Poll: Are the Institute of Medicine’s recommended restrictions on residents’ work hours good for medicine?

The Institute of Medicine recently recommended a requirement that medical and surgical residents have a minimum sleep period of 5 hours in any 24-hour work period, with a maximum shift length of 16 hours. This was a follow-up to the 2003 ruling which limited resident work-hours to 80 hours per week.

That is the focus of this week’s poll. Are the Institute of Medicine’s recommended restrictions on residents’ work hours good for medicine?

Here are the issues as I see them.

There is no doubt that fatigue impairs judgment. Residents who stay awake for more than 24 hours are impaired to a point similar to those who are legally drunk. A study compared one group of residents who slept 7 1/2 hours a day to another who slept just under one hour less. The group that received less sleep made 36 percent more serious medical errors. It seems intuitive that giving residents more rest would decrease mistakes and improve patient outcomes.

That however, isn’t always the case. Since work-hours were restricted in 2003, there are no studies that have shown any marked improvements in patient safety or outcomes. Worse, errors have arisen from the so-called “patient hand-off,” the period of communication where rested doctors replace those who are fatigued. Does increasing the frequency of patient hand-offs outweigh the benefit of better rested doctors?

Limiting resident work also increases costs, as hospitals are forced to hire more hospitalists, mid-level providers, and ancillary staff to make up for lost resident work time. For instance, implementing the new Institute of Medicine recommendations is estimated to cost an additional $1.7 billion. Are financially-strapped hospitals ready to make that commitment?

Finally, the impact on training itself has to be considered. Surgery residents are forced to do fewer cases, giving them less experience to operate in the real world. Instead of caring healers who sacrifice and dedicate themselves to patients, we are in danger training a generation of shift-work providers who punch out on the clock.

If I didn’t cover your issue, you can add it in the comments, or call into the ReachMD Listener Line at 888-639-6157 and record your comments (portions of which may air).

I encourage you to listen and vote in this week’s poll, located in the upper right column of the blog.

Please suggest future ReachMD Poll topics by emailing Poll@ReachMD.com

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  • Jerry K

    Why not just starting making modafinil or amphetamine use mandatory to all residents? It’d be a good opportunity to get some long-term, sustained-use data on some of those drugs, too. :P

  • Anonymous

    The complexity for those of us who teach physicians is how we train professionalism given the hour limitation. Is it truly professional to leave at the end of your shift when your patient — whom you have worked closely with the previous day, needs something specific one hour after your “quitting time” or should you hang around and “tuck them in”. We wrestle with this every day. If I was the patient, I know what I’d want.

  • Anonymous

    The problem is that none of these work hour restrictions apply in real life. Once you finish Residency, as an Attending there is no magical institute that will protect your work hours.

  • Supremacy Claus

    My surgeon friends complain. Recent hires are total, feminized wimps. “I can’t see this add on. I have to be at my son’s soccer game.” Thanks, IOM. New surgeons are totally wimpy.

  • Anonymous

    my solution-

    1. make residency a 40hr a week job
    2. double the length of residency training in years
    3. narrow the salary gap between residents and attendings (pay residents more and attendings less so that there isn’t such a huge jump in pay once you graduate)
    4. make a medical education cost little to no money so one comes out the other end with minimal debt
    5. eliminate the potential to “lose it all” in a lawsuit
    6. restore the public’s respect for physicians

    there. you have a profession that is respected and pays reasonably well but perhaps somewhat less than before in exchange for not graduating in 6-figure debt, not having to worry about a catastrophic lawsuit, and the career is more of a continuum rather than a limited years of torture followed by a lifetime of being “set.”

    now excuse me while i wait for hell to freeze over in the meanwhile.

  • Anonymous

    My concern is the reinforcement of an entitlement ethic instead of a responsibility ethic. How many people will just walk off and turn the beeper off figuring the “they” of the hospital staff will find someone to cover?

  • Anonymous

    I will happily turn in the beeper at the end of my shift. My family comes first over my patients. That is the only morally defensible position if you have a family. Your family should come first.

  • Anonymous

    Anon 11:57:

    What you are advocating is abandonment of professionalism if you happen to think your reasons are good enough. As it happens, yours is not the only morally defensible position to take, whether you have a family or not. And what exactly justifies the idea that your family “should come first,” besides bald assertion? Please explain what philosophical verity makes that the case. Or is that your foundation?

  • erawka

    In response to “My solution,”

    The problem with that solution is that so many hospitals are already in pretty serious debt, and unfortunately, it does cost quite a lot to train residents. Limiting the hours of work that residents give, limiting their tuition, increasing their pay, and extending their training period will only add to already sky-high costs, and has no tangible benefit for the teaching institution. Except happier residents.

    I think the solution is to simply accept more residents. Honestly, there are plenty of well-qualified medical students, and even more well-qualified pre-med students who aren’t getting into medical school in the first place. Although the institution might lose some money by training a few extra residents, it should allow for greater coverage (potentially lessening the amount of error due to shift changes), and maybe ensure everyone a few hours of sleep.

    That being said, it’s pretty clear that I do think these restrictions are a good thing, or will be in the long-run. Even if residents do get a bit of a wake up call when it comes time to practice, it makes sense not to completely overwhelm during training – when errors are already pretty likely.

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