It was the 24th hour of my call shift, and I was running on fumes. Despite my weariness, I could see the first rays of morning sunlight coming through the window in my patient’s room. It was then I knew I could make it to hour 30 (quitting time). It was grueling to keep going, but hitting the 30-hour mark only required me to keep my head down and do my job. As the finish line arrived early that afternoon, there was a sense of tired euphoria and accomplishment. I’d survived another call. Driving home was a chore, but it didn’t matter, because getting home was an afterthought. I didn’t have to be back at work for 18 hours, and I didn’t have to work 30 straight hours again for four whole days.
That was 2005 and an average call night as a medical resident. Most physicians have “war stories” from times in training when they were pushed to their physical, mental and emotional limits. Resident physician work hours have changed a little bit since then. But not much.
Resident physician work hours have been a hot topic for as long as I can remember. On one side, you have those that think the requirements of medical training are akin to punishment. “Doctors should be treated like pilots! They’re too tired to work safely!” And on the other side, there are those that think any restriction on work hours is ludicrous. “Doctors will never learn to competently care for patients! They’re lazy!” There are good points, and a bit of hysteria, on both sides of the argument.
Let’s look at resident work hours and learn what happened to finally change things.
Prior to the 1980s, there were no restrictions on resident physician work hours. Doctors in training were in the hospital as long as it took to get the job done. In fact, the term “resident” was originally coined because physicians in training literally resided at the hospital.
Then, the Libby Zion case shook the medical landscape.
In 1984, a young female named Libby Zion presented to New York Hospital with a fever and jerking movements. What transpired next has been tirelessly debated, but suffice to say she was admitted to the hospital under the care of a senior physician, and two physicians in training. The intern physician charged with monitoring her condition overnight was also busy dealing with 40 other patients. Unfortunately, at 6:30 the next morning, Libby’s fever was 107 degrees and, despite resuscitative efforts, she died.
Libby’s father, Sidney Zion, was a prominent journalist at the time and investigated the circumstances of his daughter’s death. What he discovered shocked and infuriated him. He came to find out that a potentially fatal drug interaction was missed by the medical team. In addition, Libby was given sedatives and restrained due to her worsening agitation.
Her father was quoted in the New York Times as saying, “You don’t need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life-and-death.” In addition to the intern having to cover an excessively large number of patients, the supervising resident was never awakened, and the supervising staff physician wasn’t called when Libby deteriorated.
This case, and the strong media campaign that accompanied it, led to the formation of a commission in the state of New York that recommended an 80-hour work week for resident doctors. In 1990, the Accreditation Council of Graduate Medical Education (ACGME), the governing body overseeing all residency training programs in the United States, set an 80-hour workweek, limited overnight duties to once every three nights, and mandated at least one 24-hour period off every seven days.
Any guesses on the response?
The proposal was ignored! Residency training programs continued to do their own thing and nothing really changed. It was mostly for show. Nine more years pass.
In 1999, another seminal event shook the national healthcare landscape. The Institute of Medicine (IOM) released a report called To Err Is Human: Building a Safer Health System. This shocking report stated that 44,000 people, and as many as 98,000, die in hospitals each year due to preventable medical errors. The public outcry was understandably strong, and the ACGME again targeted resident work hours and staff physician oversight.
However, two years later, in 2001, the U.S. Congress had grown impatient and introduced legislation that would limit resident physician work hours, with enforcement provided by the federal government. In my opinion, it was at this point the ACGME realized they were about to lose their oversight power — so in 2003, an 80-hour resident workweek was enacted for all specialties. In addition, it was required that residents average a day off for every seven days worked, and shifts were capped at 30 hours.
Can you guess what happened this time?
Well, once again, programs were slow to acquiesce, so the ACGME placed the high-profile program of Johns Hopkins on probation. This was eventually lifted, but it helped set the tone that this time the duty hour restrictions were serious and here to stay. No federal legislation was ever passed by Congress.
In 2011, the ACGME further tightened work hours by also restricting interns to 16-hour shifts.
But has limiting resident physician work hours helped? The truth is, no one truly knows.
Doctors in training do report feeling better and more rested. But was that the primary intent of limiting hours? Lots of medical training programs still worry their trainees aren’t getting enough experience. Similarly, medical trainees often wonder if their education and competence is somehow being short-changed by these work restrictions. And what about patient safety? Well, the jury is still mostly out on this point too.
Your guess is as good as mine, but I suspect we will continue to see further evolution of resident work hours.
Kevin Tolliver is an internal medicine physician who blogs at My Medical Musings.
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