The fallacy of the current resident duty hour rules

Discussions of resident duty hour reforms reached the point of ad nauseam a few years ago.  Everyone had their say — program directors (“In 2003 we instituted an 80 hour work week, in 2011 we switched to 16 hour shifts, what’s next – online residencies!?”), senior residents (“What? I have to write H&Ps again? I don’t even know my computer password!”), interns (“I thought I was done with cross-covering after this year”), graduating medical students (“I get to sleep in MY bed most of next year!”), and various supervising bodies (“This is what the public wants. Of course there is evidence that these reforms will work.”).

Now it’s my turn: part of the last class to have experienced 30 hour call cycles as interns — the way it should/shouldn’t be (depending on your bias).

While lamenting to my program director during residency on how my class not only had a difficult intern year but also had to assume “intern responsibilities” during my junior and senior years, he gently reminded me of his experience as an intern. It was routine for him to care for more than 20 patients on the general medicine service. Moreover, the ICU was “open” and any of his patients transferred to the unit continued to be under his care. Generously assuming 1 day off in 7, he worked more 100 hour work weeks than he’d care to remember.

As a junior resident, I was on service with my chair of medicine and he repeated many of the same stories of busy services and how the word housestaff came to be — the residents’ de facto house was the hospital. Was this dangerous? The unfortunate case of Libby Zion (and others) would suggest yes. Did my attendings became outstanding physicians, in part because of the rigorous training? Unequivocally.

Fast forward a few decades: for numerous reasons, including public pressure, an 80 hour work weeks with a maximum of 30 consecutive hours in-house (for a resident) and 16 consecutive hours (for an intern) is the new standard. In a matter of 16 hours, only so much can be accomplished. The work-up, diagnosis, and response to treatment is hardly appreciated in this short time span. The resident, who is permitted to stay in-house for 30 hours, often completes what the intern didn’t have time to do and benefits from observing in real-time the clinical course of the patient. Is this a disservice to the intern? Many would argue “yes.”

Interns now leave work after a maximum of 16 hours. The time away from the hospital is supposed to allow for a better-work life balance, enable restorative sleep, and prevent medical mistakes. A study by Kranzler and colleagues showed that this wasn’t the case. Interns did not report an increase in well-being, a decrease in depressive symptoms, more sleep, or fewer mistakes than previously.

What about patient care/outcomes? While early data from the 16 hour work day is still forthcoming, we do have recent data from the 2003 rule that capped the work week at a maximum of 80 hours. In a study published in August 2013, Volpp and colleagues examined mortality pre- and post-80 hour work weeks. More than 13 million Medicare patients (admitted to short-term, acute-care hospitals) who had primary medical diagnoses of acute MI, CHF, or GI bleed, or surgical diagnosis in general, orthopaedic, or vascular surgery were included in the study.

The authors concluded that no mortality benefit was present in the early years after the 80 hour work week was implemented and a just a trend toward improved mortality was observed in years 4-5. We will start to see mortality data from the 16 hour rule in a few years, but I suspect that no significant improvements will occur in patient outcomes. In fact, medical knowledge and hands-on experience for interns might suffer.

Completing internship used to be a rite of passage, akin to pledging a fraternity. The duty hour changes have allowed for interns to spend more time away from the hospital so that, theoretically, they are less tired and make fewer mistakes at work. In practice, this might not be the case. Unquestionably, the brutal hours that generations of past trainees faced was suboptimal. but it appears as if the current duty hour rules also might be less than ideal from a learning perspective. Hopefully, in the coming years, the ACGME will reevaluate its policies in light of the data they will see.

Akhil Narang is an internal medicine physician who blogs at Insights on Residency Training, a part of Journal Watch.

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  • Dr. Drake Ramoray

    I was in the same class as you although at a different institution. The last class of interns with work hour restrictions and the first junior resident class with work hour restrictions. The issue goes beyond intern work and sleep and quality of life (the data not showing any benefit as you demonstrate) but I still feel that my later training in 2nd year and 3rd year was compromised by still having to do intern duties. 2nd and 3rd year is when residents come into their own after learning not how to kill people as interns. I still feel the part that is missing from all of this is that it compromises the entiretly of resident education not just when young doctors are interns. Heaven help us with the plans to shorten residency training in terms of years spent now along with the exisiting work hour restrictions.

    You are correct, it is all a mater of perspective. I remember discussing a bad call night with my dad who was a surgeon (I went in at 04:30 and went home at 8 PM the next day (about 40 hrs straight) and he regaled me with stores from the 60′s when he would take open ICU call from Friday morning until Monday morning without going home.

    • Dr. Drake Ramoray

      Clarification: first intern class without restrictions and first residency class with. Discus wouldn’t let me edit.

    • Jbsilva

      I’m going to preface by saying I’m a medical student and thus have no idea about residency. However, I have been in a fraternity that prided itself on it’s hazing. Because of this, I am no stranger to what your saying. It is a “back in my day” mentality that pushes people to go farther simply to not be perceived as weak. Frankly, I believe arguments such as these are self-serving and ultimately stupid.

