Tuesday, December 12, 2006
Resident Work Hour Limitations a Bad Thing??
Over the past few months, we have been working on a documentary about the impact of resident work hours. There have been many studies about this topic, primarily relying on questionnaires, but we decided to spend several weeks with resident doctors from different specialties to see for ourselves what their work hours and their lives were really like. Several things started to become apparent.

First off, it is true that resident doctors do routinely work shifts lasting longer than 24 hours. In fact, despite regulations put in place by the Accreditation Council for Graduate Medical Education, many surgical residents work 30-hour shifts twice a week on top of their regular daily hours, for a total of 80 to 88 hours a week. While the limit is 80 hours, an extra eight hours may be added, if used specifically for learning purposes.

It also became clear that anybody who is awake for 24 hours in a row has trouble staying awake and may nod off from time to time, usually in lectures or when in front of the computer finishing paperwork.

Finally, as we interviewed people from various facets of medical education, such as deans, chairmen of training programs, residents themselves and nurses, we realized that the regulation of work hours is a very contentious issue.

At heart is the obvious, which is the possibility that sleepy doctors might make more mistakes. And, according to a study released yesterday from the division of sleep medicine at Brigham and Women's Hospital, doctors in training reported that they were four times more likely to make a fatigue-related medical error after working five or more long shifts. Others will argue that resident doctors need to work the longer shifts so they can have continuity of care with sick patients. After all, if they leave the hospital in the middle of caring for a patient, couldn't that jeopardize care? And, what about the concern that doctors who have curtailed the number of hours in a residency program might not be trained as well for real-life practice as doctors who worked the longer shifts?

It is by no means an easy question. For now, the work hours will be regulated. I am eager, though, to hear what you think.

Look for CNN Presents: Grady's Anatomy coming to CNN in March.
I'm hearing Med School now costs about 120 thousand to 300 thousand dollars now according to which college a medical student attends. And you know how everyone is crying for more nurses because we have such a shortage of them. Well it cost anywhere from an average of 25,000 to 65,000 to go to nursing school now. That's bad!!! It's almost like a sacrifice to go into the medical field these days because it's so expensive, and you can make more money in other careers that don't require the expense of education. You see I heard last year average medical staff pay was only raised by an average of 3 percent, but the price of medical schools tuitions increased on average by close to 10 percent. Having to pay for college is what's stopping a lot of people from going into the medical field. The pay is not comparable to the amount of debt that people will acquire while in the medical programs. Allied health, nursing and medical school is almost becoming outrages to pay for. I think the shortage of medical staff, nurses and doctors is going to get worst.

And honestly the amount of pay that resident doctors get is so small to the amount of work they have to do. It's such a sacrifice to go into the medical field now. I pray for all of you who are in medical field, and I hope medical care here in America can get better.
I'm glad medical training is getting a little more humane. During mine, in the early 1980s, a 120 hour workweek was not unusual. We joked that the first 24 hour stretch of a shift was the easy part; the last 12 were really tough! Not only does patient care suffer when young doctors are too exhausted even to focus their eyes, but over time the compassion drains away too. Some recover it and some don't.

Then in practice we have endless pay cuts, government intrusions and trial lawyers constantly trying to get between us and our patients.

Nowadays the best and brightest college students know that many other careers offer far more financial and personal rewards than does medicine. As I approach retirement, I fear that by the time I am old, there will be no one left who will want to do what I do.
I am a medical student, about to enter the third year of medical training and doing medical rotations. Med students get fed plenty of differing opinions and perspectives from those with more advanced training like other med students and residents, but the one consistent view point I've encountered is the benefit to patient care and doctors' sanity when it comes to capping residency hours. There is much variability between different specialities to be sure, but I find it telling that in fields such as Emergency Medicine, hours are very strictly regulated for residents and physicians alike, purposefully to improve quality of care. Alarming, however, is the apparent phenominon of departments (like surgery) manipulating the system by placing undue pressure on residents to lie about the number of hours they've worked in a typical shift so the department will not appear to be violating the law. Some residents do this to themselves, however, in the hope of impressing their attendings or thinking that they will gain a competitive advantage over their peers for the added training they gain working extended (albeit illegal) shifts. These types of situations, from what I hear, appear at top surgical programs in the country, namely those in the Northeast. I'm curious to see if your reporting will delve into this matter in any substantial way. I hope that these allegations are no more than mere rumors, but as it stands reality is very hard to discern.
The idea that one can work effectively at an cognitively demanding task such as medicine is as traditional to the field of medicine as it is ludicrous. Studies of surgical outcomes suggest one's abilitues decrease even across a 12 hr day, as early morning cases have less complications than afternoon cases. The culture discourages honost reporting of hours as well. In addition, the hours rule is honored more in breach than in fact, since pager call, in which the resident is wakene by pager every 20 min or so is not limited. The essential problem is driven by money, as from a financial perspective medicine is more profitable if fewer people are employeed for minimal money to take care of as many patients as possible. The end result is overworked residents and nurses in the name of hospital profitability, rather than by educational and petient safety concerns.
The reality of medical practice after training is that long hours will be commonplace. The public has the expectation that their doctors will be available on demand at any hour, especially in my specialty of intensive care. We continue to do our residents a dis-service by not expecting them to be able to perform under stressful/fatigued conditions. Generally those who write these rules have good intentions, but likely have forgotten or have never had to perform under conditions less than optimal. Ask any of the returning physicians from the Iraq war if they are not grateful for the stress they underwent in training. I suspect I know their answer. Practicing medicine is not easy and not for everyone who graduates from medical school. As someone wiser than me said, "If you can't stand the heat..."
I am a 4th year medical student, applying for residency to general surgery programs. People tell me I'm crazy, that I should do something else, where the hours are less demanding and the environment is not as malignant. The simple fact is this:

