Tackling The Time Crunch: Will the 80 hour work week do the job? by Angie DeBernardo
80 hours a week. That leaves only 88 hours to live the rest of your life. Sleep – now that’s a big hit. 7 hours a night for 7 days a week? 49 hours just sleeping?? Now we’re down to 39 hours. Ouch. Maybe we can eliminate some of that. Personal hygiene: 1 hour x 7days= 7 hours. 32 hours left. 4 hours commuting time each week. 28 hours. How much of it should be spent reading? How much with the family?
Forget physiology. These are the equations that are talked about in residency programs today. Doctors in training try to squeak out a life outside of work in a few hours each week. On the other side of the desk, hospital officials attempt to staff their facilities with less labor. Residency directors hope to maximize patient experience and eliminate hours of paperwork. In a profession that takes so much time, no one seems to have enough of it.
An Ongoing Battle
The debate over the hours required during medical training is persistent. In the 1970’s, there were major hospital strikes of housestaff in Washington D.C., Los Angeles, New York and Chicago. Their demands? Better pay, Q4 call, and an 80-hour work week. Strike settlements at the time promised some relief. Unfortunately, these advances were struck down by a decision from the National Labor Relations Board (NLRB) that medical residents were not employees but students and not entitled to collective bargaining.
In the 80’s, the Libby Zion case challenged the status quo in New York City hospitals. The 19-year old daughter of a New York Times writer and lawyer was brought into an emergency room with a 103 degree fever. She was admitted. In the morning, she was dead. What went wrong is disputed to this day. It is clear, however, that she was treated by overworked and poorly supervised residents.
For 11 years, her parents waged a campaign for change that resulted in New York State’s 405 rules. These regulations require that residents work an 80-hour work week, with no single stretch longer than 24 hours, followed by 24 hours of rest. They also require that there be 10 hours between shifts and that residents get one day off a week. Although the new rules have been in effect since 1989, compliance was spotty for over a decade. In 2001, additional legislation was passed to provide independent inspections of hospital programs and stiff fines for infractions. Even with this added incentive, the 2002 inspection found 60% of programs were in violation. All this was subtle progress. But the latest round of regulation may prove to be the most influential of all.
The ACGME Steps In
In the last few years, the Accreditation Council on Graduate Medical Education (ACGME) has taken the first major steps towards finding real solutions to the time crunch. New guidelines on housestaff work hours are universal. They apply to all programs and fellowships across the nation. And with the new rules linked to residency certification instead of hospital economics, these changes could have lasting results. If enforced, these limits are expected to impact medical training, hospital economics, patient care and – with any luck at all -doctors’ quality of life. Let’s take a look at where things stand.
The ACGME currently limits resident work hours to 80 hours of in house duty per week averaged over a four week period. This includes patient care and scheduled conferences. Residents are entitled to one day off from all clinical and educational requirements each week. Home call is not included under the hour restrictions but programs must still allow for one day off for each 6 days on home call each month. Moonlighting done within the same institution must be included in the hours calculation as well. (For more information see ACGME)
Medical training
One argument against hour restriction is that programs think work experience will be limited. The quick fix proposed by many is adding more years to training. So, will the new work hours make residency longer? That’s a sticking point for many medical families. Is it better to have more time with your loved one every day but train for additional years? Many might opt to train harder for less time. There are two counter arguments to this. :
First, studies have found that residents spend between 20-40 percent of their time on tasks that are non-educational. It is possible that eliminating administrative tasks would help residents concentrate on patient care instead of paperwork. This approach is helping at Case Western University. In a report submitted to ACGME, Dr. Keith Armitage describes the use of an electronic medical record system to increase efficiency. Residents using the system report a time savings of 1.6 hours per day (see the report here).
The second argument is based on anecdotal evidence only. Some have theorized that although the amount of time spent in the hospital by residents may decrease, they are actually still seeing the same number of patients. In today’s medical climate, patients are sent home sicker. Hospital stays are short. The average resident in 2005 has a sicker, busier service than a resident from years ago. If this argument holds true, then residencies would not have to lengthen in time to offer the same amount of patient experience.
Patient care
Many of the changes in work hours have been brought in the name of patient care. Sleep-deprived doctors have been shown repeatedly to make more mistakes after long shifts. The latest study in the September 7th issue of the Journal of the American Medical Association compares decisions made by doctors on 90 hour work week rotations to doctors on 44 hour work week rotations.. In this study, however, they added a twist. The well-rested doctors were tested with a blood alcohol level of .05 and compared to their sober – but tired – colleagues. The well- rested physicians did better. (To view the original study, go to the JAMA educational issue.) The study makes a point to the general public. Few would want a surgeon who had just downed 2-3 glasses of merlot. Why do you want one that has worked 90 hours this week? It seems only logical that reducing work hours would lead to better patient care.
