The Institute of Medicine is recommending “rapid implementation” of its proposed plan to further restrict medical residents’ work hours. The plan includes a 5-hour nap during extended shifts, a strict 16-hour cap on shifts without naps, reduced workload, and more days off.
But at what price?
It seems like common sense that better rested doctors make fewer errors and contribute to better patient care, but data from several large-scale studies does not back up this belief. It is likely that any benefit gained from limiting doctors’ time in the hospital is offset by errors that arise when patient care is transferred to another physician. And data has shown that most hospital errors are not necessarily caused by resident fatigue in the first place.
And, there is the overwhelming price tag. It’s estimated that it would cost the country’s teaching hospitals about 1.6 billion dollars annually to hire substitute workers to cover for residents.
We need more research on this issue. I support the position of The New England Journal of Medicine, whose editorial last month recommended that this major policy decision adhere to the standards of evidence-based medicine and comparative effectiveness. We simply don’t have the evidence that the benefit to patients is ultimately worth the cost.
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- Poll: Should doctors apologize after a medical error?
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{ 16 comments }
Would this issue be eliminated if more residency positions were opened? It makes sense to me, at least. Having more residents would not only help alleviate the physician shortage, but it would also allow hospitals to reduce the hours worked by each resident without having to hire outside non-resident physicians.
Additionally, If residents continued to work long shifts (with naps), as they do now, but worked fewer days in the week, wouldn’t this also eliminate the transfer-of-care errors that arise as a result of shorter shifts?
Hi, I’m writing from the National Academies. We are pleased to see that conversation continues surrounding the topic of resident duty hours. We have recently released the publication in its final version and encourage your readers get a copy or read it online at (http://bit.ly/toEZQ). We hope that by reading the report it will enhance the conversation.
Best,
Zenneia McLendon
There is another parameter in the discussion: motivation. How long will young people feel motivated to work this amount of hours. I am from The Netherlands, we have an 48-hours work week (theoretically, but practically not that bad with 50-55h). Although night shifts can be heavy… I keep wondering why an ultimately human-driven profession is downgraded to “just numbers”…
Residency is intended to teach & train new doctors. Part of that training is learning how to put your needs aside and focus on your patients needs. In private practice you don’t have the luxury of taking breaks to stay refreshed. Training yourself how to push through sleepiness, hunger & fatigue are vital parts of a residents training in order to be able to draw on that experience out in the real world.
Something not addressed in this discussion is by reducing the amount of hours that residents work that is fewer patients they see and less experience treating patients and learning how to manage your case load. Would this mean that the number of years students are in residency need to be increased in order to give them the experience they are there to gain? What about moon lighting hours? If the number of patients is limited by the amount of time a resident can treat patients how do they learn to manage their own service in private practice.
Increasing residency positions in teaching programs is not the best solution. In order for students to gain the knowledge & experience they are seeking you must have a good faculty to student ratio and the patient load to provide that ongoing learning. Unlike law, medicine is highly regulated by each specialty and the training is overseen by many entities to ensure residents are taught well. By increasing the number of residency positions the quality at which these students are taught will be compromised and patients will suffer. Residency is about preparing yourself to treat patients and give the best patient care drawn from your experience, if you are limited on how you are able to treat & manage patients in residency how are you to learn to do it properly in private practice?
“We simply don’t have the evidence that the benefit to patients is ultimately worth the cost.” What about the benefit to the doctors / residents…? Perhaps allowing more breaks would promote the overall health of the doctor and their ability to cope with demands at work along with juggling a family and social life.
Wouldn’t a healthier doctor be more cost-effective in the long run? Perhaps reducing burn-out and high suicide rates among doctors?
Although American, I am so thankful I will be a resident and physician in Europe. I am thankful I will be afforded rest and time for life outside of the hospital. 37.5 hours is full-time here, and anything above that pays very well in overtime.
Although this is a complex issue, without a single “right” answer, I agree with Pieter (above) that there are other factors at stake than simply patient outcomes and finances, though these are very important.
I am a pastor to medical students and healthcare professionals, and many tell me that a top priority (especially as they advance in their training and career) is balance. It seems to me that eighty-hour work weeks do not leave much time for things such as family and other facets of life that are just as important as our careers.
Although I do not pretend to have an easy solution, I do feel that failing to consider the issue of balance from many discussions on the topic reveals our culture’s overemphasis on the value of work.
The fact that replacing residents with other health care workers would cost 1.6 billion dollars a year implies that residents are underpaid by that same amount. Cost-benefit analysis of reducing resident work hours aside, isn’t it just plain unfair to make residents work longer hours while paying them less than the market value of their services? If residents are so heavily relied upon, it seems obvious that they’re providing services at least as valuable as those provided by the other skilled health care workers who would theoretically have to fill the gap created by reduced resident work hours.