The medical system that operates in this country is an established system that relies on a hierarchy. Do you think an established physician is going to wake up 2 hours earlier so that he can help his residents only work 80 hours per week, when he had to go through 120 hour weeks during his training? Of course not. The teaching hospital in America functions on the blood, sweat, and tears of its residents. They're called "house staff" and "residents" because they're supposed to (or at least they used to) live in the hospital. Without them, who's going to take care of the patients? There IS a shortage of physicians, residents, nurses, etc. and until that is corrected, or Americans start going to the hospital less and taking better care of themselves, all residents, especially surgical residents, will have to find a way to make the new system work for them.
To adapt to the 80 hour work week, every hour of every day is going to have to be utilized with supreme efficiency. Also, I think that there has been more of a shift towards hospitals hiring mid-level practitioners (Nurse Practitioners and Physician Assistants) who can help the resident staff out by staffing clinics, taking care of administrative paperwork, etc.

To put it bluntly, it's foolish to think that a system where people work 120 hours per week is going to change overnight just because the AMA or ACGME says so. It's simple math--4 residents times 100 hours per week is 400 hours of resident patient care hours per week. If you're limiting the hours per resident per week to 80, you'll need to add another resident or mid-level practitioner to make up for the difference.
Approaching my 10th year out of medical school, I experienced a residency in Internal Medicine without limitation of work hours and a fellowship/first academic position working with residents with the limitations, I am torn with regards to this issue.

I would agree that fatigue in general leads to medical errors..there were many post call days that I could barely focus on simply writing a progress note at 3pm after being up all night. Driving home later that afternoon was also a health hazard to myself and others on the road.

However, I have observed that leaving the job after a certain time period tends to lead to a sense of irresponsibility on residents behalf. How many times have a consulted as a subspecialist on a patient at 4 pm and found no physician (the one requesting the consultation) to contact with recommendations. Furthermore, I have observed medical errors directly related to the fact that up to 3 different physicians "cover" a patient over a 24 hour period without truly understanding the overall picture/sitation of a patients health.
Finally, simply limiting residents hours leads to more work for fellows, faculty members....

