Are Restricted Work Hours Better For Doctors In Training?

I still remember it like it was yesterday.

It was July 1, 1999. I turned to look at the patient board, and "Hassaballa" was listed as the responsible Intern (first-year resident) next to five patient names. It was surreal. For the previous four years, I was just a student. It sunk in at that moment that, now, I am a real doctor responsible for real patients. I took a deep breath and dove in.

And I didn't sleep that night because it was so busy.

That was the first of many, many, many, many sleepless nights during my training. Back then, there were no work hour restrictions like there are now. Back then, we took call every 4 nights and, on the next day, we went home when the work was done. If that was 1 PM, great! But it was not infrequent when we would go home after 36 hours straight.

Have I driven home and not remembered the journey? Yes. Have I barely been able to function on the next day after a long night on call? Yes. Did we harm patients, however? No, we did not.

Yet, there has been research about how sleep deprivation has negatively affected medical residents well being and their attention. And, of course, there is legitimate concern that this will negatively affect patient care.

Hence, in 2003 and then later updated in 2011, the ACGME (Accreditation Council on Graduate Medical Education), which is the governing body of residency programs in the United States, instituted work hour restrictions. Currently, medical residents cannot work more than 80 hours per week, and they cannot work more than 28 hours in a row. Sounds reasonable, right?

But, this has caused great difficulty in many residency programs, especially surgical ones. Because residents have "hard stops" on the number of hours they can work, some have had to leave in the middle of surgeries and have had to frequently "hand off" their patients to other doctors who are not as familiar with their particular case.  Yet, have the new work hour restrictions made a difference? A study released on Feb 2 by the New England Journal of Medicine seeks to answer this question.

The study authors randomly assigned two groups of surgical residency programs to one of two arms: one followed the strict work hour rules, and the other had "flexible" hour rules. All programs, however, adhered to the 80 hour work week. The results showed virtually identical outcomes: the residency programs with the "flexible" hours did not have any worse patient outcomes than the ones with the strict hour rules. Moreover, the residents working in the "flexible" hours programs also did not have worse job satisfaction.

So, does it mean that we will go back to the 120 hour work week, like my generation? Not at all. In fact, in the accompanying editorial, the author wrote:

What do the results of the FIRST Trial mean for ACGME policy on resident duty hours? The authors conclude, as will many surgeons, that surgical training programs should be afforded more flexibility in applying work-hour rules. This interpretation implicitly places the burden of proof on the ACGME. Thus, because the FIRST Trial found no evidence that removing restrictions on resident shift length and time off between shifts was harmful to patients, programs should have more autonomy to train residents as they choose.

I reach a different conclusion. The FIRST Trial effectively debunks concerns that patients will suffer as a result of increased handoffs and breaks in the continuity of care. Rather than backtrack on the ACGME duty-hour rules, surgical leaders should focus on developing safe, resilient health systems that do not depend on overworked resident physicians. They should also recognize the changing expectations of postmillennial learners. To many current residents and medical students, 80-hour (or even 72-hour) workweeks and 24-hour shifts probably seem long enough. Although few surgical residents would ever acknowledge this publicly, I’m sure that many love to hear, “We can take care of this case without you. Go home, see your family, and come in fresh tomorrow.”

He makes a valid point. I don't need a resident to do my job: I am ultimately responsible for the care of my patients. And I have frequently sent home early both medical students and residents when there is no educational benefit to staying late with me.

Yet, I must be honest here: it is definitely true that driving home in a comatose stupor from sleep deprivation is not safe. At the same time, however, there was some merit to the tough training through which I, and the generations of doctors before me, went. It instilled a robust work ethic. I didn't go home until all my work was done. In fact, I made little "check boxes" for each task I needed to complete on every patient under my care. When all my check boxes were filled, I got to go home.

Moreover, the real world does not have "fixed hours." Yes, we have shifts. But there are so many times when an emergency will occur right at the end of my shift, and I have to tend to it, even if there is a colleague to relieve me. My fear is that the residents now in training - who have only known fixed hours and mandatory stop times - may not be able to handle the reality of the medical workplace. And I'm not alone in that fear.

Dr. Dominic Valentino, a colleague of mine who practices Critical Care Medicine in the Philadelphia area and is directly involved with training residents, told me: "These work hour restrictions are only making for unprepared, under exposed, and less confident residents." Dr. Valentino hopes that the research study above may help bring some much-needed balance in the training of our country's future doctors.

Although I often joke with residents nowadays and say: "You guys don't know how good you have it," I'm not advocating we should go back to the "good old days." At the same time, however, those "good old days" definitely made me a much better doctor than I otherwise would have been.

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