Medical training has always been arduous. In the past, it was not uncommon for Physicians to spend upwards of 120 hours in the hospital per week. There was no such thing is an 80 hour work week and there was no limit upon the number of consecutive hours that could be worked. Residents were known to work nonstop for 48 hours or more in some instances. This, in fact, is where the term resident originated because they basically lived in the hospital. The discussion of resident work hours began with the Libby Zion case in New York in 1984. Ms. Zion was a young woman who was admitted to the hospital and ultimately died from Serotonin Syndrome when the residents caring for her failed to recognize the dangerous interaction among medications she was being given. A jury on the case found that fatigue and medical error played a part in her death as residents were likely to tired to pay attention to detail and missed a small, but significant point that might have noticed it they were more alert. Over recent years, increasing attention has been paid to the number of hours that residents work and how this affects their performance. In the last 5 to 10 years the medical profession has seen the implementation of guidelines that restrict the number of hours a resident may work per week to 80. However, a recent study by the Institute of Medicine (IOM) is suggesting that those hours be further limited.
Few things in medicine are as hotly debated as is the question of resident work hour restrictions. Attendings often point out that when they were training they were required to work 100 to 120 hours per week. It is often suggested that this intensive work schedule was necessary for residents to obtain the necessary experience to become adequate physicians and that limiting the week to anything less than 80 hours would result in inadequately trained, incompetent doctors. Many, however, find this philosophy to be shortsighted and downright hardheaded. On December 2, 2008 the Institute of Medicine, an agency under the tutelage of the National Academy of Science, released a report suggesting that strict limitations on the number of hours residents work are necessary in order to protect patients against “fatigue-related” errors as well as to enhance the ability of doctors in training to learn. Basically, the IOM is not only refuting the claim that long hours are necessary to produce competent doctors, but that the opposite is true and a better education can be obtained by limiting work hours and reducing fatigue. While the report does not mandate a reduction in the current 80 hour work week, it is likely the first step in passing regulation to further reduce the number of hours residents work. Among its recommendations is the suggestion that residents be limited to 16 hour days, down from the current limit of 30 hours. In addition, the report recommends that time between shifts be increased from 10 to 12 hours and that resident recieve 5 days off per month rather than the customary 4 days currently in effect.
What many older physicians fail to take into account when they fondly reminisce about their days in residency training is that the environment in the hospital has changed greatly and so have the needs of residents in their personal lives. To start, patients admitted to the hospital today are far sicker than they were 20 years ago. Simple cases that would have been “no-brainers” but still admitted to the hospital 20 years ago are now managed on an outpatient basis. While attendings often discuss their patient load of 30-40 patients that they stayed up all night to care for, they fail to take into account that fact that only five or six of the patients were critically ill and required intensive time and work to understand an treat. People live a lot long today and as a result are presenting to the hospital with multiple diseases. No longer is it a simple case of pneumonia or heart failure, rather any given patient is suffering from heart failure secondary to COPD that is being exacerbated by pneumonia. All this is on top of their other chronic diseases like diabetes, asthma, sleep apnea, obesity, and kidney failure. Add to all of this the explosion in the number of drugs individuals take and it is easy to see how complex life has become for residents. Gone are the days of treating a single disease with a single agent. Residents today must treat multiple diseases at one time and understand all of the medications a patient is taking (which can easily mount to 30 or more) along with their side effects, drug – drug interactions, and whether the patient’s insurance covers it. In addition, there are far more machines, procedures, and technology in general that a resident must understand that his predecessors did not have to deal with. Medicine is more complicated now that it ever has been.
A second change that is forcing medicine to rethink the way it educates and treats residents is cultural. Even 20 years ago, the female doctor was rare. Medicine was a men’s only club and as such they were free to devote all of their time to the hospital while the “little woman” stayed home to raise the kids, cook the meals, and maintain the house. Those days are gone and I say “good riddance.” Half of all medical students and residents are female now and the responsibility of raising a family is shared more equally among men and women. This means it is not possible for residents to devote all of their time to medicine and still raise a family and it certainly is not fair to ask all residents to choose between career and family. If we do that, there won’t be any doctors left. The point is that times have changed, people’s priorities have changed, and it is time for medicine to adapt.