Which leads me to my final concern which has been echoed in previous posts...the status of academic medicine for faculty. Luckily, I received a full scholarship to a private institution for medical school...I look back now and wonder how on earth I would have paid my loans with a job in academics. I know for a fact that nurses and pharmacists make more than my starting salary at an academic institution as a board certified subspecialist. In short, I am getting out, as I feel that I will not be able to provide the best for my children (send them to the same caliber institutions...) with such income. With the low salaries and more work (given the resident limitations), I feel that academia will lose a lot of persons in upcoming years if something is not done...
I do believe the state of medical care in the US is headed downhill. In part, it has to do with all the sacrifices both financially and emotionally that health care providers have to go through. As has been mentioned before, the cost of medical and nursing school is skyrocketting.
The years required to complete training keep increasing and during this time pay is minimal. I remember going to McDonalds after being on call for 40 hours, and realizing that I was making less than a McDonalds worker. I am in my 30's and my pay has not increased that much, since I am still in training- over 28 years of schooling since age 4.
Malpractice insurance costs, and malpractice suits , many frivolous, keep increasing. Many patients do not trust or appreciate their physicians, which in turn leads to burnout for the physicians that do still care. And some patients and many lawyers see physicians as their lottery ticket. To top it off insurance reimbursement keeps dropping for physicians, despite the so called increased cost of health care. Yet patient's don't realize that it's not the physicians getting the extra money everytime their insurance premiums increase. Maybe the insurance CEO's salaries should get published every year along with the best paid actors.
So, in conclusion, why would an intelligent, caring, compassionate individual want to go into the medical field- where they are in debt, have to postpone or possibly sacrifice having a family to complete training, get paid less and less every year, have to worry about getting sued for every decision they make, and ultimately, not even being thanked for anything they do, by the patients that they try to help. I believe in the future the smartest and brightest will start picking other fields.
i have been an RN for 12 years- 8 of those were spent working in a teaching hospital- for the first few years i was employed the residents worked the 100++ hours required by the program- we would watch them from their first day- well groomed- rested- friendly and ready to learn through the first year where they became not so neatly dressed- exhausted- short-tempered and already feeling like they knew everything- as they progressed through the program they adapted to the long hours but not without consequences- they aged virtually over night - lost all joy in learning and patient care and friendly- well- let's just say it wasn't pretty- as the new residents came in with the 80++ hours you truly could see a difference- they were tired of course- but not the bone deep exhaustion that the previous residents suffered- they seemed more focused- their attitudes both towards the patients and the rest of the staff was much more positive and they seemed more willing to go that extra mile to help out when the residents before clearly did not have the energy- i cannot say which group will go on to be better doctors- but i cannot see how exhaustion can ever be conducive to learning- i personally would want a physician that i knew had at least a few hours of sleep the night before as he came into the OR and i was his patient!!! and while i have this open forum- i will say i have left nursing after 12 years- it is truly one of the most under appreciated- under paid- under staffed and over worked professions out there- i had such dreams when i first entered nursing school- but they ended up nightmares after 12 years in the trenches- changes need to be made because there will be no one to care for the patients if nurses aren't given the status and the respect they deserve in the medical community-
As a 4th year medical student applying for residency I think it is very important to understand the shift that is occurring in medicine. As I interview for a position in Internal Medicine, I have noticed a shift from the traditional night call system (30+ hours in a row) to that of a night float system. This concept was foreign to me when I began my interview trail, but many programs say that the night float system, in which a separate team comes in for a 7pm - 7am shift, is the only way to truly comply. This begs 2 questions in my mind: 1) How does the continuity of care work when one team admits the patient overnight, and another takes care of the patient for the day, and 2) what does this say for all those programs out there that do not have a night float system? In this day and age where our attendings worked in the old setting of unlimited hours, I definitely have to say that there is an unwritten pressure to work as long as it takes to get the job done, ie impress the attending and faculty.

I hope that your report will shed some light on this shift in medical training.
Maybe the government can use rising medical tuition costs to the advantage of poorer people by making tuition free or reduced for doctors and nurses who agree to work in underserved areas or go into fields that are less lucrative and less popular (e.g. primary care).

