Limiting resident work hours: Patients remain our utmost priority

When I was a fourth-year medical student in 2002, I signed up for an intense sub-internship rotation in family medicine.  My goals for this rotation were two-fold: first, I wanted to make sure that I was ready for intern year and, second, I needed a good letter of recommendation to match into a good family medicine residency program.

On this rotation, I was essentially treated like the other interns.  I had patients assigned to me and was supervised by the senior resident on the team.  I took ownership of my patients, made treatment decisions, and even wrote orders (all approved and co-signed by the senior resident, of course).  I took night call (along with the same senior resident).  In short, I lived the same life that the interns did, just with more supervision and guidance.

The interns on the service took q5 night call, meaning that every fifth night they each stayed in the hospital admitting patients and responding to emergencies.  So like the other interns, every fifth night, after working the full day (since 7am), I stayed in the hospital overnight.  The next day, I worked my regular day, typically leaving around 6pm.

As you can imagine, these 35 hour shifts were not a whole lot of fun.  Some nights I only got a couple of hours of sleep.  But I slogged though, I learned what I needed to learn, and I got that letter.

When I started residency in 2003, the ACGME began to limit resident work hours. Studies had shown that brains that had been awake for 24 hours functioned like brains exposed to a blood alcohol level of 0.10 (legally intoxicated in most states).  Anecdotes abounded of mistakes made by tired residents.  So, during my residency, I was only permitted to work 80 hours a week, no more than 24 hours at a time, and I had to have 10 hours off between shifts.

Mind you, 80 hours a week is still tiring.  But I felt that these limits were reasonable.  I had accepted, long ago, that the goal of residency was to become a competent family doctor.  I knew that residency was my one opportunity to establish a foundation of skills for my whole career, and I was willing to put in the work to get there.

A few years ago, though, the ACGME decided that further limits were needed on resident work hours.  Fueled by a report from the IOM, the ACGME decreed that residents needed to gradually adapt to working long hours during residency.  So, now first year residents may only work 16 hours without a break.  Senior residents, by contrast, have far fewer restrictions.

I was skeptical of this change, but figured I’d wait to see what would happen.  Interns would now have additional time to sleep, study, and recreate.  With this additional rest and study, surely they’d provide better care.  And, surely they’d be happier, right?

Well, Dr. Pauline Chen challenges this notion:

Now, two years after the 16-hour mandate was established, studies on the outcomes are being published, and the results reveal one thing …

… Contrary to expectations, these studies have shown that interns have not been getting significantly more sleep. Moreover, they are not happier, nor are they studying more. In one national survey, nearly half of all doctors in training disapproved of the regulations altogether. Another study revealed that interns were spending less time in educational activities because the additional time required for such conferences and lectures would push them over the 16-hour limit.  In addition, there has been no significant improvement in the quality of care since the work limits took effect.

These findings ring true for me.  Limiting shifts to 16 hours means that everybody has to work more shifts to cover the work.  A full 24 hours off is far more restful than just 12 or 18 hours, but with more shifts that happens less often.  Additionally, with these more frequent shift changes, handoff errors may be happening more often.

It’s my fervent hope that the ACGME reverses the decision on 16 hour shifts for interns, but in the meantime, I’m trying to help my residency program respond by authoring a new, longitudinal patient safety curriculum.  Because at the end of the day, the discussion shouldn’t be just about the residents – our patients must be our utmost priority.

Jennifer Middleton is a family physician who blogs at The Singing Pen of Doctor Jen.

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  • Dr. Drake Ramoray

    With all due respect we don’t need a “longitudinal patient safety curriculum.” Just add work hours to the long list of problems created by doctors not in the trenches and these authoritative out of touch beancounters then propose solutions to a problem they created which then makes that problem worse. Rinse and repeat. To quote Dr. Robert Wachter (that would be the Chair of the ABIM) from a post elsewhere on this blog “Why banning curbside consults may not be the answer”

    “In 2003, cutting residency duty hours seemed like a straightforward solution to a tangible problem: resident fatigue. Yet we now know that this change did not result in improved safety (or education, for that matter), because we failed to address the many collateral issues, ranging from resident scut work to the dangers of handoffs, nor fully appreciate how care is actually delivered in the trenches.”

    The variables in residency work hours is really simple.

    1.) There are not enough hours in the day

    2.) There are not enough residents to do the work

    3.) There is too much non-medical work to be done (at this rate this last bit is a good primer for residents for what they should expect in the future as practicing physicians are spending increasing amount of time not doing MD work. It’s a little late by residency to realize you should have chosen a specialty with a better lifestyle)

    As such the solutions are easy and I will list them in the order of efficacy and probability.

    1.) Slow the rotation of the earth, alter normal human circadian rhythm and start 40 hour work days, productivity will increase and their will be less fractured medical care. Very effective but highly improbable.

    2.) Hire more residents (see need money from Medicare to pay for them). Somewhat less effective but only marginally less probable.

    3.) Hire non-medical clerical people to do the on-medical clerical work. (Not very effective and not very probable (see Medicare: need more funding), as much of what residents due is really required and requires some knowledge of the patient, but protocol, inefficiency, and their lack of power makes everything more complicated than it needs to be.) To hire someone with the required skills, appropriate compensation, and benefits it would probably be cheaper to hire another resident given the pay they make and the hours they work.

    The solution is more residents….. there is/ is going to be a doctor shortage remember.

    • buzzkillerjsmith

      Excellent buzzkill. Keep up the good work, doctor.

  • querywoman

    Doctors are not the only ones who work 80 hours a week. Most of the upper middle salaried professional classes in the US are overworked as well. It’s a fact that overtime laws don’t apply to salaried professionals.
    Engineers and programmers work ungodly hours and have none of the social status of doctors and lawyers. Most lawyers WITH jobs are seriously overworked.
    The medical doctor has the peculiar ability to give other people a piece of paper, an excuse, to get them off work! Isn’t that insane, docs?
    What we really need are laws to protect all salaried professionals from overwork!

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