The 80 hour resident work week balances fatigue and independence

How many hours can a doctor work?

The residency regulators are back. About ten years ago, the national organization that accredits residency programs (ACGME) set out its first guidelines about how many hours a doctor-in-training can work. Interns and residents finally achieved the vaunted 80-hour workweek. New York State was 15 years ahead on this, having mandated an 80-hour work week in 1989, stemming from the Libby Zion case.

Every patient wants a doctor who is well rested and alert, but limiting residents to 80 hours per week wasn’t as simple a panacea as it seemed, as I wrote in an editorial in the New England Journal of Medicine shortly after the ACGME regulations were issued.

Practical issues abounded, mainly concerning the increased number of hand-offs required, as patients had to be cycled between teams of doctors. Less quantifiable, though no less concerning, was the inevitable progression toward “shift-mentality” and a decrease in professionalism.

In fact, the 80-hour workweek did not decrease errors and did not increase sleep time for the doctors. The ACGME has recognized this and has now issued a new report. In essence, they have admitted what all of us who teach new doctors already know, that medicine is far too complex to apply simple formulas. What really helps doctors-in-training practice good medicine, decrease errors, and maintain a high standard of professionalism is good supervision.

It might seem like stating the obvious, but fresh-off-the-boat interns need near-total supervision. These eager new doctors were medical students just an eye-blink ago, and a parchment diploma did not ratchet up their clinical skills overnight. A good supervisor needs to watch closely and teach intensively during this early period.

Over the next several years, as the residents gain skill and confidence, supervisors can ease back, offering more opportunities for independent decision-making. The overall thrust is that the quality of medicine delivered by residency training programs depends heavily on the quality and quantity of supervision provided.

The changes in this area are palpable. When I did my medical residency training almost twenty years ago, senior physicians (attendings) were barely present. The attending showed up once a day to see all the newly admitted patients during an “attending rounds” session, and then returned to his or her private practice. We were on our own for the rest of the patients’ care, even if it lasted weeks.

Now, I am an attending at the very same hospital, but the model is entirely different. When I spend a month supervising a team on the medical wards, I am there full-time. We still have that attending rounds session to talk about new admissions, but we also have the rest of the day. I don’t follow two steps behind my residents and interns every waking moment, but we talk constantly during the day. I also examine the patients independently to make my own clinical assessment. We work as a team six days per week and I can be reasonably sure that we are all on the same page with the patients’ care.

Do errors still happen? Are residents still exhausted? Yes, and yes. But I do think patient care is better for it.

The trick now is to teach them independence and to foster the do-whatever-it-takes-for-your-patients credo that suffused my training years. Not to mention the joys and rewards of medicine.

But that can be done in 80 hours, or at least I am hoping so.

Danielle Ofri is an internal medicine physician and author of What Doctors Feel: How Emotions Affect the Practice of Medicine.

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  • Shata hari

    I am glad that I am in Australia.We have 40 hrs per week here and interns in ED have continuous supervision with a consultant dedicated to supervise interns during day time.

  • Dan

    …and so in Australia second year residents have less than half of the experience of their US counterparts

  • Rob Mathews

    I’m an Australian final year medical student and am about to enter the workforce. I have to say that I am very glad that we only have a 40 hour work week. Sure we do our fair share of overtime but 80 hours sounds very unsafe!
    I think people are fooling themselves if they feel that they can perform effective and safe patient care with such a ridiculous work load! Surely one is biting of more than they can chew if they have enough patients to require them to stay at the hospital for 80 hours a week. Would it not be better to hire another doctor and split the patient responsibility?
    What about the mental health of the doctor? How can someone have a life outside of medicine if they are working 80 hours? How can you have a successful relationship or have downtime to pursue your interests outside of medicine?
    Perhaps I don’t understand the difficulties of healthcare in the US.

  • Patient Taylor

    While I agree that it may not be the safest/best for doctors to work 80 hours a week, an 80 hour week has become the norm for some professions in the US. I have friends that practice law or work in investment banking and they average 70 to 80+ hours. I understand people will argue well they’re not taking care of patients etc, but peoples livelihoods are on the line in some cases.

  • jimmyz

    common sense again loses to arrogance in the name of eviden e. Ask any common person if they would rather have a well rested resident do their surgery or worry about a “hand off”. I will wager they go for the well rested resident. Come on educators and program directors, face the music, we are all going to shift work and MUST learn to formulate policies for handoffs. The next generation of physicians will not and should not tolerate such inhumane and unsafe working conditions…..at least do it for the patient’s sake.