Interestingly, it isn’t clear that the current changes will improve medical treatment. Let’s return to the Libby Zion case for a moment. Although Libby Zion was treated by chronically tired and overworked residents, the real issue was supervision. As things stand in most programs today, work hours have decreased but supervision has as well. With more residents home and resting, fewer doctors keep watch over patients. In fact, more studies are showing that shift change and lack of continuity of care contribute to physician error.
Hospital economics
Clearly, if residents are to work less, someone has to work more. So who will it be? In many hospitals, the gap is being filled be physician assistants and nurse practitioners. In the wake of the 2003 mandate by ACGME, hiring for these positions has increased. This solution offers the added benefit of continuity of care. Physician assistants and nurse practitioners do not rotate. They are available every day to help facilitate the flow of information. Of course, some institutions do not have the funds to add new medical staff. It is also difficult to fill overnight shifts traditionally taken by residents.
Others have applied for additional residents – a logical solution. Unfortunately, this takes significant lead time. A program must apply for more residents and demonstrate that it has the patient volume to educate them. Also, since the federal government provides funding to the hospital for each resident slot, new positions may only be filled in select institutions.
But for some systems, the extra work has been kicked upstairs; residents go home, so fellows pick up the work. Fellows get work hour restrictions, and the work shifts to attendings. What will happen in these systems when the attendings begin to feel the pinch? Patient load is not expected to decrease – in fact with the baby boom entering their senior years, it will probably increase. Health care systems that have no real solution to the staffing issue could face trouble in the years ahead.
There have been calls for the government to ease this transition. Dr. Jaya Agrawal and Dr. Joshua P. Rising wrote in their 2002 report on patient safety in American Family Physician (read it here) that the U.S. government should assist in the substantial cost of the transition. They argue that the government would demand regulatory authority over residents in return for cash; in return, government could provide unbiased research into patient care and safety to shape new policy. Unfortunately, most medical organizations are against government interference in the training process. The money for transition will most likely come from increased cost to patients.
Quality of life
Has all this made doctor’s lives better? We can only guess. The most recent data from the ACGME suggests that most programs are working to adapt. In a survey of 33, 204 residents across all specialties, only 3% reported working in excess of 80 hours a week. Inspection of 2, 002 programs last year resulted in only 195 citations. (For a full report, click here.) As their work demands decrease, it is expected that doctors in training will enjoy a better home life. At least they’ll get the rest they need to function.
Are these reports accurate? It is hard to know. Some residents may see reporting a program as a career killer. At the very least, peer pressure from other residents and from above makes it difficult to report a program for misconduct. That’ what was found by a preliminary study presented at the Annual Meeting of the Association for Surgical Education last Spring. In a report from the Surgery Program at Vanderbilt University, 80% of 170 residents polled claimed that they had exceeded work hour restrictions in the last 6 months. 49% admitted under-reporting work hours to their program directors. Respondents cited patient care as the number one reason for over work, but an alarming 30% reported over work due to their senior resident’s expectations. If this holds true, it suggests that many residents work in a culture that expects them to work beyond restrictions and lie about it. In programs that do not enforce, hour restrictions add an ethical dilemma to an already difficult training process. – and glowing reports to the ACGME may be inaccurate. Independent auditing would become necessary – just as it did in New York 10 years after the introduction of the 405 rules.
Making a Report
If you are in a program that does not enforce the hours restrictions, your options are limited. There is currently no independent monitoring of compliance. Once a report is made, the program will be notified. In small programs, there is a significant risk that you will be identified. After hours restrictions began, Dr. Troy Madsen , a resident in Johns Hopkins Emergency Medicine reported the internal medicine program for violations. Although his report resulted in investigation and suspension of the program’s accreditation, his personal experience was grim. His account of the aftermath can be read here..
The ACGME suggests the following. Report problems to your chief resident. If that doesn’t help, move on to the program director. All institutions are required to have an institutional graduate education committee or similar oversight body. This should be the first step outside your program. Some hospitals have house officer organizations and the AMA has a resident physician section; complaints can be made to these organizations as well. If all else fails, contact the appropriate Residency Review Committee. Both you and the executive director of the review committee must sign an official complaint. You may not bring complaints anonymously; however, the ACGME makes every attempt to maintain confidentiality. After your complaint is received, the program director and the CEO of the institution will be notified. They may respond to the complaint. The review committee will decide to cite the program, dismiss the complaint or investigate via a site visit. You will be notified no matter what happens. A complete list of Residency Review Committees can be found at the ACGME website.
At least residents aren’;t in this fight alone. There is pressure from patient advocacy groups, sleep researchers – even the federal government. For the third time in less than five years, a federal regulation has been proposed to regulate physician work hours. The Patient and Physician Safety and Protection Act was originally introduced by Rep. John Coyners (D-Michigan) and Sen. John Corzine (D- NJ) in 2001. The proposed national law does provide for independent monitoring of programs and link compliance to Medicaid payments for institutions. With the threat of federal regulation looming, things are sure to move forward.
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