Doctors will often argue that learning how to cope with long hours in residency is necessary to allow them to perform well under these same pressures when in a private practice setting. The scenario is often created where a single doctor is ending a long shift in a small rural hospital, miles from nowhere, when two trauma victims are brought to the ED and require immediate surgery necessitating that the doctor work long into the night to save the lives of these patients. This is a very romantic scenario where the lone doctor saves two dying patients who are forever grateful for his skill and determination, but it is also chauvinistic, narcissistic, and extremely unlikely in today’s world of helicopters and tertiary referral centers. Truth be told, this situation is so unlikely that it borders on the impossible. Today, transportation and medical response time are so rapid that patients in such situations are often flow to center with advanced capabilities and throngs of surgeons waiting to serve them. A hospital so small as to have only one surgeon on duty at any time would be too small to handle such a case anyway and the patients would automatically be routed to a larger center with more staff. I doubt there even exists a hospital that has only one surgeon to choose from at any given time. Even the smallest of hospitals often have half a dozen choices. This argument reflects something that all doctors are guilty of at some point in their careers, which is that they think they are the only people in the room (hospital, maybe even the world) of providing the right career to a given patient. Their narcissism gets the better of them and they are deluded into thinking that without them the hospital will cease to function. The CEO of a very prominent pharmaceutical company once espoused in a lecture that believing you are so important that a company or organization cannot go on without you is a fundamental flaw in mot CEO’s thinking. He pointed out that even the best CEO can be replaced the very next with only minor blips in the operation of a company. The same holds true for doctors. A given surgeon can be replaced at any moment and few will notice the change except his or her closest friends. The operation of the hospital will change minutely, if at all. This argument is bunk and any physician who makes it should find his or her way to the therapist for a long talk about personality disorders. Not surprisingly, this argument is most often made by surgeons who, among physicians, tend have the biggest egos in a profession where overdosing in self-importance is the name of the game.
Another often quoted argument is that limiting work hours will interfere with education and force residents to train for longer periods of time before they gain enough experience to practice on their own. There are a myriad of rebuttals to this argument, so we will look at only a few. First, the IOM study points out that the three many objectives of residency training are gradual assumption of responsibility, sufficient continuity of care with any given patient, and time to engage in reflective learning. They correctly point out that what matters most is not the number of hours logged, but rather that an environment exists that satisfies the three principles above during the hours that residents are on duty. In medical training, the attending is an experienced physician who is in charge of attending to all of the patients that a given group is taking care of. It is his or her job to teach the residents and guide them in the day to day care of their patients. The problem is that the workload in an average hospital prevents an attending from spending any significant amount of time teaching. Ideally, each resident would have one attending who oversees his or her work and helps guide the resident in performing procedures. In this way, the resident would get the maximum amount of education and the patient would receive the maximum attention from the most experienced physician. The problem, of course, is the expense. This solution obviously needs to be expounded upon and altered to be feasible, but the point is clear. It is not the quantity of time that a resident spends in the hospital but rather the quality of the time that is important. Medical education is on the precipice of change, it simply needs o take the initiative and update a methodology that is nearly 200 years old.
Another reason long work hours do not benefit education is something that every mother has been aware of since the dawn of time. Good sleep results in happier, more alert students who are able to process and retain information better. Why doctors do not yield to this argument is beyond me, because their own research into sleep and cognition proves that individuals need adequate sleep in order to function at their best. It has been shown conclusively that consolidation of information learned throughout the day and strengthening of memory occurs during sleep. In addition, well-rested people are more attentive and more likely to pick up on subtle detail than those who are fatigued. Time and time again, research has shown that adequate sleep is essential for learning. If doctors want to be the best that they can be, and believe me that it is a sense of pride that ensures that they do, then need to maintain good sleep hygiene and achieve adequate rest. Working 30 hour shifts and 80 hours in a week does not leave enough time to rest properly.
Finally, if nothing in the above arguments is convincing, then the safety of the residents should be. Every year, residents are killed in automobile accidents while driving while sleep deprived. Studies show that after being up for 30 hours straight, a person’s mental function is equivalent to someone with a blood alcohol level o 0.1. That is legally drunk. We certainly would not force residents to get plastered before driving home, so why force them to do the equivalent by staying up all night. If for no other reason, the happiness and the safety of the residents should lead to reduced work hours.
Work hour restrictions will be tightened, there is no doubt. Regulatory agencies will begin to enforce them more strictly and there will be consequences for hospitals that break the rules. The culture has changed and the way medical care is delivered is different. The change is coming and there is no stopping it, so rather than arguing that residents need to work long hours to learn and be good doctors, that energy would be better spent coming up with good ideas for ensuring that residents get proper training, patients receive proper care, and that it is all done in a reasonable work day. I mean, doctors are supposed to be some of the smartest in society; I would hope that they can come up with something a little more creative than working themselves to death.