Also, I think rising costs of nursing tuition is extremely sad. Doctors will be able to make that money back so rising costs will hopefully weed out the people who go into medicine for the money. The last thing the healthcare system needs is another greedy doctor who doesnt care about treating people who are most in need but who aren't insured.
One thing I know is that residents are pressured to lie about the number of hours they do work. A friend is in a specialty residency program and has been pressured numerous times to change his call sheets to reflect fewer hours so that the program doesn't get fined. Failure to do so, means having your name blacklisted and will make the likelihood of getting a fellowship difficult. No win situation. Yet the EU's residents work substantially less hours, yet are no less skilled?
The discussion seems to be centering around tired physicians making mistakes. What about the mistakes made at sign outs. In Emergency Medicine (my speciality) most malpractice suits occur when a patient is signed off to another physician to cover. In my group we don't sign patients out. We stay until our patients are taken care of.
If residents, who don't have the knowledge base of practicing physicians participate in the practice of signing patients out because their shift is over, I am concerned about patient's getting the best care.
I can tell you firsthand from working in a hospital that mistakes are being made by the residents. The same people who tell us how important it is to get enough sleep every night are the ones who put our lives in jeopardy for lack of it. The only people who benefit from the long hours and low pay are the ones concerned with the making money for the hospital. I think it should be illegal for this to continue on. Patients die everyday due to medical errors, how many are made by overworked employees?
This is a huge question. Anyone in their right mind knows this is not healthy for anyone. Most importantly this lack of sleep effects the ability to think clearly at all times. I vote for longer clinicals and decrease in work hours. How are you going to retain what you learn if you are sleep deprived?
Thank you for looking into this matter. I am a 2nd year medical student with 3 children and a future $250K debt. I realized when I went into this field that I'm doing it for the job that I want to do and not the financial rewards that doctors used to be rewarded. I really find the argument ridiculous that continuity of care may be in jeopardy just because residents are working less. There was a study that showed driving while exhausted was comparable to drive while intoxicated. And I'm sure everyone agrees that no one should practice medicine under alcohols influnce. We are humans and we require sleep. The real reason against limiting the hours is money. Just as previously mentioned, academic hospitals were not given any additional money when the 80 hour restriction was placed and they simply cannot cover the same work load. Most hospitals are not making money and cannot create more residency positions. So who's going to fill the slack?
I was happy to hear that the 80 hour restriction was in place prior to me starting school. However, this is one of many problems/challenges that is facing the future of the healthcare system. I believe RADICAL changes are required within my early medical career or it will spin out of control.
I graduated medical school in 1987, several years just prior to the on going discussions of resident hours. I was first a medicine intern and then resident, and then (just for the punishment!) a psychiatry intern and resident. The hours were brutal. More so for medicine then psych, but still just gruelling. It was part of the culture, part of the way life was, you just did it, and learned to survive.
There is a real benifit for this kind of education, however, that I rarely see refered to. When you are up in the middle of the night doing something, there is a real need to do it right, and do it right the first time, because then , maybe, you can go (back?) to bed! If you screw it up, the nurses etc are calling you, and wow! no sleep! In this kind of situation lessons are learnt fast, and very thouroughly! There's no time for the miriad of daytime distractions like gossip and lunch and rounds and lectures and families etc etc. There is only the clinical situation and learning in its most sublime and efficient state!
I graduated with an MD/PhD in neuroscience and I started my training in neurosurgery in Philadelphia in 1998 prior to the new policy limiting resident hours. At the time, I was 32yrs old with 2 young children (2yrs & 6mos old). I worked the 120hr weeks at a very active trauma center and spent all night up, every other night, caring for patients and often didn't sign out post-call until 10p (still no sleep) having to then go to medical records to dictate charts for a couple of more hours just to get unsuspended for the next day. I'd get home by midnight and have to be up at 4am to return for the next day. After a couple of months of that physical and pyschological torture, I became more and more depressed, angry all the time from being yelled at by nurses and attendings and myself yelling at nurses, patients, and med students. I increasingly found myself crying in the call room alone and feeling helpless and hopeless. By 6 months into my internship, I had hardly ever seen my children awake and my wife felt I was becoming more and more distant. One night during a particularly brutal call, I found myself facing a list of ~65 patients for whom I only had a name, room number and diagnosis and a beeper that wouldn't stop going off. That night I felt like there were 2 ways out -- one was off the roof of the hospital and the other was out the front door. Thank God I had the strength to choose the front door. That day I quit and never returned and I have never regretted that decision which saved both my life and my family. I re-matched in Pediatrics and completed my medical training thankful for only having to work 80hr weeks (imagine that?!). I still get emotional recounting those difficult times. Was it necessary to make me work 80-120hrs in order for me to become a 'good' physician -- absolutely NOT. It dehumanized me and I can assure you that patients don't benefit from the care of dehumanized physicians. How can you care for someone else if you can't even care for yourself? Forget 24hrs, NOBODY should be expected to work longer than 12 continuous hours with full days off during each 7 day period. Anything else is INHUMANE and unecessary and benefits nobody. As dramatic as my story may sound, it is hardly unique. I'm glad there has been some progress with this very important issue, but there is much, much more to accomplish and I salute those making a stand.
I also look forward to changes in Resident work hours. I agree that it is not safe for Residents to make pertinent medical decisions at times when they are extremely fatigued. Research has already shown that Patient Safety is compromised when fatigued Residents are making critical decisions. Studies have also shown that a Resident's Personal Safety is at risk after working long uninterrupted on-call shifts. Nevertheless, the ultimate goal is to survive Residency, as suitable Resident protection and support is often deficient in the Graduate Medical Education environment.

Even though the ACGME placed constraints on Resident work hours, as a Senior Resident, I still worked 88-108 hours a week in the hospital. I spent the remainder of my "free time" on-call from home and managing patients and Team Members throughout the night. Despite the schedule placed upon me, I worked the hours and took on the extra responsibility placed upon me with due diligence. I was aware that complaining or failing to accept the schedule could mean the end of my career in Residency.

