Should medical resident training be limited to 40 hours per week?

Dr. Sam Ko says resident work hours should be limited to 40 per week. Via Twitter, I warned him that I would rebut his assertion.

Without any data or references except a tangential one, he bases his opinion on four premises.

1. Residents will be happier and nicer to patients because they will be less stressed. There is no proof that this is so. In fact, a recent paper in JAMA Surgery says about one-third of interns who work a maximum of 16 hours per day “demonstrated weekly symptoms of emotional exhaustion (28%) or depersonalization (28%) or reported that their personal-professional balance was either “very poor” or “not great” (32%).”

And “at the end of their intern year, 44% [of interns] said they did not believe that the work hours limits led to reduced fatigue.” This is not a very resounding confirmation of the theory that reduced work hours leads to happier or better rested residents.

2. “But we did it so you have to do it to.” Under this heading, Dr. Ko says, “We are busier than they were 20-30 years ago. Before they probably got more sleep and had less patients in the hospital.”

With the exceptions of more paperwork and the burden of the electronic medical record, I’m not so sure residents are busier today, but if they are, what’s making them busier is reduced work hours. This recent paper from JAMA Internal Medicine concluded the following: “Compared with a 2003-compliant model, two 2011 duty hour regulation–compliant models were associated with increased sleep duration during the on-call period and with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.”

The supposition that there were fewer patients in the hospital 30 years ago is incorrect. When I was a resident over 30 years ago, cholecystectomy patients stayed in the hospital for 4 to 6 days. Even herniorrhaphies stayed 1 or 2 nights. Day surgery was in its infancy. Patients could be admitted for workups which are now done as outpatients. These people all needed H&Ps, had to be rounded on daily and notes had to be written. We had to draw routine and stat bloodwork and start IVs ourselves, we often transported patients to radiology and the OR. I could go on.

Dr. Ko is right about one thing. We did get more sleep when we were on call because we weren’t cross-covering many patients that we didn’t know very well. The abomination known as “night float” did not exist.

3. Residents won’t get enough training. Dr. Ko dismisses this objection by pointing out that menial tasks should be delegated to others. But who are those others, and how will they be funded? In addition to the bolded portion of the sentence at the end of the paragraph above, here’s another paper (of many such papers) documenting that many residents are already being poorly trained. And Dr. Ko wants to cut hours by half.

4. Less depression, anxiety and alcohol/drug abuse. He cites a statistic that 300-400 physicians commit suicide very year. That may be true, but there is no proof that decreasing work hours will alleviate that problem. Most papers on the subject seem to indicate that suicide is a problem of physicians who have completed training and are in practice. Did I mention that there are no work hours limits for doctors who are in practice?

Being a doctor is a stressful job. Sleep, or its lack of, is not the only factor causing stress. Limiting resident training to 40 hours per week would be a catastrophe for residents, their education and most of all, their patients.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

Comments are moderated before they are published. Please read the comment policy.

  • Noni

    Making residency a supportive encouraging learning environment would probably do more for stress reduction than further cutting hours. However, the entire environment of health care is going through a major overhaul. Those at the top are more stressed out than anyone; how can they possibly train underlings in a less stressful environment?

  • http://www.thehappymd.com/ Dike Drummond MD

    Looking simply at the number of hours is simplistic and doomed to failure. That is like saying … less arsenic is not as bad for you. Do you see the mangled thought process.

    I work with burned out doctors all day long. I see them on the far side of their residency experience and can tell you it is the PROGRAMMING of the medical education experience and not simply the sheer mass of hours that sets up burnout down the road.

    The key is to fundamentally change the training environment from a survival contest to a learning experience that teaches you both
    - how to perform the tasks of a clinician
    - how to build a fulfilling life as a medical doctor (the big picture)

    It does not matter how much you cut hours if they still are not taught …
    How to set boundaries around their career
    How to build life balance
    How to organize, delegate to and lead a care team
    The symptoms, causes and prevention of physician burnout

    I also does not make sense for the training process to leave them completely unprepared for life after residency. Think about it … do you know a full time doctor who only works 40 hours a week? If that is all they did in residency … they would crash and burn in their first year of private practice.

