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Will Resident Work Hours Be Reduced?
Thomas Robey -- One of the (many) things I pay more attention to now that I'm interviewing for residency is work hours restrictions. Granted, residents in emergency medicine (EM) typically fall well under the current limits of 80 hours a week (averaged over a month), maximum 30-hour shifts, and a minimum 12 hours between shifts. (EM residents have their own numbers: 12-hour shift limit, at least an equivalent period of time off between shifts, and a 60-hour work week with an additional 12 hours for education.) But when it comes to off-service rotations –- when I work in the ICU, for instance, or on the medical floors -- I'll log my hours along with everyone else.
Some of my stock questions when I interview include direct inquiries about work hours. Thanks to an Institute of Medicine (IOM) report issued on December 2, I have a new way of asking. You can try it too: “How do you expect your institution will respond to the new IOM recommendations that resident shifts be shortened to 16 hours?”
At my medical school, most rotation sites provide sleep rooms for students so that they may take overnight call with the team. This means that I've had a taste of 30-hour call and 80-hour clinical work weeks. (Keep in mind that these restrictions do not apply to medical students -– there are no restrictions for us!) My experiences on call helped me learn how to work up a patient from start to finish, introduced me to multitasking between several clinical tasks, and provided several others on my team with interesting diversions (in the form of delirious post-call musings). Low on the list of why I chose emergency medicine is that I will not have very many 30-hour call nights. But it is on the list.
So when the IOM report came out last week, I took notice. Keep in mind that these are recommendations, and are not policy (yet!). Here are the details:
Shift length now: 30 hours (admitting patients up to 24 hours, then 6 additional hours for transitional and educational activities)
Proposed shift length: 30 hours (admitting patients for up to 16 hours, plus 5-hour protected sleep period between 10 p.m. and 8 a.m., with the remaining hours for transition and educational activities); 16 hours if no protected sleep period
Time off between shifts now: 10 hours
Proposed time off: 10 hours after day shift; 12 hours after night shift; 14 hours after any extended duty period of 30 hours, with no return until 6 a.m. of next day
Days off now: 4 days per month; 1 day (24 hours) per week, averaged over 4 weeks
Proposed days off: 5 days per month; 1 day (24 hours) per week with no averaging; at least 1 48-hour period off per month
There would be no change to the 80-hour weekly limit or to emergency room shifts. A one-page digest comparing the current policy with the IOM's recommendations is available here.
Remember, these are just recommendations. It is hard to say whether the Accreditation Council for Graduate Medical Education (ACGME) will act on these recommendations. My biased hope is that they do, even if it doesn't change my off-service rotation work hours. The ACGME indicated in a news release that work groups within the council will convene in April to consider the IOM recommendations.
Among the issues to be discussed will be the cost of these proposed changes. Perhaps there is something to the oft applied phrase “cheap labor” when discussing residents: The IOM estimated the annual cost for additional personnel to handle reduced resident work could be $1.7 billion. That's less than 0.5% (yes, one half of one percent!) of what Medicare spends on Americans annually. But something tells me the current economic situation may be a detracting factor in progress on this issue...
So, what can we medical students do? I think a good first step is to talk about it -– with peers, residents, and the residency directors we interview with this year.
December 8, 2008 in Thomas Robey | Permalink
Comments
They should be reduced, the current and past practices are/were barbaric. What is the difference between Training or brainwashing? Answer: about 40 hours.
Posted by: VforV | Dec 9, 2008 3:42:25 PM
I think things should stay the way they are unless people are willing to have longer residencies. Otherwise how are residents going to get adequate training?
Posted by: M | Dec 9, 2008 3:48:51 PM
I am a second year family medicine resident at Grandview Medical Center in Dayton, Ohio. We are currently addressing this issue right now in our residents advisory committee. This is a very complex issue. The current overwhelming opinion held by the residents at our hospital is that the new recommendations will greatly impact our experiences at the hospital. The proposed recommendations will especially effect OB and Surgical residencies and their ability to cover cases within the hospital. Right now we do not feel that there is a need to further restrict work hours.
Yes, call can be very difficult at times. However, looking back on my call shifts as an Intern I feel they were excellent learning opportunities, and memories and experiences I greatly value. As attending physicians we will not have work hour restrictions and may have to work longer than 30 hours, or more than 80 hours in a week.