Strange that somehow they’re able to find the money to pay overtime for the RNs, RTs, Security, Housekeeping, every other Tom Dick and Harry, except for those slacker residents who only work 80 hours/week…
Who wrote this post? Is this an advertisement?
Evidence is cited in the post, but no references given. How are we supposed to weigh the evidence without this basic attribute of evidence-based medicine?
Since the rate of new knowledge in medicine every year easily outpaces the average adult’s ability to keep up with it, would not this same rationale also work for current docs? I mean, if education and learning is so important, why shouldn’t doctors just continue working 80 or 100 hour work weeks for their entire career??
Lunacy parading as tradition. Appeals to emotion (with the constant mention of some hypothetical huge price tag) over logic.
Wow, medicine must be real special to turns its nose up at the significant body of existing research in the occupational sector (we’re talking *hundreds* of empirical studies) that show that skilled workers work more badly with lack of sleep and a disrespect for normal industrialized, civilized human working conditions (the upper limit being generally something between 50 to 60 hours a week).
More research? Bah. Look at something outside of your narrow field of medicine and you’ll see plenty of research about work hours and quality of work. What doctors do is not so special that this research doesn’t apply.
Could they reduce the number of hours and at the same time decrease the salary of the residents, say to 40 hours/week and 1/2 the salary. I could then do some research/part time job for 20 hours and still end up with a similar salary.
I think you’re missing a key point: Transfer errors are correctable while fatigue just gets exponentially worse over time.
under the 100+ hour schedule you’re assuming a higher level of fatigue right off the bat.
If you’re trying to MAXIMIZE the quality of care to patients, the best way would be to focus on having physcially able residents working an adequate numbers of hours, and seemlessly switch off before quality of work fades.
The problem is we haven’t devised a way to reduce errors in communication.
Yes, the most time-saving and cost-saving practice is the continuity of care by the same physician;
;
otherwise twin tests are ordered, the re-assigned doctor will need time “again” for his own observations (b/c it is his license that is now on shift
People assume that less hours is obviously better. As is pointed out, there’s very little to suggest this is true, at least as it applies to residents. The most cited study, which led to the adoption of the 80 hour week was deeply flawed. It was meant to be a direct comparison of different schedules for interns, and supposedly showed that the interns who worked less made less errors. What wasn’t accounted for was that the seniors on the ICU service ended up doing most of the work for the short hour interns, because the short hour interns didn’t know the patients as well…
I graduated from Medical school in 1992. There were many times when internship and residency felt blatantly userous. Sometimes it reminded me of my college fraternity days and of “pledging” and “hell week”. I’m not sure what the answer is in terms of creating the better physician but I can tell you from experience that this issue, as do most, revolves around the almighty dollar. Shocker huh? Behave honorably, do what’s in your heart, be prepared and maximize your efforts in whatever system is there for you and you’ll do just fine.
I suggest that if residents are made to work 80 hours a week then the attendings should also stay in the hospital for 80 hours a week to supervise them (Because residents are not legally allowed to practice medicine independently). Doesn’t this sound fair? All in favor…
This resident work hour problem should solve by itself.
The current system of training medical graduates forces them to work long hours that ultimately deprives them of time with family, sleep and outside study time. Basically, as physicians, we’re hypocrites. We can tell patients to get plenty of sleep and eat right, keep a healthy balance between work and family in order to stay healthy mentally. We then turn around and ask residents to make medical decisions while incredibly sleep deprived (and yes, the amount of sleep deprivation depends on the program) which equates to making medical decisions while drunk (if driving sleepy is worse than driving drunk, then wouldn’t it be the same for making medical decisions?). We force residents to make a trade off between work and family–as a resident you have no choice in how much you work, and if you have a family then your family definitely suffers. As physicians how is it healthy and justifiable to subject young children to that kind of family life? As for the 80 hours a week leading to more learning from more patients, as it is there is no time to learn from your patients because you have only a very hurried didactic time during the day, and absolutely no chance to do outside reading. So, how am i learning? Instead of learning things from their fundamental cause on through to treatment, you learn things by rote memorization–look for these symptoms and treat with this drug. The why is not important because you have no time to find out–this is supposed to make me a good physician?
Additionally, with the demographics of medical school student changing to an older class with more women in it, there will be an absolute need for these students to be able to balance family life with work.
So what if residency time has to increase? A study done surveying the interest in part-time residencies showed a significant interest in one med school class, and there’s no doubt there would be the same interest among graduates of all med schools. I would gladly go to an internal medicine residency program that guaranteed no more than 60 hours per week but was a 4 year program, and there are many of my fellow residents that would do the same. The idea of being able to train and still have some kind of pseudo-balance in terms of family or social life is too great to resist. The primary care residencies in particular should be paying this idea more attention– as the interest in these residencies fall this would be a great way to make them desirable again.
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