    A knee jerk, simplistic response to any issue inside the healthcare training or delivery system is always wrong … this is just one more example.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

    You

  • Daniel

    Pretend you have an machine with a dual fuel supply (electricity and gas). When running optimally, it runs primarily off of electricity. It runs smoothly, quietly, and produces no pollution. When the electric supply is low, however, the machine becomes more and more polluting as it switches over to gas. It runs more roughly, makes more noise, and generates a thick cloud of hydrocarbons. Let’s say the amount of battery power is 50 units. The gas tank holds 118 units.

    Suppose you like you use the machine to do 120 units worth of work before recharging the batteries. About 70 units of work has to be done with the machine running on gas. (Not exactly, because of the switch over process, but let’s not worry about that for now.)

    Your customers complain about the poor work your machine has been doing. Your neighbors complain about the noise and smoke you’re generating. So you announce that you’re cutting down to 80 units of work between recharges. The machine still has to run on gas for about 30 units of work. Your customers and your neighbors don’t stop complaining.

    WTF is wrong with them? You already cut down from 120 units to 80 units. Those ungrateful… You’re able to get less done with your machine, and they won’t stop complaining. Might as well go back to 120 units, right?

    • PCPMD

      The “simple” solution – residents working 30 hours per week (they need to also factor in time for reading, self-education, etc.) – would lead to either A) terribly under-trained doctors, or B) residencies that were 50-100% longer in duration (which would lead to fewer people entering medicine, and fewer doctors graduating, further worsening the physician shortage we already have). Which would you prefer happen?

  • Steven Reznick

    My understanding is that even though the number of hours a doctor in training works has been limited by law and regulation, the workload has not been reduced. If they are performing the same work in less time now it must be extremely stressful. If in addtion, by virtue of the new work hours, they are not getting the benefit of going to the operating room to cure and care for the patients they admitted due to work hour restrictions they are not getting any of the positive feedback.
    I expect the programs where the teaching faculty are hands on and supportive produce residents who are happier and less stressed than programs that use their trainees as an inexpensive workforce.

    • Dr. Drake Ramoray

      With the new work regulations the intern work is done by the upper level residents. Instead of having one year of scut (for medicine), and two years of really consolidating your knowledge. You basically get three years of scut. The longitudinal learning patients is also lost.

      As an Endocrinologist I have oneof the best lifestyle fields (I don’t get paid like derm though) On non call weeks I probably work 50-60 hours. What’s the point of having residents work bankers ours and then work at least 50% harder when they are finished? This doesn’t even touch some specialties like OB and most surgical specialities who will work wihout sleep and through the night for the rest of their lives.

      The answer is more residents

      • Steven Reznick

        Thank you for the explanation

      • Noni

        So you don’t get called in at night? That sounds lovely :).

        I do remember you saying you left corp med – what is your practice environment like now?

        • Dr. Drake Ramoray

          Called at night, sure. Called in at night no. There are not that many Endocrine emergencies (thyroid storm, DKA, Adrenal crisis) and for the most part the hospitalists are smart enough to handle them till the morning (or call with pointed questions).

          Currently I am in a small single specialty private practice group. The key in my field is to find a place where the hospital has (or is willing to let you develop) a robust internal medicine/hospitalist driven diabetes program.
          The first place I worked was almost exclusively outpatient till it was purchased. It is impossible for 1,2 or even 3 docs to provide comprehensive diabetes management for a 5-600 bed facility, which is what some places want. Some academic centers have one or two inpatient diabetologists and an army of nurse practitioners who do exclusively inpatient care.

          There is millions to be saved in decreased length of stay for lots of procedures by improving diabetic control but most corporate types are not smart enough to see that it’s not worth the low medicare E&M reimbursement rates for an Endo to devote significant time to inpatient diabetes care. At my last hospital, I could have designed a full time job (not one I would want to do) with just a pager some nurse practitioners and virtually no other overhead, but you couldn’t make a living without a beancounter willing to see the big picture.