In sum, this is a complex issue. A dramatic change should not be made without great consideration. Residents at my hospital feel that further restriction on work hours will detrimentally impact our post graduate medical education.
Posted by: Adam | Dec 9, 2008 3:49:24 PM
excellent article
Posted by: akash ferdaus | Dec 9, 2008 4:19:09 PM
Increased residency lengths are an option, sure - but an even more streamlined approach to medical competence would be to eliminate all of the excess nonsense learned during the preclinical years and concentrate instead of practical medicine. Michaelis-mentin enzyme kinetics ? Will never use 'em. JAK-STAT receptor memorization ? Clinically useless. Don't waste the burgeoning physician's time by beating them down with pointless academic gymnastics, and let them learn the art of medicine. If you want to do research; go and get a PhD.
Posted by: J | Dec 9, 2008 4:24:45 PM
The proposition of reducing work hours even further is ridiculous. The purpose of being a resident is not to allow you to enjoy your life, but rather to provide the foundation of knowledge to practice medicine for the next 20-50 years. Taking care of very sick patients while you are sleep deprived teaches you invaluable lessons about yourself; the physician you are now as well as the physician you will become. Your residency should be grueling, and upon completion you should feel that you are capable of providing the best care to ANY patient within your field of study. Without pushing yourself (or being pushed) during your training, you have the potential to negatively impact countless individuals in the future.
For example, let's say that in 10 years you are the only surgeon in a small rural community. You have been in the OR all day, and just when you are about to go home you get paged about a multiple MVA with 2 patients who require urgent life-saving surgery. If[when]you are in this situation, you should NEVER have to say "I'm not sure I can do this, I've never operated for this many consecutive hours." Instead your response should be "I have successfully completed far more complex surgeries on far less sleep dozens of times in my past." To allow yourself to feel anything but the latter of these two responses is frightening. Those 2 trauma victims will never know that you were in the OR all day before you operated on them, and even if they did they wouldn't care. All that matters to them is that you function at your best regardless of whether your tired or well rested, your dog just died, or your child was just born.
Cutting work hours in half and doubling the length of residency would provide a much more relaxed environment in which to live and work, but the ultimate result would be the graduation of older, less competent physicians. If you are not tested mentally and physically during your training you are not only doing a disservice to yourself but also to every patient you will see during your career. Becoming a physician is not an easy task, and anyone who believes it should be easy is naive. We have dedicated ourselves to providing medical care to others, even if that means sacrificing our own time/personal lives.
Some argue that sleep deprivation causes more mistakes to be made, and perhaps this is true. We have all heard the statement "your learn more from one mistake than from 100 successes." Would you rather make a few mistakes EARLY in your career, so you can learn from them and correct your actions early, or would you rather be continuously put in challenging situations in which you are unsure of how to proceed for the rest of your career?
Posted by: Mike | Dec 9, 2008 4:36:22 PM
They should absolutely be reduced. A study was done which showed that 28 hours without sleep leaves a person with the judgement impairment of an equivalent .1% BAC. Tell me, would any of you come to work that drunk? Thats assuming you got there without being pulled over for a DIU. If you're not legal to do something they let 16 year old high school students do should be legal to provide medical care to the critically ill?!
http://oem.bmj.com/cgi/content/abstract/57/10/649
Posted by: Joshua | Dec 9, 2008 4:41:37 PM
We should have the same descent hours that any other American has at work. If internists are not able to learn enough with shorter hours then there might be something wrong with the teaching system. So, lets fix it.
Posted by: angelou | Dec 9, 2008 4:47:37 PM
Some are viewing the proposed restrictions as resident-oriented, but I think they're equally, if not more, patient-oriented. As someone mentioned above, sleep impairment kills patients. That's the simple truth. As for those who think residency will no longer be rigorous enough: I believe people will still find ways to be tested to their limits.
Posted by: Mike | Dec 9, 2008 5:03:25 PM
I worked for years in the British NHS, and in my last job (before I quit and came over to the USA) I was working 96 hour weeks. It was unbearable. Believe me when I say you can't look after patients properly when you're so tired you can't remember your own name, or how to make an elevator work.
