Resident’s Working Hours- Should We Let Sleeping Docs Lie?

The Accreditation Council for Graduate Medical Education (ACGME) has released proposed new standards to limit working hours for medical residents. Bus drivers are allowed to drive for 10 hours and then are required to have 8 hours off duty. Airline pilots can be scheduled for up to 16 hours on duty — being at work, ready to fly — and up to eight hours of actual flight time in a 24-hour period, with a minimum of eight hours for rest between shifts. Physicians in residency training work 80 hours or more a week (compared to 75 hours a month for airline pilots) and are regularly on duty for more than 24 hours at a time. If adequate rest is an important safety measure for drivers and pilots, isn’t it important for doctors too?

When I was an intern and resident, my hours were a little better than some. Instead of every other night, I was on call every third night. I had to work from about 7 AM one day to 5 PM the following day (34 consecutive hours). I stayed in the hospital: there was a call room with a bed, but if we got to lie down it was never for very long. When I got off duty, my sleep-deprived body demanded that I go home and crash. It was only every third day when I worked “only” a 10 hour shift, that I could devote an evening to all the other activities of my life like laundry, grocery shopping, and trying to read medical journals. One memorable weekend I worked from Saturday morning to Monday evening and only got to lie down for about 20 minutes. I don’t think I made any fatigue-induced mistakes that hurt patients, but by Monday afternoon I was groping my way through brain fog and running on fumes.

The arguments for the brutal schedule seemed to boil down to these:

1. We had to do it in our training, so we’re going to make you suffer too. (Were they arguing for tradition or revenge?)
2. You need to spend all night at the hospital to have the experience of continuity of care for your patients, to see how illnesses evolve over 24+ hours.
3. Someone has to be there to take care of the patients at night, and there are only so many residents.
4. It teaches you that when you feel like you are so fatigued that you can’t possibly carry on any longer, you actually can. This is a valuable lesson to learn before you are confronted with a situation in your practice or in a disaster where your sleep is interrupted.
5. It’ll grow hair on your chest.

I thought:

1. Since you had to do it yourselves, you should have some compassion.
2. Is there any evidence that getting the experience of continuity in this way actually produces better doctors? If so, is it possible that we could find a more humane way to get that kind of experience?
3. So hire more residents or put staff physicians into the roster.
4. Couldn’t you wait to learn that same lesson naturally during an actual emergency situation? Aren’t we smart enough to learn this lesson from one experience? Does it really require repetition every 3 days for several years?
5. No thank you, I’m a girl.

Libby Zion and Repercussions

We bitched a lot, but nothing happened until a young woman named Libby Zion died in 1984. The ensuing accusations of murder and an official investigation and civil suit attracted a lot of media attention. Libby’s case was complicated, but her death was attributed to an injudicious combination of medications, and it came out that the prescribing doctor was an intern 8 months out of medical school who was making middle-of-the-night decisions on her own during a long shift (well over 24 hours), was responsible for 40 patients, and was supervised by an attending physician who was at home and available only by phone. In 1989, New York State passed the Libby Zion Law restricting residents to an 80 hour work week and 24 hour shifts and requiring attending physicians to be physically present in the hospital. (It is far from clear that Libby’s outcome would have been different if those restrictions had been in place at the time.)

In 2003 the ACGME followed New York State’s example and enacted similar standards for all accredited residency programs in the US.The 24-hour shift limit can be extended by up to 6 additional hours to allow residents to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care. “Adequate supervision” by qualified faculty is required but not clearly defined.

Did it do any good? We’re not entirely sure. This study showed no increase in re-admissions or deaths following the 2003 reforms. These results were questioned: hours worked were self-reported; the actual hours worked may not have decreased. Another study showed that interns made substantially more serious medical errors when they worked longer shifts of 24 hours or more.

When a resident’s shift is over, responsibility for patients is transferred to another resident who didn’t do the admission or workup, knows the patients only on paper, and may easily miss crucial details. Will patient care suffer as much from lack of continuity as it does from physician fatigue? We don’t know.

New Recommendations

A task force of the ACGME recently reported:

Over the past year, the task force conducted a thorough examination of patient safety, duty hours, resident supervision, educational outcomes and training standards that included hearing testimony from more than 100 individuals, receiving written presentations from 100 medical organizations and commissioning three independent reviews of the literature on sleep issues, patient safety and resident training.

In response to the recommendations of its own task force and to an independent report by the Institute of Medicine (IOM) the Accreditation Council for Graduate Medical Education (ACGME) has issued enhanced standards scheduled to take effect in July 2011. Programs will have to follow them or lose their accreditation. Shifts will be limited to 16 hours for first year residents and 24 hours for subsequent years, with 4 more hours for handing off patients or remaining with an acutely ill patient. First-year residents will get more supervision.

Anticipated Adverse Impact on Family Medicine Residencies

In a letter to the ACGME, the AAFP and five other organizations have raised concerns.They are worried that the new requirements

• will decrease the overall educational time and clinical experiences for family medicine residents.
• will impair many programs’ ability to meet the required continuity patient care visit thresholds in the ambulatory setting, thus compromising a key educational component of family physician training.
• are likely to promote a “shift work” approach to practice that is not consistent with efforts to move toward more patient-centered care.
• could result in the need to extend family medicine training to 48 months, thus increasing costs and potentially hurting current efforts to recruit medical students to choose careers in primary care.
• have the potential to cripple small, community-based residency programs because of insufficient personnel to provide full patient care coverage.Worse, according to results of a July 2010 survey of family medicine residency programs, the adoption of the proposed standards would threaten the existence of nearly 40 percent of programs with fewer than 22 residents.

Among other recommendations they ask the ACGME to :

• develop and implement pilot studies in which different duty hour requirements are measured against medical errors and patient safety guidelines;
• publicly acknowledge that the new duty hour restrictions will require an increase in training program faculty, with associated increases in program costs;

Other Dissenting Opinions

A letter to the editor in the New England Journal of Medicine (NEJM) argued that the new guidelines redistribute the responsibility for care.

This forced change diminishes a critical experience that previously contributed to defining a physician as having a profession rather than just a job. Personally, we would rather be cared for by a fatigued professional who feels responsible for our care than by a well-rested shift worker who does not.

An article in the same issue raised other concerns. The IOM report stressed that additional funding would be needed. They estimated that approximately $1.7 billion would be required to hire other medical providers just to bring programs into compliance with the 2003 ACGME standards.

The American College of Surgeons expressed grave concerns, predicting “a negative impact on patient safety and continuity of care unless there is a substantial increase in human resources to replace the residents.”

A Duty Hours Congress convened by the ACGME voiced opposition to the recommendation for extended sleep periods, and the AMA adopted a policy opposing it.

Conclusion

The proposed new guidelines will be kinder to residents (more sleep, more time with family). They can be expected to reduce physician fatigue, reduce fatigue-induced errors, and improve supervision. They can also be expected to increase the cost of medical education, result in the closing of some training programs, reduce hours of education, reduce direct responsibility and continuity of care, and possibly increase errors in patient care due to lack of continuity. Whether there will be a net benefit to patient care or physician education remains to be seen.