Undoubtedly, Patient and Resident Safety are paramount issues facing the field of healthcare today. Currently, Medical Students and Residents are aware that they have to do whatever is necessary to survive Residency, or they may face the dire consequences of being terminated. If this means they will only receive two days off a month or must work a continuous 36 hour shift, it is done without question. It's "Survival of the Fittest." This often leads to Residents under-reporting their actual work hours, dealing with issues of anxiety and depression, and placing their own personal relationships at risk. Residents also understand that there is currently no notable protection provided them, even by the ACGME. Therefore, doing whatever is required, suggested, or assumed by their Department is unquestioned. Otherwise, as many vocal Residents find out each year, they will be looking for new careers.
I am a primary care physician recently out of a four year residency. I did my residency in New York State where limitations on resident work hours similar to the ones instituted nationally have been in place for over 15 years. However, I went to a traditional southern medical school where to even mention work hours limitations would be tantamount to weakness. This is a complicated issue for two reasons: money and convention. Attendings who have been taught in a traditional manner feel as though limiting work hours adversely affects medical education and patient care. Hospitals and residencies have no incentive to enforce work hours as it forces them to hire more residents, more mid-level providers, and/or have attendings work longer hours.

Anyone who has trained in a traditional environment cannot discount the effect lack of sleep, horribly long work months, and poor nutrition has on medical students, residents, and (often unrecognized), their families. The rates of divorce, suicide, depression, and drug abuse are disturbing in the medical profession.

Having trained in a place where the kinks in limiting work hours has been worked out, I have no doubt I am a BETTER physician for the limitations. I am certainly a happier and better PERSON, and I think that feeds back into my ability to care for patients. Ask the nurses who work in residency programs if they would want their family members to be cared for by the residents who work 36 hours straight and 100 hours a week. It is NOT SAFE. Residents will always make mistakes but it has been proven that they make significantly more and more severe mistakes when they have been awake for 24 hours. It is common sense.

Residency programs need to work out a system that ensures patient safety AND patient continuity. Nobody is saying that residents have to leave in the middle of critical patient care. There are effective ways to train physicians that ensure superior education while limiting them to under 80 hours a week. I applaud the ACGME for their recent restrictions and I hope they are strongly enforced (if not, the predominant undercurrent of one-upsmanship and pride will prevail). This will only be a positive thing for doctors, patients, and the health care system.
Medical research has shown what happens to people with sleep deprivation and their errors in judgement. Why would I as a patient want a doctor who is sleep deprived? I don't need that and the consequences can be devastating. The reasoning for long hours in residency programs are illogical and totally without sound reasoning. This is coming from doctors who are supposedly of above average intelligence, educated and highly trained.
Dr. Gupta,
I was an ER nurse for almost 20 years- please allow me to then state some facts and personal observations: ANY creature, human or not, NEEDS sleep. It recharges the brain and allows it to perform its functions and think clearly. If sleep is deprived, the brain is simply not going to "think" sharply- mistakes get made, anger escalates. In patient care, nurses provide physical and emotional support for patients during their 12 hour shifts. At the end of 12 hours, due to exhaustion and the probability of excessive errors, that RN gives "report" to another RN- explaining the condition and needs of her/his patients. That next RN, fully "charged" assumes the care of those patients for the next 12 hours, etc. To think that ANY HUMAN, no matter WHAT their credentials, can bypass the simple physics of the human brain is ridiculous. Fatigue, in my experience, creates danger- this danger translates into poor and sometimes detrimental care. Physicians are certainly not above the laws of nature. If a physician has been awake, performing patient care & making life & death decisions for an extended period of time, THEY WILL MAKE MISTAKES. Now, to sum this up- who would you rather have caring for you or your loved ones in a critical setting, the doctor that has slept and is thinking clearly, or the one that has been sloshing day old coffee for 24 plus hours? I know what I'd choose.
I, as a patient, would never want a doctor with "brain fatigue" working on me.
No-one can provide continuity of care --if that means the same medical person and the same patient, for each, every and all time-- unless the patient is only briefly needs attention. That excuse for abusing medical residents is ridiculous.
My Dad's Doctor missed a brain tumor in the early 80's. It was discovered he was on one of those marathon shifts. Long story short, my Dad's death could have been prevented.