          The reason a small single specialty group remains somewhat viable in Endo is because there are only about 6000 of us in the whole country. I have patients who come from 100-150 miles a way to see me. That gives us some leverage in negotiations with insurance companies. It also presents a unique challenge in folks you can’t see very often and manage by phone/labs alone between appointments.

          We probably don’t have as much negotiating power as the big hospital systems but the big hospitals usually insist on radiology doing ultrasound, nuc med etc. (for inflated prices) and they don’t do as good of a job in my opinion. One place where I worked very temporarily the radiology department couldn’t do a thyroid cancer surveillance ultrasound to save their lives. This is in addition to the above mentioned diabetes issues of hospitals.

          Concierge route would be a lot harder for Endo as we don’t provide much in the way of primary care services and that model doesn’t support specialty care on it’s own very well imo (at least at this time in our area). We are looking into expanding into clinical trials though as the short to medium term future looks pretty rough for free standing independent doctors offices (facility fees and meaningful use). If the system blows up I’ll go teach and become one of those academic types I typically rail against.

  • J.M.

    I should have insisted on a 40-hour work week back when I was a Navy Corpsman. Hahaha.

  • Skeptical Scalpel

    Thanks or all the comments. It is a very touchy subject with deep feelings on both sides. I’m at an international conference on surgical education. It takes 8 years to become a surgeon in Ireland. Do we want that in the US? I don’t think so.

    • Jonathan

      This doesn’t make sense. People in Ireland begin medical school immediately after high school or after a few years. Very few graduates have attended a 4 year undergraduate degree prior to obtaining a medical degree.

      The 8 years you claim are only 2 years more than in the US- where the average surgeon takes 6 years (a few are 5 years but they are shrinking).

      Regardless-by the time a doctor completes surgery in Ireland they will be on average younger than a US doctor.

      • Skeptical Scalpel

        I’m not sure what doesn’t make sense. Surgical training in Ireland takes 8 years. That’s not a claim. It’s a fact. With rare exceptions, everyone in the US graduates from college after 4 years and then does 4 years of med school. Surgical residency in the US is. 5 years plus at lest a year of fellowship. That extra year is done because many graduates of residency don’t feel confident to operate independently due to their inadequate training. If you shorten the hours to 40 per week, residency will have to be lengthened to 10 years.

  • LBENT

    These residents are not well trained enough in only 80 hours a week, especially not surgeons. I am a surgeon, I was an educator of surgeons, so I speak with some authority.

    More than 70% are seeking further training in fellowships. My work week is about 80 hours including my call, and I have been doing this for 30 years, had 3 kids and still am happily married and very active physically and socially.

    The residents will be really depressed when they go out into practice and cannot do the job right b/c they were not trained adequately to work well even when they were tired.

    This is not b/c it’s the way it was done, it is because it is the way it has to be done. Physicians have to build stamina and strength. Hand-offs are more error prone than any tired doctor.

  • Sara Stein MD

    Sure. Limit it to 40 hours a week and double it to 7-8 years. Otherwise, if there is a medical resident alive that thinks that they can be an effective physician with the same amount of work as someone in an office, send me their name so I can avoid them like holy hell.

    For the record I trained in surgery with 90-110 hrs a week , and psychiatry with 70-80 hrs a week, and I still, 20 years later, see things I’ve never seen before. It’s an immersion that is essential if you are going to step out in the world and take responsibility for people’s lives.

    Regarding fatigue and depression – there’s enough evidence to do away with 36 hr days. But the depression of medical residency is not simply related to fatigue, but to the suffering surrounding us and the grind of having to keep going, no matter what. Make room for compassion and debriefing – and the occasional leave early after a terrible outcome – and more sleep. Not less exposure.

  • Kelly Wright

    They are already limited to 50 hours per week in Australia. I did a rotation there. I met a surgery resident in her 11th year of training (after 4 years of college and 4 years of med school). You bet she was ready to get on with her life at age 36. Their program director told them never to complain since they weren’t working long hours. It doesn’t mean the job was any easier after 11 years!