On November 4th, the Accreditation Council for Graduate Medical Education (ACGME), the governing body that regulates United States medical training programs, proposed a set of revisions lessening the requirements on how many hours a medical intern can work. After years of not regulating the work hours of these young doctors, the ACGME is set to go backwards in terms of these regulations. To understand the gravity of this proposed change and why it represents a poor decision, a little background information is in order.
In the late 19th century, the first formal medical residency program was established in Baltimore, Maryland at Johns Hopkins Hospital. Prior to the establishment of residency programs, graduated medical students (doctors) participated in brief and relatively unstructured programs to receive specialized medical training (e.g. surgery, obstetrics, etc.). With the initiation of residency programs, these doctors in training literally “resided” in the hospital, hence the name residency. To this day, the collective group of these doctors in a hospital is referred to as ‘house staff’ because their training largely resided in the hospital, or ‘house’.
Federal law does not regulate the number of hours a medical resident can work. In the past, this has led to incredible numbers of hours residents could work during their residency. Overnight call every other night was commonplace for decades as were 100+ hour work weeks.
In 2003, the ACGME, a non-profit council that accredits the majority of medical training programs in this country, determined that residents should have their work hours restricted to a maximum of 80 hours per week with every other night call eliminated and 10 hours off between shifts. This decision was made in large part because of research demonstrating 35.9% more medical errors when residents were sleep deprived working traditional hours versus a schedule of reduced work hours [1].
My residency in neurology began in 2000, so it bridged these two eras. I participated in every other night call during my residency, and I’m certain I made errors. One night I was so sleep deprived entering medication orders on a patient that I was inadvertently sending them to the cafeteria instead of the pharmacy. As an upper level resident, I can remember waking up in the middle of phone conversations with residents of whom I was in charge. I was literally giving instructions for how to manage an acute stroke patient in my sleep.
In 2003, with the ACGME duty hour restriction ruling, our lives as residents changed dramatically. As chief neurology resident, my job quickly became making sure that our neurology house staff was fully compliant with the duty hour restrictions. It was incredibly hard. Seemingly overnight, our schedules had radically changed, yet the number of patients to care for, and the number of residents to do the work had not. The result: far more frequent transitions of patient care.
I’ll be honest, we did not like it at first. When a resident admits a patient, that resident takes ownership of that patient and has a strong interest in seeing that his care through, particularly for the first part of that patient’s stay. With the duty hour restrictions, that resident is forced to “hand off” the patient much sooner to a resident who may not be as familiar with that patient, and in many cases, the hand offs keep coming.
With the number of hours residents can work reduced, residents are under the gun to get their work done quickly. This has the effect of squeezing out teaching and educational time. Blood work results need to be tracked down, spinal taps performed, consults ordered—no time to sit around in a classroom and discuss patient cases.
Despite the ACGME restricting residency hours even more in 2011 (no more than 16 hours per shift for first year residents, or interns), there is a new proposal to lift these intern work hour restrictions by the ACGME because of new research showing the reduced duty hours do not seem to change patient outcomes and would help interns prepare for real life situations [2]. Some hospitals and medical groups are questioning whether issues like frequent transitions of patient care may actually be causing more harm to patients than the previous extended work hours. These groups are advocating for this relaxation of the duty hour restrictions.
As a sleep specialist who lived through both sides of this argument, I strongly believe going backwards would be a huge mistake. We need to recognize and come to grips with the very negative consequences of sleep deprivation for not only our medical residents, but anyone engaged in long duty hours. The research on shift workers has shown a profoundly negative effect on cardiovascular health, weight gain, and an increased incidence of diabetes. In short, despite the research that longer duty hours may not hurt patients, they are most certainly hazardous to a resident’s health.
There is another solution to this issue. Change the system; these prolonged hours only reflect “real world situations” if we continue to allow them to in our hospitals. Create more residency positions. Hire more doctors or mid-levels to help with the patient load. We need to recognize that this is not just a problem within our country’s teaching hospitals; the issues regarding the negative outcomes of shift work disorder are everywhere. It is essential that in the short term, we protect the health and well-being of our future medical professionals as well as the patients they serve. The ACGME is soliciting public comment via their website until December 19th . Let them know that returning to the ways of the past is not a path forward.
References:
1. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA (2004). “Effect of reducing interns’ work hours on serious medical errors in intensive care units”. N Engl J Med. 351 (18): 1838–48.
2. Bilimoria KY, Chung JW, Hedges LV, Dahlke AR, Love R, Cohen ME, Hoyt DB, Yang AD, Tarpley JL, Mellinger JD, Mahvi DM, Kelz RR, Ko CY, Odell DD, Stulberg JJ, Lewis FR. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. N Engl J Med. 2016 Feb 25;374(8):713-27.