by Vineet Arora, MD
Anyone affiliated with a teaching hospital knows that the controversy regarding resident work hours is heating up again. It’s been over 5 years since the ACGME limited resident hours to 80 hours per week with a maximum of 30 consecutive hours. While this may not sound like ‘reform’, as someone who trained prior to these rules, it is definitely a change.
More recently, the Institute of Medicine issued a report titled, “Resident Duty Hours: Enhancing Sleep, Supervision & Safety” which recommended cutting hours of resident physicians even more to 16 hours per shift OR a 5 hour ‘mandated’ nap in the current 30 hour system.
The report cites literature from sleep science demonstrating the perils of resident fatigue. These recommendations have ignited a renewed furor – with groups on both sides of the fence. For example, the AMA student section recently passed a resolution against the ‘nap’ stating that it would hurt continuity of care. Other medical societies have highlighted the current issues complying with the 2003 ACGME duty hours and the enormous cost of implementing the IOM recommendations. The cost of 1.6 billion would be cost-neutral to society if we expected an 11% reduction in preventable adverse events. As a result of this report, the ACGME has convened a task force to issue new duty hour recommendations in 2011.
As physicians debate these positions, public support for further limits is growing. Recently, 40 patient advocacy groups, including Public Citizen, have signed a petition urging the ACGME to adopt the IOM recommendations and others to sign the petition at a website cleverly named wakeupdoctor.org. The website states “Missing: A Patient Perspective on the Need to Reduce Resident Work Hours” and explains the problem “You’ve seen them on Scrubs, ER and Grey’s Anatomy – deeply fatigued interns and residents. But truth is stranger than fiction.” The website does cite evidence that sleep deprived residents make mistakes and the recent IOM report. Interestingly, the safety risks regarding handoffs are not mentioned.
With shorter hours, there will be an increase in handoffs, with associated risks for patients. The IOM report acknowledged handoffs were risky, but highlighted that duty hour reforms should not be hampered due to concerns regarding handoffs. The IOM did recommend that all trainees receive education on how to perform handoffs. Unfortunately, it is unclear how to train residents to do handoffs and what improvements actually result in better outcomes.
Of course, no one wants a tired doctor. But, the more relevant question is whether you prefer a tired doctor that knows you or a well rested doctor that doesn’t know you? Acknowledging the tradeoff makes it harder to answer. My answer – it depends. For a simple procedure, I would choose the well-rested resident (the one that’s most experienced in fact). But, for a more complex decision where familiarity with the patient matters, I prefer the resident who may be tired, but knows me better.
Of course residents can’t work 24/7 (like they did when they were truly lived in the hospital hence ‘resident’) so handoffs will occur and limits on hours are needed. But, to arrive at the best solution, we must present this debate in a more informed way for the public.
Since I’ve explored duty hours in my research, here are my thoughts on some of the common questions I am asked about this topic:
1) Will reductions in hours lead to more well rested residents? Reductions in hours will lead to some improvement in sleep, but sleep is often deprioritized because residents (like most people) have limited free time and sleep is competing with socializing, family obligations, and other general living life things.
2) Can we mandate residents take naps (for 5h!)? No, you can’t force anyone to sleep. But, you can mandate break time. Breaks are used in other long shift industries. Unfortunately, residents are unwilling to use a break or nap if they still have high workloads or are concerned about handoffs.
3) How can we improve patient safety during handoffs? This is unclear, but it is clear that the process is fairly haphazard currently so that certainly investments can be made (i.e. formal training etc) so residents feel more capable in conducting handoffs. More work is needed to know how to train residents in handoffs and also whether handoff improvements actually result in improved safety.
4) Why not just get rid of extended shifts (longer than 24h)? This question is interesting and it rests on whether there is really an educational value for residents following patients through the course of disease – and does that experience translate into better decision making in the future. We don’t know currently since outcomes of residents graduated under duty hours vs. those without duty hours have not been compared since we are just starting to graduate trainees entirely trained under duty hours. There are anecdotal reports that current resident graduates are less prepared to practice independently after duty hours.
5) If Europe can have shorter hours for their doctors in training, why is it so controversial here? Actually, the European Working Time Directive mandates a 48 hour work week for ALL workers, not just physicians. This includes everyone, highlighting a major cultural difference between the US and Europe. Junior doctors (what they call residents) were not granted an exception. Moreover, the leaders of major European medical societies have opposed this regulation and have cited detrimental effects on resident experience. Reports have also emerged that junior doctors are lying about their actual hours.
6) Why can’t we just extend training? Extending residency training is not a popular option with students. Unlike Europe where medical education is publicly funded, the average graduating medical student has well over $150,000 in debt. In fact, due to concerns of a doctor shortage, most specialty societies are advocating for shortening the length of training in the United States.
Vineet Arora is an internal medicine physician who blogs at FutureDocs.
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{ 9 comments }
jsmith,
I like it. Now what do you do if the residents in the shorter work week turn out to be incompetent at the end of their residency?
Your point is well-taken. Extent the study. The problem with that, of course, is that once the shorter hours genie is out of the bottle, there might be no way to it put it back in. I for one am skeptical about bankers’ hours for residents.
Should be extend, not extent. Workin’ too much.
It seems as if a little experimentation is in order. Have System A implement shorter hours and System B not. Get the Biostat guys to figure out the sample sizes and other such details. See which system gives better results here in the USA, with our system of postgrad medical education. (Europe doesn’t count because of potential extrapolation error. ) Do it over a year, and randomize after the match so as not to get intern choice of spots as a confounding variable.
Well when I trained, in the 80’s we worked 300 hrs/week, every other night call, all for $17,000/year and 2 White Coats. And We did it all on GUTS, and INITIIATIVE!
And 10 grams of Amphetamine Sulfate/Week…
and I know, we had Mullets, wore Stone Washed Jeans, and Drove IROCs with T-Tops, so obviously our judgement was impaired, to be generous.
Problem is there’s still the same amount of work to be done, probably MORE, since even a CABG/AVR/MVR gets done as an outpatient now a days, and even “Physican Extenders(sounds like an ED tx) won’t work nights/weekends, at least not for the <$10/hr Residents make…
Frank M.D.
The patient has to be handed off sometime during their hospital stay. So what does it matter if it’s at hour 12, 16, or 30? There will be always be discontinuity of patient care unless the resident is there 24/7 until the patient is discharged.
Typical arrogance of modern medicine to think that there isn’t “evidence” of improved patient outcomes with better sleep. Are you F***ing serious? There needs to be a study linking physicians with lack of common sense. Every industry that has safety issues such as truckers, airline pilots, oil tankers (Oil Pollution Act 1990) have mandated sleep requirements and work hours. So what if there ain’t evidence of improved outcomes? Even an idiot knows that people perform better without sleep…they don’t need some study to prove it. Unfortunately, doctors are either driven by money (less residents = more costs to hospitals) or are pretty stupid. Probably both.
the problem is that truck drivers stop driving, pilots stop flying, but patients continue to need care. Also there needs to be some training to recognize you are going to be working tired when you get out of residency. That’s life. I’m a obgyn, I got tired last night at 9pm when my patient came in labor. I would have loved to have said I’m going home, I know you just had a seizure but the next guy is pretty good, see you in the morning hopefully.
I fail to see your logic…..so you think a supertanker can drop an anchor in the middle of the Pacific if it violates mandated rest periods? No, they implemented those laws because sailors, pilots and truckers made more money by working OT or driving more miles. If you were so tired last night at 9pm, then why don’t you hire extra OBGYN’s to cover for you…..wait, it probably means that you will make less money.
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