Preparing physicians for the real world

The current situation for trainees reflects tensions among needs for timely and adequate exposure to clinical experience, opportunities to attend — and benefit from — formal education sessions and provision of 24-hour coverage, as well as the priorities of health care budgets. Self-management of fatigue may be an important but unstated aspect of physician training. However, increasing sleep deprivation is associated with deterioration in performance for all human beings1 and the occurrence of errors2 and adverse events3 in health care. Discontinuity of care also increases adverse events.4

But is the reality of professional life for physicians, as described by John Acres, a desirable reality that we should be striving to sustain? In our study5 the average departure time of staff intensivists was after 9 pm, they were away from the unit for an average of 9.5 hours per day, they returned overnight every fifth on-call day, and they had contact with on-call, in-house physicians once or twice each night. With continuous on-call periods of 3 to 4 days, the potential for sleep deprivation and fatigue among these staff physicians should not be discounted, but any fatigue-related effect on patients was probably counterbalanced by the benefits of continuity. The “best” practice pattern has yet to be defined6 but it requires balancing a variety of factors related to continuity of care, fatigue and physician well-being.

In short, the final answers to the broader question raised by Acres are not yet in. Diverse and potentially competing interests will make resolution of this problem particularly challenging. Given the magnitude of the changes that will be required, careful evaluation is warranted before expensive but imperfect solutions are put into place.

Christopher S. Parshuram Department of Critical Care Medicine Hospital for Sick Children Toronto, Ont.