The working conditions of medical and surgical interns and residents have been the subject of controversy for a number of years. The highly publicized death in a New York hospital of 18-year-old Libby Zion, who was primarily cared for by residents, ignited emotions, and the subsequent litigation brought the issue of long resident work hours to the forefront. The case led to the adoption of regulations by the state of New York that limited resident schedules to 80 hours per week and to 24 consecutive hours per shift. Recent media reports on patient safety and several studies on the effect of long resident work hours have continued to keep this subject in the spotlight.
Surveys Suggest That Long Hours Are Dangerous
The tenet of residency training is to balance work with education. Cost cutting measures by teaching hospitals have reportedly shifted the balance in favor of work rather than education. The Accreditation Council for Graduate Medical Education (ACGME) has developed guidelines to discourage long working hours and ensure a reasonable quality of life and education. However, a number of resident surveys have identified excessive working hours as the main factor impacting negatively on patient care, resident health and education. In one study, reported in the Academic Emergency Medicine journal, Mark T. Steele, MD, and others reported that 8 percent of emergency medicine residents said they had been involved in automobile crashes, while greater than 50 percent said they had been involved in one or more near-crashes, in both cases mostly after a night shift. Analysis showed that the crashes and near crashes were positively related to the number of night shifts worked per month. The study concluded that driving home after a night shift appeared to be a significant occupational risk for emergency medicine residents. Reports such as this and a general perception that the ACGME is unable to enforce its resident hour guidelines resulted in the filing of a petition with the Occupational Safety and Health Administration (OSHA) seeking federal regulations that would limit work hours for residents and fellows. The petitioners include Public Citizen, Committee of Interns and Residents and the American Medical Student Association.
The Institute of Medicine estimates that medical errors cause more than 1 million injuries to patients in U.S. hospitals each year and may trigger as many as 98,000 deaths annually. Resident surveys regarding work schedules, such as the survey reported in the “Long Hours and Little Sleep” article by Gerald B. Holzman and others that appeared in Obstetrics & Gynecology, have shown that residents in substantial numbers perceive that long hours compromise their abilities. However, few studies have been conducted to test the hypothesis that long hours with little sleep jeopardize both the health of physicians and the safety of their patients. A nationwide study funded by the National Institute for Occupational Safety and Health and the Agency for Healthcare Research and Quality is planned in 2002 to test this hypothesis. A hypothesis that also should be studied is that frequent shift changes and sign-outs as a result of limiting work hours increase errors.
Limiting Work Hours May Exact a Price
The hallmark of surgical training has been commitment to patient care without regard to time, day of week, hours worked, or on-call schedule according to Lazar Greenfield, MD, chairman of the Department of Surgery at the University of Michigan School of Medicine. Dr. Greenfield’s comments appeared in Lynne Lamberg’s article “Long Hours, Little Sleep” in the Journal of the American Medical Association. Limiting work hours across specialties may have many unintended implications, especially with regard to surgical specialties. Continuity of patient care is important in terms of the educational value of following through on complications, as well as patient satisfaction, and this will be lost when work hours are limiited.
Additionally, the opportunity to see rare diseases or surgical cases may be lost by strict enforcement of work hour limits. Further, artificially limiting work hours in residency may not prepare the resident for the “real world” of a practicing physician or surgeon where work hours are determined by the practice conditions, patient census and emergency room coverage and not by guidelines determined by a governing body.
Is federal regulation the answer to the improvement of resident education and quality of life or is this a simplistic solution to a complex issue? It may be too late to reverse this transition toward reduced work hours, but the debate should continue because future surgeons, especially future neurosurgeons, face the possibility that longer residency programs will be required to attain the level of competence and efficiency achieved by the current system of training.
Prithvi Narayan, MD, is a resident at Emory University School of Medicine, Atlanta, Georgia.