This is the first of two perspectives on whether FACEMs should work night night shifts, for the second, see Michelle Johnston’s ‘FACEMs at Night: A Mattress Stuffed with Flaw‘.
My father, an active general surgeon who has been in practice for almost five decades often recounts stories of “the good ‘ole days” when it was interns and junior residents who cared for patients most of the day. Supervising physicians were uncommonly found in patient care areas (except the operating room). Residents made critical decisions, often without the necessary training, and they and their patients lived (or died) with them. This system makes for amazing stories and experiences and surely has shaped him into the physician he now is.
It’s with this background that I read the pro (Runciman 2014) and con (Markwell 2014) editorials in Emergency Medicine Australasia discussing whether FACEM certified consultants should expand their coverage of Emergency Departments from 60% to 100% coverage. Essentially, this begs the question of whether board certified physicians should work overnight with their trainees. It would be impossible for me, an American, to give a reasonable opinion on the matter since I neither live nor work in Australia. However, I thought it would be helpful to give a perspective from EM in the states as it was less than 20 years ago that we went through the same discussion and debate.
The story in the US starts with the Libby Zion case in 1984. Although many physicians know this story, it’s worth a review. After her death, New York State worked to enact a law (widely known as the Libby Zion law) to limit resident work hours to 80/week. Along with this, forward thinking EM physicians also recommended that physicians supervising trainees in the Emergency Department should have a minimum of three years of training in Emergency Medicine with the intention to become board certified. In April 1994, The Josiah Macy Jr. Foundation created a panel to give recommendations on what level of training should be required to provide emergency care. A New York Times article published comments from leading EM physicians at the time including Dr. Lewis Goldfrank.
The argument at that time against 24/7 board certified (or board eligible) EM physicians was similar to those detailed in the current editorials: working night shifts would be disruptive to academics, trainees wouldn’t learn as well because of the security blanket etc. Interestingly, there was less of a debate centered on burnout and physician satisfaction.
Ultimately, the decision to staff EDs with board certified/eligible Emergency Physicians round the clock came down to what was believed to be best for the patient. Who would I want to take care of my mother should she fall ill in the middle of the night? Of course, this is a zero-sum game. If we add 24/7 coverage, something else must be sacrificed. I think it’s easy to argue that coverage at night from trained Emergency Physicians is far more valuable than having the same consultant during the day. Why? Because while we in the ED work 24 hours a day, many of our subspeciality colleagues do not. Getting a consultant in ENT or orthopedics is considerably easier during banking hours than at 3:00 am. So what we actually need in the middle of the night, is the ED physician who has experience to handle anything that comes in without back up.
In the US, the motto of EM is anyone, anywhere, anytime. Training and patient care has benefited from the presence of board certified physicians around the clock. Do trainees still learn by doing? The answer is definitively yes. Is it the same as it was 50 years ago? No. But patient safety is improved. There is ample room for middle ground. Consultants can be present without holding the residents hand but rather allowing them to run the show with expert supervision close at hand. None of us are asking to return to the days of the “Wild, Wild West” when interns ran the roost. The question really is what sacrifices need to be made to move towards 100% coverage and are they worth it.
I’m interested to hear your thoughts.
References and Links