The problem was, though, that just as your system has done here, the European Working Time Directive had already theoretically "capped" our hours to a legal limit of 56 a week, but the hospitals ignored it, or found loopholes in the law. That is why I would always check with doctors in a job to find out whether what is promised is the same as what is delivered.
And don't tell me that we "need" 80 hours or more a week in order to learn. I found I learnt a lot more when I was in a job working only 46 hours a week, had plenty of sleep, time to eat proper meals, study, read up on cases, and spend quality time with patients. It may add a year or two to training, but fewer patients will get hurt, and fewer doctors will get sued.
Posted by: Karen | Dec 9, 2008 5:13:11 PM
Has anyone thought of paying residents by the hour? Why is it that everyone else in America gets overtime pay for anything over 40 hours per week when the resident works 80-120 hours per week with no consequence for the hospital and no pay for time spent working. If the hospital were paying residents on an hourly basis they might think twice about keeping them over 80 hours doing tasks that do not contribute to learning in any way.
Posted by: Tracy Childs | Dec 9, 2008 5:19:19 PM
I'm a year one medical student who is jumping up and down with joy over this!
Posted by: Jennifer Lipka | Dec 9, 2008 5:22:51 PM
I'd like to shed a little light on this subject from a different perspective. Currently I'm a second year surgery resident. Let me first state that the current 80 hour work week is more than detrimental to both patients and resident education. To restrict us anymore would be down right dangerous, and furthermore, make the arduous task of completing a surgical residency in 5 years basically impossible.
I round with my team at 6am sharp on our 20-30 patients daily. We then hit the OR from 7am to 4-5pm with little down time in between cases. Afterwards we try to figure out what's been done and what needs to still get done on our patients and even more difficult we need to be out of the hospital by 7pm. God forbid a case runs late because we encounter bleeding (which believe it or not can happen in the mythical OR) or one of my fresh post-ops is crashes, doesn't matter. I can't stay. If I do I place my program at risk to be put on probation for hours non-compliance. Forget about the patient, the ACGME & RRC couldn't care less about the patient. All they care about is work hours! Give me a break! I thought we were doctors here. I'm not advocating the old school 130 hour work weeks, but enough is enough. The current system is going to produce a class of under trained, clock watching, me-first, time card punching shift worker who want to be called doctors. If you think the public opinion looks down upon doctors now, just wait till they see us running out of the hospital while their loved one is dying. Maybe then the media will push to have us work more again. See where I'm going with this? Oh, to the ones who say, oh no big deal just sign out your fresh post-op who is crashing. Clearly anyone who makes this statement is not a surgery resident. There is absolutely no way to give "adequate" sign out to the oncoming resident to take care of MY sick patient who I just violated with a scalpel. If you weren't in the case then you don't know what's going on. You are just putting out fires until the primary team is allowed back in the hospital.
Do me a favor with you're support of these inflexible work restrictions. Try being a resident before you start calling changes. At the current moment you have no clue what we go through. You may think you do, but you don't. Trust me. Be care what you wish for ... It may all come true.
Posted by: Rich | Dec 9, 2008 5:57:08 PM
I'm right there with the poster of this blog. I am a ms-3 student and can see how 80 hours a week doesn't do anyone any good. I have been arguing amongst my classmates for the past year, that the whole medical education system needs an overhaul. My undergraduate degree in engineering, provided plenty of time for me to learn and to practice as a successful engineer while acquiring 4 patents in less than 2 years before I decided to apply to medical school.
First, the first year of medical school is relatively useless, and so is ones senior year of college, if not all of undergrad, relative to medicine.
Second, if pilots cannot fly overseas solo (12 hrs - must have 2 crews) why can a resident, in training, work 30 hours straight? How does sleep deprivation contribute to quality of quantity of learning? I'm sure pulling all nights worked great for everyone here.
Third, for the posters who stated would you rather make mistakes throughout your career or all during residency? I do not ever want to make a mistake. Unfortunately, that will not be the case, but if I make a mistake now, versus as a physician, I will learn and will attempt to not repeat it.
Lastly, for the poster who talked about a surgeon at the end of a long shift, and she should be used to putting patients in harms way because she is tired is absurd. Again, unfortunately, in this case, hopefully her humanity and compassion will be enough to operate. But most likely these patients should have been transported to a hospital with adequate staffing.