If someone could please tell me the REASON for these long shifts...
i have been in medicine long enough and can say that junior doctors all over the world are the worst exploited of all workers in the service industry ( medical care is part of the service economy). continuity of product management can mean that an engineer is made responsible for ongoing problems and complaints about a product no matter what time of day or night it is and is continuously on call. can we think of such a situation-never. continuity of care is a lame excuse all over the western world in particular to keep health costs relating to doctors pay as low as possible. i am a hundred percent sure that medicine has already stopped attracting the brightest and the best. senior doctors in collusion with political interests are to blame
I find this practice very disturbing. As a patient, I would not want a Doctor or Resident taking care of my health that has worked for that amount of time.
I think it is funny how as Doctors, they can subject Residents to this kind of torture. It's not good for the Resident or for the patient.
Truck drivers can not drive after so many hours without a set amount of hours of rest because of the dangers of being on the road with so little rest, so why is it okay for Residents and Doctors to do this?
Just because they are called Residents, dosen't mean they have to reside in the hospital!
I've been in health care for over 24 years, in both patient care and administrative roles. I honestly believe that using concerns over `continuity of care' as an excuse to continue the `good old boy' system of resident abuse is absurd. Want to address continuity of care issues? Do your documentation thoroughly & promptly & allow your staff time to do the same. Many hospitals (including the one I work) still use archaic handwritten physician & nursing progress notes, which often are virtually illegible or are not completed in a timely fashion (frequently because of staffing issues). Someone who is so sleep deprived that they basically have the IQ of a moderately retarded person should be NOT be making life or death decisions about health care. Residency isn't supposed to be some sadistic boot camp where people should be `tough enough to take it'. With the ludicrous cost of health care & the current litigatious atmosphere, putting severely sleep deprived residents on the front line seems incredibly irresponsible, not to mention inhumane to all involved.
As a relatively recent graduate of an internal medicine residency program I can definately tell you that patient care is compromised when physicians are forced to work without rest for hours and hours. I recall my residency and remember admitting all night long and continuing for 36 hours without rest, having to write medication orders, many of which have inumerable interactions and contraindications and trying to concentrate as my eyes involuntarily close. How can you leave this choice to someone who can barely stay awake?! Medicine has changed, the amount of information and drugs on the market has exploded in the past few years, doctor's are expected to know these things and keep up with the latest trends, this is a challenge and one best not undertaken while sleep deprived. As far as continuity of care...does this mean a doctor should never go home? What about family and children, do these things not exist for physicians? Patients are sick for weeks in intensive care units, is it impossible to turn over care to another physician? I think it is not only appropriate but necessary and it is not something I would not only mandate with residents but attending physicians as well. Having a medical license does not give you a right to work so many hours so that you can become a hazard to patients. Physician work hours need to be tested further and restrictions placed for all physicians to ensure patient safety.
Eighty to over one hundred hours per week at salaries on an hourly basis amounting to less than minimum wages. Let us just call this what it is, a sweat shop. These practices are illegal in other areas, why have have labor laws not been enforced here.
Having spent more than 20 years in the military I know what long periods with little sleep does to people. It is more than just miserable, you reach a point where thinking becomes narrow and perception limited. It becomes easy to overlook all but the obvious and jump to incorrect conclusions. Not an ideal frame of mind for a doctor.

In reality these oft sited excuses are not the true reason that change is not supported. If 30 hours shifts were necessary for continuity of care then shouldn't all doctors working in hospitals work 30 hour shifts. If the amount of experience is the issue then wouldn't a longer residency with fewer weekly hours be even better. That way they could actually learn instead of treating patients while sleep walking.

It all comes down to tradition and labor costs. Few in the upper ranks of the medical profession are willing to allow others an easier road then they traveled and if residents worked fewer hours then more highly expensive staff would be needed to fill the void.
To an outsider of the medical field and residency, the answers appear obvious... shorter shifts and more workers. Simple, right?
As my favorite TV attending on Scrubs would say in his sarcastic falsetto tone "No, no,no,noooo.... no,no,no,noooo."
As someone that has "survived" residency a few years ago and experienced the difficulty of making coverage schedules, it is not that easy to make such apparent simplistic changes. Why?
- There are a limited number of residents for each hospital-based program. If we reduce someone's call shcedule, another one of their classmates has to cover that slot. This time often comes at the expense of learning outside electives or treating patients in a clinic-based setting.
- Medicare provides the funding for most residency programs, as many residency programs are based in public hospitals. Do you want to try to squeeze more money out of Medicare to increase the number of residency slots? I do not.
- Not only do you add residents, you need to add more attendings to oversee those residents, more continuity clinic staff, more space for the residents, and more money to cover insurance costs, etc... Ouch.
- Do more mistakes happen because of someone being in their 28th hour of call, or from signing-out a patient to 3 different people in a 24-hour period? Signing-out involves giving all of the important details of a patient, studies that are pending, and often a plan of action for that coverage period. In my experience, the more a patient was signed-out to others, the more likely an error would be made or a study forgotten.

