weeks, particularly since so many of those 80 hours are spent fighting bureaucracy rather than in patient care, but that’s another issue….)

One of the greatest aspects of becoming an intern (and thus a “real” doctor) is taking ownership of patients. The responsibility of “knowing” your patient is both humbling and exciting. This is the primary reason why I absolutely do not miss being a medical student. Interns possess the most data: They conduct the interviews, perform the exams, order the tests, share the results, and have the most contact with patient. Though they may not know exactly what to do, they’re often the ones actually doing it. There’s an element of intimacy to this. This intimacy is what we refer to as “caring” for the patient.

In theory, “signing out” provides a thorough yet succinct summary about patients so that while you are out of the hospital, the person who is covering for you has some working knowledge about your patients and can provide care in the interim.

In practice, “signing out” usually consists of handing over several sheets of paper with minimal (but deemed important) information about your patients and reviewing very, very briefly What Needs to Be Done (particularly should Something Bad happen—yes, we try to be clairvoyants).

This is frustrating, particularly when someone is “sick sick”.

Most of us in medicine want to do good by everyone and, in my anecdotal experience, most of us have purposely broken the 30-hour shift and the 80-hour work week rule for the sake of patient care—because of the aforementioned intimacy. Part of it may be the hackneyed “savior” fantasy (and it is absolutely a fantasy!); part of it is honestly efficiency. We want to know the results of the test we ordered; we want to speak with the patient’s outpatient provider to get more information. We also know it is easier to tie up the loose ends ourselves rather than sign them out to someone else who is unfamiliar with the patient.

We also know that the person who is receiving our sign out is also covering upwards of forty patients (because we’ve all done it, too) and thus, we try to “tuck everyone in” (this entry is more about medical slang, apparently) before we go. It’s highly anxiety-provoking to provide care for a Crashing Patient that you don’t know (and when there’s no time to review the chart). We try to limit that experience for our colleagues.

A few people just don’t leave “good” sign out. They omit highly significant details either because they forgot to write them down or they never asked for them.

Then there are the few people that you do not entirely trust and yet, they will be covering your patients. Even though you may leave explicit instructions about Things to Do, you are not totally confident that they will actually Get Done. Or they will do Things You Never Asked to Be Done.

There is something about closely following a patient’s course for a longer period of time. Observing this longer-term progress (or lack thereof) is educational, likely beneficial for the patient, and, because information isn’t changing hands so frequently, potentially creates less errors (there is no data to support or disprove this). However, sleep deprivation is not educational, is not beneficial for the patient, and does promote errors.

And this is also the appeal of outpatient care—there is continuity. The “intimacy” is present and because (ideally) only one physician is managing this one patient’s care, she is (hopefully) less like to commit errors. (Outpatient care, however, does not involve acute medical problems and, often, inpatient work is reduced to the task of keeping someone alive.)

I don’t have any great solutions to this dilemma. Psychiatry is also a field where this issue doesn’t entirely apply: Most patients change (grow, heal, get better, whatever verb you want to use) on an outpatient basis; usually, the goal of inpatient hospitalization is to get patients enrolled (and invested in) outpatient care. It is naive to believe that a patient will be cured of all that ails him after taking a medication for five days while in a hospital.

Shift work doesn’t resolve the “sign out” issue. Having residents to live in the hospital is antiquated and is not a sacrifice anyone—residents and attendings alike—will make. Perhaps residents could have less patients on their panels at any one time, but that would limit the amount of experience residents receive. Would people agree to even more years spent in training? Are there enough doctors in training to pull that off?

In the meantime, we try to teach each other how to provide adequate sign out… and we express our deepest gratitude to our nightfloat and on-call residents who provide excellent care for our patients while we are gone.