  • http://www.ohiosurgery.blogspot.com buckeye surgeon

    By JimmyZ’s rationale, NFL teams ought to bench their starting QB’s come playoff time because the backups will all be far better “rested” than the starters. Bright eyed and bushy tailed incompetence is still incompetence no matter how you try to spin it.

  • http://www.blue-genes.net Nicholas Swetenham

    To my knowledge, the United States is the only developed nation which mandates an 80h working week for its junior doctors.

    Most developed countries, including the US’ northern neighbour Canada and all 27 countries of the EU have a legal maximum of 48h or less (on average – individual weeks may be more or less intensive). Of course, the actual number of hours worked sometimes exceeds this for various reasons.

    The US is a very attractive place to undergo residency because of the high quality of teaching, but my UK colleagues are often tempted by Australia or New Zealand with their 40h weeks instead.

  • in theory

    The thing is that I doubt that the lawyer is working 80 hours EVERY week of the year. The medical resident actually can work OVER 80 hours a week; the 80 weekly hours are averaged over a month. Thus, the resident might work 90 hours one week and 70 the next. They are also doing 30 hour shifts; does the lawyer do that?

    Finally, 80 hours is the “prescribed” amount. Some programs make you lie and say that you worked 80 hours even though you did 90 or 100. (surgery)

    Patient Taylor August 13, 2010 at 12:58 am

    While I agree that it may not be the safest/best for doctors to work 80 hours a week, an 80 hour week has become the norm for some professions in the US. I have friends that practice law or work in investment banking and they average 70 to 80+ hours. I understand people will argue well they’re not taking care of patients etc, but peoples livelihoods are on the line in some cases.

    • Patient Taylor

      Yes, the lawyer prob isn’t working 80 hours EVERY week. However, the doctor isn’t in residency forever? And I know a few investment bankers in NYC (not that they’re the most admired profession in the US right now!) who regularly work 10am-3am Mon-Fri and then noon-6pm on Sat/Sun. That adds up to way more than 80 hours a week and they’re the ones partially controlling the economy. Oh, we see how well that has been going as of late… I’m just saying.

  • http://evimedgroup.blogspot.com Marya Zilberberg

    80 hours seems like a vacation compared to what we did 15-20 years ago! There were months when I spent 120 hours/week at the hospital. I am not saying that it is good or bad — it was, obviously, both. And that is the point: in any change there is a trade-off. We can only hope that the decisions we make balance out on the positive side of the trade-off. Professionalism has been the currency of medicine, but I am not sure that we can blame the work hours limits for its ebb — I see so much unprofessional sentiment on the physician-only discussion boards I frequent from seasoned people! Medicine is changing, and resident hours are but a small drop in the vast ocean of change. Perhaps it is more reasonable to blame for the dwindling professionalism the fact that residents are being taught more about how to discharge patients rapidly than about how to be a thorough physician?

    Just thinking out loud. It may not look like it, but I am a big fan of continuity of care by the same team.

  • Mandy

    Buckeye,

    That fatigued resident at the end of his shift started off his day “bright eyed and bushytailed”. Are you saying that the patient is less safe during the time he was rested and alert? What are the success rates of judgment calls made by exhausted novice doctors, especically during a crisis?

    Also, as a handoff has to occur at some time during patient care, why is it considered safer at the 100 hour mark rather than at the 80 or 60? Aren’t the same steps performed for whenever the handoff occurs? Potential crises where the original doctor might be needed can happen at any time.

  • jsmith

    Forty hours per week is not enough to learn inpt and outpt skills, not nearly enough. You Australians need to work harder. We attending docs in the USA work 50-60 hours per week. Are you telling us that your training is less intense than your real jobs? Scary. How many hours per week to attending docs in your country?
    I’m surprised to read that the author of this post is in the hospital supervising her residents. When I trained it was the interns and residents only, and the attending rounded in the morning. No one died that wasn’t going to die anyway.
    I don’t know about the youth of today.

  • Shata hari

    Everyone works 40 hrs per week.interns to attendings,nurses.
    so your training is same as your job.

    “NO ONE DIED THAT WAS GOING TO DIE ANYWAY”
    are you sure??
    may be thats how we justify our mistakes????

  • Mandy

    “No one died that wasn’t going to die anyway.”

    Is this a medical pearl that’s passed on to new doctors; a crutch so they don’t have to accept any responsibility for negative patient outcome?

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