I am not condoning a return to the "old days" of 120-hour work weeks and spending every other night in the hospital. I am just saying that things are not as simple, or as terrible, as they seem. For those that are driven to be in medicine for the money, I agree that they will choose other fields. For those that are drawn to medicine for reasons of compassion and knowledge, I feel that they will still be rewarded on the other side of residency. Hang in there.
My wife, a 4th year resident, is currently working her 56th consecutive day at the hospital. Every shift is at least 12 hours, several are 24, some are longer. She's learned an incredible amount in the last four years, but is also pulling apart at the seams.

The resident salary is pathetic - it's insufficient to cover even interest payments on substantial loans from undergrad and medical school. The salaries remain depressed so the hospitals (which operate in the red?) can afford to pay them. As long as it is cost effective, programs will try to (have to) get every hour of labor they can out of dirt cheap resident labor.
In my opinion, limit resident hours.

Enough of the Doctor-is-God complex. This is 2006, not 1946.

Everyone knows the Doctor is Human. Highly educated, hopefully with a brain full of life-saving knowledge and commonsense. Nonetheless, human.

In the last 50 years, new research has proved that lack of sleep is mentally and physically debilitating.

Enough is enough. If your motto is First, Do No Harm, then act on it.
I feel that this practice only provides cheap hospital labor and usually in an inner city settting. After it is over the doctor is at least 100k in debt and is faced with competing with a SURPLUS of doctors. On top of this surplus, there are allied health professionals who have or are seeking prescription writing privelages (nurse practitioners, psychologists etc). Who take the place of doctors. Corporations (hospitals and HMOs) don't want to hire many doctors especially if they are more than ten years from graduation. Doctors are faced with mountains of regulatory laws when trying to open up a practice and in some areas the HMOs, insurance companies and liability force them out of business. Most physicians are unknowledable about, intimidated by and made weary by the the thought and process of self-employment. Now, who in their right mind would be a doctor these days?
Listening to NPR one day last week , and hearing the person being interviewed state that the Doctor who first instigated the 30 hour work sessions for interns , and or residents was in fact a Cocaine Addict, who later became a cocain/morphine addict.. (that was the treatment for cocaine addiction in those good old days) seems to me to indicate a rethink of the way in which doctors are trained in the USA.. what more needs to be said, other than.. the usual excuses for continuing on the same course, having finally uncovered evidence of how this 'insane' amount of hours working was managed by the orginal doctor.. and how it go to be the 'norm'. Are we to be bound by what turns out to have been an addicts' delusional plan?
I am a second year medicine resident at large University hospital. As a medical student I witnessed a neurosurgery resident nap in the OR. When he was waiting his turn to remove some vertebral disc, he would close his eyes and sleep for 30 sec. Then he would wake up and remove some disc and go back to sleep. Or how about the third year cardiology fellow bragging about how in his day as an intern he would admit 20 patients a night on his own. He didn't know anything about his patients other than a name and ID number. Are there problems with coverage and sign out? Yes there are. We are going to have errors. But I would rather have an error caused from a fixable event -- eg sign out -- not because everyone is angry and brain-fried. The only systems based fix for fatigue is rest.

For clarification, if any resident is still on call after 24 hours that is a work hour violation. We are allowed 24 hours of call followed by 6 hours to finish up for a total of 30. We must have 4 days off in 30 and it is a rolling average of 80 hours per week over 4 weeks. So two months ago when I was one of the senior residents in the MICU I did have two weeks with close to 90 hours, but my rolling average was less than 80 and therefore compliant.

My program tries very hard to make us stay compliant with ACGME rules. We are encouraged to be as honest as possible with our hours reporting. I have NEVER been told to lie about my hours.
As to 30+ hour shifts, I think the patient care danger from fatigue outweighs the care continuity concerns as well as the educational concerns. I think the extra time is used to foster an irrational "we've been through hell" confidence.
I am a practicing physician and I think that those who want physicians in training to work ludicrous hours should consider whether they would want to be the patient in the hospital bed with a life-threatening illness looking up at a cranky, sleepy doctor who does not have the ability to give him his very best. Mistakes will happen, even when a doctor is fully awake. Unfortunately, unlike with other professions, when physicians make mistakes they can be fatal. We are all human and we all make mistakes. Why promote a culture in which mistakes are more common, especially when the outcome could be devastasting.

AH, MD
Would you get on a plane piloted by someone who had been working without sleep for 30 straight hours? Of course you wouldn't, and for that matter, nor would the FAA ever allow such a situation to occur.

