A day too long: rethinking physician work hours.

The long hours worked by resident physicians, and the mandated reduction of those hours in recent years, are widely known. A related issue--perhaps an even more important issue--has so far received less attention. This was brought home to me one day, many years after my residency was over, during the care of an infant with a rare and frequently fatal birth defect in the newborn intensive care unit of the teaching hospital where I am an attending neonatalogist. My day began around quarter after seven in the morning. I started by taking a look at the x-rays from overnight, then examining some of my patients before rounds. At eight o'clock I began rounding with my team (one of three in the newborn intensive care unit), which consisted of a neonatal nurse practitioner, two pediatric residents, a neonatology fellow, and several nurses. We discussed the recent events, current status, outstanding problems, and plan for each patient. Once rounds were done, the remainder of the day was filled with more physical exams, speaking with parents and consultants, teaching, documentation, and supervision of medical management and procedures for sixteen intensive care patients. The team regrouped at two o'clock in the afternoon, as is our daily practice, to review the x-rays from the previous twenty-four hours with a pediatric radiologist. I was on call that night, so at around half past five, I took sign-out from the attendings for the other teams. I made it home by half past six, but at ten o'clock that evening I received a call that a child with a prenatal diagnosis of congenital diaphragmatic hernia would soon be delivered, so I headed back to the hospital. Diaphragmatic hernia is a birth defect that essentially consists of a hole in the diaphragm. During gestation, some of the abdominal contents (stomach, intestines, sometimes liver) migrate through the defect into the chest. This is usually associated with some degree of underdevelopment of the lungs (pulmonary hypoplasia). Sometimes the pulmonary problems are so severe that these newborns cannot survive despite all of our efforts, and even among those who do survive, the first hours and days are often quite difficult. The child was born at about one o'clock in the morning. The team did a good job in the resuscitation and management of the patient, who, as feared, was very sick from the outset. The resident, nurse practitioner, nurses, and respiratory therapist all acted quickly and skillfully, ably directed by the neonatology fellow. My role was to oversee their effort and provide back-up and guidance as needed. If they could not get the endotracheal tube in quickly, it would fall to me. If they were unsure how to prioritize the management, or optimize the mechanical ventilation, I would tell them. The fellow in this case, nearly finished with her neonatology training, did a fine job, with only an occasional suggestion or redirection from me. As the attending, though, it clearly fell to me to decide if and when to stop, which we did before the sun came up. And it fell to me to explain to the parents that we were unable to save their daughter. Once the dust settled, it was time to begin my exams. Then came rounds, and essentially a repeat of the day before, supervising the care of the same sixteen intensive care patients. At two in the afternoon, we gathered to review the films. As each x-ray came up on the screen, a resident or practitioner provided a brief presentation of the case, and the radiologist gave his reading. After going through several films, a remarkable image appeared on the screen, and the room was silent. Many in the room recognized the pattern of intestinal gas in the chest as being diagnostic for diaphragmatic hernia, but no one else knew the case. The fellow, residents, and nurse practitioners who had cared for this child through the night had long since gone home. When I was a first-year resident in the early 1980s, I was asked by an attending what I thought of the residency program. …