      What I find constantly missing from this conversation about work hour restrictions is the proposal of actual ideas. Maybe the 16 hours in a row restriction is counterproductive, but the 80 hours a week limit isn’t. Also, people fail to address the fact that residency is especially cheap labor that we are forcing horribly debt laden individuals to undertake. Pushing to work harder while ignoring the realities that indeed healthcare is now a business that is doing all it can to squeeze doctors seems counter-productive. Again I don’t know the answers, however I don’t feel were getting anywhere when the people at the top are more concerned about chest-pounding than adapting to current realities.

      • Dr. Drake Ramoray

        Perhaps you misread my post as the conclusions you have drawn are not consistent with what I was trying to communicate. I am not advocating for the kind of hours and abuse that my father had to deal with, I was merely using that to illustrate a point that it use to be worse from a work hour standpoint. What I am saying, and as Fedup says in a more articulate fashion than I did, is that the current work hour restrictions hurts everyone. The interns don’t learn as much, aren’t supervised as much (the resident is busy doing their work) and the interns aren’t any happier, the residents are now re-siterns and aren’t able to supervise and consolidate their knowledge like in the past (I eluded to this when I stated that I felt my education in second and third year suffered as a result.).

        Furthermore, the conversation with my Dad was not with him beating his chest but using it to illustrate that you get through it and that there are valuable lessons learned by being at the bedside and learning directly from patient cases.

        As for the people at the top (I don’t really consider myself one as I’m but a lowly private practice physician in a small rural group), they are all making lots of ill informed decisions (work hours just being one of them) that are not making life any easier for docs. Most of the time the bad ideas are propogated are started by the AMA, AFP, and ACP. I don’t have any solutions for them either, although that is why there membership (especially the AMA) has dwindled.

        Board pass rates are the lowest they have ever been. While I’m not aware of any studies that charge that this is secondary to the change in work hour restrictions, some of the other suspects discussed in the below articles is generational. I suppose it’s also possible that smarter people are gravitating to specialities. Having experienced the transition first hand when it changed and being surrounded by colleagues only a year or two my senior, I don’t feel that I’m being a chest thumping person at the top when I state I feel that the current work hour restrction rules are not helping physician education at any level.

        http://healthcare.dmagazine.com/2013/07/16/pass-rate-for-internal-medicine-board-exam-falls-to-84-percent/

  • PoliticallyIncorrectMD

    Cutting residents’ duty hours is an example of many poorly thought through “feel good” policy decisions in the name of “safety”, not based on data and designed simply to make the public feel better about the healthcare delivery. Not surprising that such policy carries many unintended negative consequences. One would hope that the ACGME would get enough common sense (wishful thinking here) to admit their mistake and stop pushing this agenda even further.

  • buzzkillerjsmith

    There is simply no substitute for being physically present to observe the clinical course of your recently admitted patients. That’s why we learn (or at least used to learn) more medicine in internship than at any other time. New docs need to learn the average clinical course of acute serious diseases, but they also need to learn the variability of the courses. I remember a pt of mine who died a few hours after being admitted for ascending cholangitis. Experience is the only way to improve judgement.

    That said, the extra stuff like taking blood to the lab and wheeling the pt to X-ray is totally inappropriate for a new physician or even for a med student. Do they still make you do that crap? I would add that being a clerk (jockeying the EHR) is also inappropriate for a highly-trained professional, but we’ve gone over this before.

    • Dr. Drake Ramoray

      My only job on the first day as a third year medical student on an IM rotation at the VA was to find a gurney AND hide it. The rule was interns/med students take patients to their tests. If they don’t get their tests they don’t go home. There aren’t enough in the hospital for all the patients so the team with the best crew of interns/med students gets to send their patients home.

      I suspect this day and age they don’t draw blood anymore or do stuff like I had too. They spend most of their time clicking a mouse on a computer (there is actually an article on this site about the computer time for interns) As pointed out then the amount of computer work they do is actually probably pretty comparable to what they will have to do in practice. The current state of medical education is sad to say the least.

    • Tiredoc

      I think that taking bloodwork to the lab and wheeling patients is completely appropriate for interns. Teaches them both humility and a reasonable expectation of the time that it takes to do something. And when you get to private practice and actually need to draw blood and put in an IV you know how to do it.

      I like the hiding of gurneys. Did you auction them off? I did one rotation at a hospital that counted the dead delivered from nursing homes as an admission on the duty rotation. It’s a telling feature of the job of intern that doing an H&P on a corpse is a relief.

  • T H

    The biggest mistake of the 80 hour work week was not automatically adding another year (or two, for surgical trainees) to residency training. How would that go over? Like a Pb balloon.

    Like many feel good policies, the unintended consequences are a crop of physicians who have more difficulty making challenging decisions while under pressure because they did not have to do it as much while they were supervised during residency. Do all of them have this problem? No, clearly not. But the ones who do have the chance to make some whoppers.