The situation with a medical resident is analogous. It simply isn't acceptable for someone to try to function on sleep deprivation (except in a true disaster or emergency situation) when the lives and well-being of others depend on their ability to think clearly and make sound judgements.
Small town practice is no different than residency. Care is often rendered by tired, sleep deprived doctors putting the patients needs ahead of their own wellbeing , trying to make the best of the limited resources, rationalizing that the health care professions may be a calling.
Having had a resident misdiagnose my appendicitis which resulted in a rupture appendix and a near death from peritonitis, I think hours should be limited.
As a 15 year practicing surgeon I realize limitation on resident work hours is a double edged sword. True, performance falls after X hours (with greater likelihood of medical errors) but so does the ability to observe the progress of any given disease process - infectious, airway obstructive, heart failure, response to medications, etc. etc. If a trainee only has the opportunity to observe a limited time segment of this process, they'll be limited in the ability to predict future clinical outcomes when confronted with the same situation. I see this time and again with the residents whom I train, in that because they lack the extended continuity of care experience, they're unable to make statistically probable and accurate predictions in clinical progress and outcomes.

Furthermore, who has capped hours in practice AFTER residency? There are many of us who, because of call/emergencies/routine practice obligations, work greater than 12 to 15 hours on end. I attribute in part my competent ability to do this to my "extended hours" internship and residency.

I offer no easy solutions, but I also know that merely capping residency training hours in the absence of other residency and post graduate training modifications is NOT likely to benefit patient care in the long term.
I personally think an intern/doctor working those long hours are asking for problems. One thing a doctor always says is to get sleep, at least 8 hours. They should practice what they say//////////////////
12 - 15 hours days are typical days when there is no call. The problem is 2 AM when you have been up for 21 hours and working 20 hours straight. 15 hour days are when you go for a run followed by dinner with all of your "free time."
I am a victim of a medical error commited by a resident doctor due to lack of sleep, and I have since then had an interest in this issue. From my research I know the replies on this thread will follow the typical pattern. Attending doctoprs will make a case for long resident hours(so they don't have to put in more hours themselves) and residents will make a case for shorter hours. We can however look at the empirical data that shows most medical errors being related to fatigue and sleep deprivation, so anyone with common sense should be able to figure out who is right on this issue. Dr Gupta, we really don't need research to show that doctors are more likely to make mistakes if they have worked 25 hours straight without sleep, we just need good old fashion common sense. Hopefully this documentary will be successful in making the connection between sleep deprivation and medical errors. A connection that people in the medical community have known for years but choose to conceal. We pay a lot for medical care in this country, and I believe we deserve more than the equivalent of drunk doctors.
Residents (and interns and medical students) are stupid enough and ignorant enough and arrogant enough without being sleep-deprived. They mess up enough without the added impairment of lack of sleep.

My ordinarly inclination would be to tell the little whiners to shut up and deal with it, but that policy endangers MY health. I'd like to see all residents, interns and medical students closely watched and monitored at all times by experienced health care professionals who know what the hell they are doing. And I'd like dope-slapping to be an acceptable option when a young doctor or student does or says something stupid.

If you are wondering why I'm so cranky, it's because so many young physicians don't know their pharmacology and physiology. They don't know their microbiology. It's inexcusable: I know what they have to learn in medical school because I work in a research department at one of them. I see their exams from time to time. I overhear them cramming. I work with their instructors. And I expect them to know AT LEAST what I pick up casually just being around the place as I mix my reactions and analyze experiments.
As a current second-year internal medicine resident, it is safe to say the patients we take care of generally have more complex medical conditions and are easily on more medications compared to patients even ten to fifteen years ago.

Those doctors who trained at least that long ago and have the attitude "I did it so can you" commonly fail to appreciate this. Yes, the hours in private practice may be longer than in residency, but a choice exists whether or not to work such long hours (i.e. join a group practice, work for a managed-care organization under contract, etc.).

I do what it takes to get my work done; if that means 12+hrs. on a non-call day, so be it. If I have to stay over 30hrs. on a call day, same story.

However, those of us in residency don't have much of a choice when it comes to 30(+)hr. calls & 80(+)hr. workweeks because it is considered "part of our medical training."
I was a general surgery resident in 99 when the new rules had not been enacted - I pulled 130 hours a week and sometimes a 40 hour shift on Transplant rotations. Now after spending time for 3 years as a General Medical officer, I returned in '03 as a PGY3 to the new hours - and it is very nice - only 80 hours a week. I am now in my last year of URology training and I'm looking forward to practicing "normal" working hours with out all the grunt work.
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