Question 1 Confusion: an argument for “No”

If Question 1 merely restricts the number of patients a nurse is expected to care for, why are so many nurses urging you to Vote No on 1? Some thoughts from a former surgical resident reminiscing about early implementation of the 80-hour work week… and why an inflexible law regarding patient care has no business at the bedside.

In 2001, I began a General Surgery residency at a well-known hospital on the Upper East Side. At that time, many programs were attempting to enact an 80-hour workweek for surgical trainees, ahead of the ACGME*-mandated law that would be enforced after July of 2003. During orientation, we were warned sternly (and with more than a modicum of sneering derision from our Chief Residents) to keep track of our work hours. After all, they had put in 110-hour workweeks for years without complaining. As they passed out the little cards, we knew they already thought we were “soft.”

Certainly an 80-hour workweek is not worthy of you’re-so-lazy eye rolling. And here is exactly how much we were “allowed” to work in the words of the ACGME:

“The new requirements include an 80-hour weekly limit, averaged over 4 weeks; at least 10 hours of rest between duty periods; a 24-hour limit to continuous duty plus up to 6 more hours for continuity of care and education; 1 day in 7 free from patient care; and in-house call no more than once every 3 nights averaged over 4 weeks.”

So, you know, easy peasy (eye roll). If you do the math, you’ll notice a 30-hour day was well within the rules, and for us, didn’t include the extra hour of travel time to an outside hospital rotation. In any case, these work hour restrictions did not make residency easier… because no one was working that little.

After I turned in my first little stack of time cards, with faithful tracking of all hours I was in the hospital or home answering the beeper (and often going back into the hospital), the assistant to the Chief of Surgery called me at my apartment.

“Britt, we need you to come in to talk to the boss about your time cards.”

“Did I do it wrong?”

“Well, you wrote that you are working 100 to 110 hour weeks. We need to discuss with you why you are unable to finish your work in a timely fashion.”

“Oh! I definitely did it wrong. I’ll hand in new ones tomorrow.”

I thought they were going to fire me. Eventually, and probably before the actual law rolled out, my program figured out how to have residents actually working less instead of just lying about it. One way programs tried to solve the work hour issue was to assign a resident the “night float” beeper. After each service finished evening rounds, they would arrange to meet with the Night Float who would hold its beeper and list of patients until rounds the next morning. It’s a great system, unless you are Night Float to a program with six services.

On a slow night, there were still probably 30-40 patients scattered over a handful of pages with instructions to check on a few who had gotten out of surgery late, or who needed labs ordered or drawn. Busier nights, which were far more frequent, meant running from floor to floor to answer questions about patients I might have only learned about six minutes before and whose chart I’d never seen. It was such a night when a patient’s daughter insisted she speak with The Doctor about her father who had just endured a rather messy gallbladder removal. There was a bile leak requiring a drain, and maybe this hadn’t been explained well by the surgeon, or maybe this was an entirely different daughter than the one in the PACU, or maybe Dad oozing green was just plain alarming. Either way, this woman wanted answers. Now. From The Doctor.

Enter Night Float Britt, The Doctor. The intern assigned to the service had “signed out” to me before this patient landed on the “floor.” This Dad wasn’t even on my list. I introduced myself to the anxious family members and confessed that I was the Night Float and would need a minute before I could answer questions.

“So you’re telling me that you are the physician in charge of my father tonight and you have no idea what is going on?”

“Yes. But I promise—“

“SHAME ON YOU.”

I’ll never forget it. Shame, indeed. She wasn’t wrong. The system was wrong. In order to adhere to work hour restrictions, the very people who were in the operating room with her dad were required to leave. Ultimately, I was able to flag down a Chief Resident to explain the green oozing and by the end of the night was on good terms with the daughter. But there were many times I watched residents fudge the work hour rules not only because it was in the best interest of the patient, but also because we cared about the patient and we were there to learn. And that night, strictly following restrictions designed to protect us, an intern was unable to follow through communicating with the family and trust between patients and providers was compromised. That night, following the rules wasn’t necessarily the right thing to do.

Patients with their unpredictable diseases cannot be expected to adhere to even the most well-intentioned timetable, nor should their doctors be forced (by law!) to abandon them. It is called the Art of Medicine for this reason, and the quality of its delivery is diminished by inflexible rules regarding the hours it can be practiced. Ask any doctor about a pivotal moment in her training and I’ll bet 80% of the time it happened during hours that would be considered “overtime” in any other profession.

In Massachusetts on November 6th, citizens will be asked to vote for a similar sort of restrictions for nurses. Though limiting the number of patients any one nurse should be allowed to cover sounds reasonable, all of the best nurses I know want you to vote against it. (And I know many, many nurses.) Voting NO on 1 means we trust that nurses and their administrators know the limits of their services. No on 1 means we have our best patient advocates, our nurses, deciding how to allocate care with informed adjustments. No on 1 might mean fewer family members saying, “Shame on you.” Patient load restrictions intended to protect our front-line care providers may undermine their judgment and hamstring their talent, instead. And you can go ahead and make comparisons to pilots or daycare workers whose profession is certainly safer for law-mandated restrictions, but when it comes to caring for a vulnerable human at the bedside, well, it’s just different.

Admittedly, the 80-hour workweek was ultimately good for surgical residents. Once they worked out the kinks, it was shown to improve quality of life and decrease “burnout” without affecting the quality of care delivered. However, there were many studies that revealed how restricting hours had a negative impact on metrics of “continuity of care” and contributed to a “shiftwork mentality” in a profession that had always prided itself to condemn. But with a bit of “give” in how work hours could be adjusted to be in compliance with ACGME guidelines, surgeons in training still have the option to see the aortic aneurysm repair to completion, check an x-ray, or even say goodnight to a patient and his family– because mandated work hours can be averaged over time.

However, a “Yes” on 1 has no such leniency and would (rather paternalistically) deny nurses any autonomy over their patient load. This is the most worrisome aspect of the ballot question because it reduces humans to mere numbers. Never included in examples around Question 1 is how a nurse with a patient that requires all of his time, faculties, patience, and skill might be asked to take on a few more because his quota is not filled. Or how the ER nurse who knows your “frequent flier” asthmatic son best might have to hand him off because the kid with a sports form that needs signing “counts” as a patient. Also, preliminary data regarding patient load-limiting for ICU nurses has shown that care was not improved after implementing restrictions. Meanwhile, both sides will agree that enforcing strict nurse staffing ratios will be difficult and very, very pricy.

Box checkers do not belong in medicine. I am wary whenever people who have never taken direct care of a patient have power over how it is practiced. I hope I have illustrated here how the argument is nuanced, and why there is so much confusion over Question 1. Some limits are good, even necessary. No one wants to, or even can sustainably, work 110-hour weeks. But anyone who has taken care of a patient in any medical capacity knows that blanket, one-size-fits-all restrictions go against the human aspect of doctoring, nursing, healing. The only people who should be calculating nurse to patient ratios are those delivering the care, and it’s a delicate balance that changes daily, hourly. At times a single patient is too much, other times 8 means you still have time to pee. I worry that strict mandated law will undermine the “art” in medicine. And here, in Massachusetts, and especially in Boston, we can trust our nurses to know how to get the work done responsibly and safely without a law telling them how to do that. Here in Massachusetts, our nurses anything but “soft.”

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Posted on FB by my favorite nurse… who is voting No on 1.

*Accreditation Council for Graduate Medical Education