  • Ron Smith

    In a strange sort of way, I’m thankful for the long hours that my Pediatrics residency put me through 30 years ago. It wasn’t easy so don’t get me wrong. But being ‘battle hardened’ to the long hours that real medicine demands is just as important as the runner training for the marathon. It has made me able to go the distance that medicine requires, especially in my current solo private practice.

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Noni

      I think most of us who trained during the “dark days before work hour restrictions” agree with you. I hated my residency; it was the hardest time of my life to date. However, now that I’m established in my career I’m grateful for it. I learned a lot and (maybe more importantly) had the opportunity to make supervised mistakes. I also really got to know patients and their pathology with it’s typical or unique presentation. That experience beat me to a pulp but I wouldn’t trade it for the type of training they have now.

  • Mengles

    Program Directors only care about “work hour restrictions” bc it impacts them at a financial level. Residents are CHEAP LABOR – pure and simple. They don’t care about actually “teaching” residents. Attendings don’t “supervise” – they sign the note the next day with their nodding head of approval counting as “teaching”. Then we wonder why the best medical students go for fields that have good hours DURING residency.

    • PoliticallyIncorrectMD

      “Denial of all outside of our own limited experience is absurd.”
      Annie Besant
      Sorry your residency experience was so discouraging. My was quite the opposite, in spite of long working hours. My attendings tought quite a bit and we also learned by doing. Residency is different from the undergrad education – nobody will spoonfeed you anymore. As far as top students going to cushy residencies – not true either. I’ve graduated # 1 of my 150+ people medical school class and my board scores were in 95 percentile, still I have chosen to complete the internal medicine residency and sub specialize in critical care – very far from glamorous radiology and dermatology. And I am loving every minute of what I am doing!

      • Mengles

        I should clarify – I mean program directors AND hospital CEOs, who are essentially on the same page as one pays the salary of the other. Residencies wouldn’t exist without hospitals. Residents are a cheap source of labor and the truth of the matter is that it is cheaper to hire a resident than to hire a NP or PA. And unlike an NP or PA who can leave anytime and move if they feel they aren’t paid enough, residents have no way out.
        It’s why the AMA keeps flipping on deciding when residents are in fact “employees” or “students” so that hospitals benefit financially, as the detriment to residents themselves.
        Your generation of being gluttons for punishment and holding it as a medal of honor is why government and insurance companies have called the shots on reimbursement and taken away doctors’ autonomy on clinical medicine. Notice the dentists don’t have the same problem that medicine does.
        Over 20 years ago, top students went into IM or General Surgery. That is no longer the case. The research literature is quite clear the fields where the top medical students esp. those who are AOA go to: Radiology, Ophthalmology, Anesthesiology, and Dermatology. Your n=1 study is nice, but not the trend.

        • PoliticallyIncorrectMD

          I don’t quite follow your logic. You say years ago [when the duty hour were longer] the top students went into IM or Surgery. Now [when the duty hours are shorter] many avoid joining those labor intensive and less lucrative specialities. You can’t blame the trend then on the duty hours. In my opinion, the change is directly related to the difference in work ethics. Nowadays, the medicine is less about commitment and service and more about business and profit. It is less about patients and more about doctors. No wonder many (but far from all) new physicians are looking for an opportunity to work less and get paid more. To me, this is not something to brag about. And if anything, constant catering to “poor residents” fosters wrong priorities.

  • Tiredoc

    When the U.S. Congress started the Marine Corps, they posted an advertisement: “Volunteers to report at the induction center with boots and rifle. Uniform to be provided.”. The first day a few men lined up at the table. The first recruit received his uniform, slung his rifle on his shoulder and put his boots on top of the neatly stacked uniform. He then proceeded to start the queue on the far side of the table. The second recruit said to the clerk, “I’d like to join, but I don’t have a rifle.”. The clerk nodded, reached under the table and brought out a new rifle from a crate. He handed the second recruit the rifle and uniform. The recruit slung his new rifle and stood behind the first recruit. The first recruit turned to the second recruit and said, “In the old Marine Corps, we had to bring our own rifle.”

  • Noni

    Pretty shocking stuff. Seems most of the physicians who comment on this board all trained before the work hour restriction and are disheartened at what medical training has devolved into. What will happen when these physicians get out into the “real world?” The quality of the physicians we are training is going to decrease. However, as medicine moves towards employing more midlevels, corp med hospital systems and team based patient care maybe it won’t even matter. Disheartening indeed.

  • Noni

    No, but there is a lot to be said for following a patient day in day out for hours on end and into the night. The learning one accrues from experience is really invaluable, and that learning is retained. I may not remember some resident lectures or any of the questions from shelf exams but I definitely remember specific patient presentations, certain cases, complications that developed post operatively, etc. Trainees today simply don’t get the opportunity to take ownership of patients through thick and thin and really know their pathology. They get sign off, do their obligatory rounds and scut work, type crap into an EHR, and then prepare their handoff list.

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