Posted by: David | Dec 9, 2008 6:11:02 PM
5 hours of "protected sleep time at night"...please...this sounds more like a day at elementary school with "recess" built in. I am doing EM as well and one of the many reasons why is because of no call but residency is supposed to be hard. It's supposed to have long hours so you can see a lot of patients and different problems. You need those nights of call to see those patients through and while I agree that the previous 100+ hour weeks were barbaric and unnecessary- doing anything less than 80 a week is going to compromise your education. You have be able to make decisions under stress and no sleep and how are you going to learn how to do that if you get to check out for 5 hours each night? These new recommendations are ridiculous and, if enacted, will be a major barrier to my education and I don't want them at all.
Posted by: Steve | Dec 9, 2008 6:15:19 PM
What a ridiculous article and of course it's written by some lazy 4th year student that's doing ER. You signed up for this, so deal with it. Our hours are nothing compared to 20 years ago. I say this as a gen surg resident workig well over 80 hrs/week.
Posted by: jenny | Dec 9, 2008 6:46:17 PM
you people are crazy...why on earth would you find all your meaning and purpose in life for a job...because at the end of the day what you do only means so much...who you are means a lot too...and I have worked with a lot of jerky medical people. I know in a life-threatenin circumstance I would want my children to have the best trained people around, but there will always be someone there to care for them...maybe not YOU, but hey maybe it's just a control issue and wanting to prove yourself. But for what? You have no quality of life? Maybe you have money...but that will only get you so much. We only pass through once people...your life will not make as great an impact as you think it will.
Posted by: Kristal | Dec 9, 2008 6:50:51 PM
I think there should be a balance. I could never call myself a doctor pulling less hours than an overworked pizza delivery boy. If you wanted a 9-5, then this is the wrong profession, at least during residency anyways (private practice or purely consult specialties may be the closet you'll get). Residency is grueling for a reason (actually for multiple reasons as others have already alluded to), but just like the first year of medical school, it's a necessary evil that molds us from lazy, multiple choice answering freaks, into a physician that can actually diagnose and manage medical illnesses. Am I saying that this can't be done in less than 80hr work weeks? Who knows??? Maybe psychiatry residents can get away with those hours and still become competent doctors (nothing against psych, although I worked more hours as a Wal-Mart employee in college than I did on my psychiatry rotation), but as the age old adage goes "practice makes perfect," and quite frankly, the less hours we work, the more lackluster we become. That goes for any job. Work hard play hard is the motto I live by. I knew what I was getting into when I signed up for this profession and I will work as many hours as I need in order to become as comfortable as possible with caring for those in need of my assistance.
Posted by: BP | Dec 9, 2008 7:06:06 PM
"I say this as a gen surg resident (sp)workig well over 80 hrs/week."
Gold star for you Jenny. Maybe your spelling is as poor as it is because of lack of sleep. I hope it doesn't impact your patient care. I wonder what other rules you disregard because you don't agree with them.
Posted by: joe | Dec 9, 2008 7:09:08 PM
This lazy 4th year student doing ER started a non-profit organization, teaches a medical ethics class, thinks extra 'volunteer' shifts in his local county ED are fun, is a student advocate, writes ridiculous articles, spends quality time with his medical student wife and is often the last person on his call team to go home. Remember, it's not me who's making the recommendations - it's America's most respected physicians elected by their peers to the National Acadamies of Science's Institute of Medicine.
Posted by: thomas | Dec 9, 2008 7:13:06 PM
Clearly this is a very controversial topic... I'm a psych intern and the mother of a 5 1/2 year old daughter. One thing I have not heard anyone mention in this blog and the NYTimes blog on the same topic is the fact that many residents these days have families. Gone are the days when all residents were twenty-something men. These days many of us had lives before medicine, and many of us have families. Our life experiences will ultimately enrich our medical practices, will make us stronger doctors. But in the training we are pushed to our limits emotionally, spiritually by the extreme time commitments. My time spent with my family is time that helps me put the medicine in perspective; it gives me balance and purpose. I learn best when I am fully engaged and not falling asleep on my feet. I can best help my patients when I am clear-headed and thoughtful.
As to the many surgery-oriented comments. Sure, there is a long tradition/culture of time over-extension in surgery. But look at the burn-out rates, look at the level of dissatisfaction among surgeons mid-career. All of that work and training, and the self is lost; the time to build relationships and start a family is lost. And the time commitment for surgeons does not end with residency. However, with the introduction of more PAs and other auxiliary staff into the OR, SICU, and surgical ward, I should think that there are more than enough capable staff to care for post-op patients. And, as for the cases that run late in the OR, yes, of course the surgeons need to see the cases through and make sure that the transfer of care is managed smoothly, but if cases running over is the norm rather than the exception, clearly there are problems. Even teaching cases should go relatively according to schedule, or the patient is being put unduly at risk. Perhaps surgical residents should spend more time in the simulator lab learning procedures and less time doing scut so that when they are in the OR they can be truly efficient and do procedures well, while well-rested.
We all want to be the best doctors we can be. As one of my training directors put it in my interview: "We expect that our residents will have balance in their lives during residency, because we believe that residency training should be training for one's career after residency. If you don't have balance during residency, how are you to know how to have balance in your professional life?"
Posted by: Jen | Dec 9, 2008 7:44:25 PM
consider this scenario: after 29hrs on call, you're paged. as you introduce yourself, the pt's family says in passing "hope you're well-rested, i overheard the nurse say you're on call. did you sleep much? you tell them politely "no sleep, but i'm fine". the pt's mother refuses your help and requests another caregiver.
you can slice and dice this issue anyway you like, but the bottom line is this. everyone knows working 30hr shifts or 80hr/wk when there is natural disaster, terrorism etc is not unusual. but even the lay person knows doing this from day to day under normal everyday circumstances is just stupid. smarten up folks.
Posted by: Icey | Dec 9, 2008 8:06:04 PM
Mike,
"Taking care of very sick patients while you are sleep deprived teaches you invaluable lessons about yourself; the physician you are now as well as the physician you will become. Your residency should be grueling"
What a wondrous nonsense! Residency is NOT field training with SAS (Special Air Services for those who do not know the acronym.) Still, to make the point a bit clearer: I wonder if you'd ever board a transoceanic ot trans-Andean flight knowing that the crew in the front office is sleep deprived, dog tired, and cognitively useless. I may be wrong, but I believe you must have missed the results of all studies on sleep deprivation and cognitive performance. Since practice of medicine is largely based on the latter, I fear that yours is a pious but also patently ridiculous pontification. Altogether, Old Fruit, there are enough medical errors committed by sheer stupidity of many within the system without further contribution by physicians who are zombied because their training must be "grueling." If you really want that, join Special Forces. Otherwise, insist on solid training: there is a lot to be wished here too.
Posted by: Dag von Lubitz | Dec 9, 2008 9:06:23 PM
80hr/wk not enough? and it surprises some when the best US students choose ophtho, ENT, Rads, Derm and stuff like this. among hospital staff, there are slaves and there are servants. i choose to be the latter.
Posted by: Icey | Dec 9, 2008 9:32:10 PM
"What a ridiculous article and of course it's written by some lazy 4th year student that's doing ER."
"5 hours of "protected sleep time at night"...please...this sounds more like a day at elementary school with "recess" built in"
...Well, as an outsider to this profession (I just completed a masters program in cognitive neuroscience) I'm very surprised to see otherwise intelligent residents spewing macho sounding crap like the two quotes above. Besides the very well-documented impairments in judgment that come from sleep-deprivation, we should remember that memory consolidation happens WHILE WE SLEEP! If you really want to learn something well, you have to sleep on it (and not just 30 hours later).
Is it really helpful to your education to suffer decreased immune function, diminished cell-repair, mood deterioration, reduced alertness, diminished concentration and of course the aforementioned memory problems all because you don't want to "wimp out" and take a 5 hour nap?
No, I don't have an insiders view of what a residency is all about. But I do know (just like you know) that sleep deprivation negatively impacts brain health and clearly leads residents/doctors to make errors that can cost patients dearly.
So if I'm ever admitted to one of your hospitals and you are assigned to treat me while you haven't slept in more than 24 hours... please just stay the hell away from me. For some reason, I can't help but think that my life is more important than your perceived need for a grueling, sleep-deprived medical education.
Posted by: Eric | Dec 9, 2008 10:25:44 PM
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