Resident and Student Voice
Resident Education and Patient Safety
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Am Fam Physician. 2002 Oct 15;66(8):1569-1576.
The earliest studies documenting the effects of resident fatigue on patient care took place in the late 1960s and early 1970s. During that time, an article in the New England Journal of Medicine noted, “There never was a good reason to indulge in the false heroism of 36-hour duty stints by the interns. We now appreciate excellent reasons for abandoning this practice.”1 In the intervening three decades, although health care delivery in this country has undergone many transformations, residents have continued to work long hours. During the past 15 months, however, organizations both inside and outside the health care field have initiated a number of efforts to address the problem of resident physician overwork. These initiatives are:
A petition sent by Public Citizen, the Committee of Interns and Residents, and the American Medical Student Association to the Occupational Safety and Health Administration (OSHA).
The introduction of the Patient and Physician Safety and Protection Act (PPSPA) in the U.S. Congress by Rep. John Conyers (D-Mich.) and Sen. John Corzine (D-N.J.).
The threatened loss of accreditation by the Yale surgical residency program unless dramatic changes are made in the number of hours worked by residents.
An antitrust lawsuit against the National Residency Matching Program.
Passage of legislation by the New Jersey State Assembly limiting resident work hours.
Proposed regulations by the Accreditation Council on Graduate Medical Education (ACGME) that would apply to all residency programs.
In this article, we address two issues: first, we discuss which, if any, of these initiatives holds promise in the effort to improve resident working conditions; second, we address why change has been so slow in coming. The answer to the latter is clear: significant change has not occurred because many in the medical community have been unwilling to publicly address the problem, and they remain fragmented in their view of a solution. The major points of the debate are summarized in this commentary.
Medical Education and Professionalism
Many fear that in an effort to limit hours, resident education will be compromised. We argue, however, that current working conditions often provide a poor learning environment. For example, studies show that residents spend anywhere from 20 to 40 percent of their time on noneducational tasks that could be accomplished by ancillary support staff.2,3
One might question just how much more residents could be expected to learn if they were to work 100 hours a week instead of 80. There is no evidence to support the theory that longer hours produce better physicians. Another question to consider is how well do residents learn when they are exhausted? The literature attempting to characterize the effects of long hours on medical education is scant. Of note, one 1990 study showed a decline in family medicine residents' scores on a four-hour written examination after a night of acute sleep deprivation.4
Some worry that limiting resident hours will erode professionalism. Opponents of work-hour limits for residents comment that the practice of medicine is not like aviation or truck driving, and “if we impose rigid shift hours on graduate medical trainees and make them abandon their patients' bedsides at pre-established times, we will give future practitioners the wrong message about caring for patients.”5 This is a crude simplification of the debate, because no regulation or legislation, however stringent, would require a physician to abandon a patient's bedside in a time of need.
The following account from a second-year resident addresses the concern about professionalism from another perspective: “I have witnessed the erosion of professional values and behavior of both myself and my colleagues when fatigue begins to set in. As a resident, it becomes exceptionally difficult to put forth the same amount of thought and offer the same emotional support to patients after a long 36-hour shift. The most disheartening feeling as a resident physician is when you feel that your own patients have become the enemy. By enemy, I mean the one thing that stands between you and a few hours of sleep.”6
Resident Health and Safety
A series of articles in the Annals of Internal Medicine has drawn recent attention to the issue of burnout and stress in residency.7–9 The deleterious impact of residency on the health, safety, and well-being of resident physicians is well documented. Residents have high rates of motor vehicle crashes,10,11 obstetric complications,12,13 and depression.14,15 Although the causes may be multifactorial, studies show a direct link between these health consequences and the number of hours worked.12,15,16 It is particularly surprising that the incidence of fatal automobile crashes involving residents driving home after being on call have not prompted reform from within the profession.
More than 30 studies have attempted to examine the relationship between resident fatigue and patient care. Unfortunately, many of these studies suffer from poor design or results that are difficult to extrapolate to the clinical setting.17 A well-cited study18 from 2001, however, showed that after just 17 hours on call, surgeons performing laparoscopic tasks took significantly longer on five out of six tasks and made more errors on two of the six.
Surveys of residents clearly show their point of view on this issue. A 1991 survey19 showed that 41 percent of 145 residents who were questioned cited fatigue as a cause of their most serious mistake; in nearly one third of these situations, the patient died as a result of the error. More recently, in a study20 of residents in obstetrics and gynecology, 75 percent of respondents reported wanting their hours to be limited, and 60 percent feared that the quality of care they delivered was being compromised by the hours they worked.
One of the authors of the Institute of Medicine's report on medical errors stated in testimony before the U.S. Congress: “To people outside healthcare, this is a no-brainer. We all know you make more mistakes when you are tired. We don't allow a pilot to fly more than eight hours.”21
Some opponents of work-hour reform express concern that limiting shift hours will interfere with continuity of care and thus affect the quality of care. However, breaks in the continuity of care are unavoidable—resident schedules cannot be made to follow the course of a disease. The answer lies not in 40-hour shifts but in providing a quality system for the transition of care.
Need for External Regulation
In recent months, the climate of the debate has shifted so that the question is no longer “should resident work hours be limited?” but rather “who should oversee limitations?” and “how much should we limit them?” Working conditions for residents, as with most other aspects of medicine and medical training, have been regulated internally. The ACGME22 has recently developed universal guidelines for residents' working conditions in an effort to stave off federal regulations. At first glance, these regulations appear similar to those of the PPSPA—no more than 80 hours per week, no more than 24 consecutive hours, and on call no more often than every third night.
However, these guidelines would provide little relief for today's overworked residents. Under these proposed standards, programs could apply for a 10 percent extension, turning the 80-hour weekly limit into 88 hours. The regulations also would allow an additional six hours at the end of the 24 consecutive hours, for “inpatient and outpatient continuity, transfer of care, educational debriefing, and formal didactic activities.”22 One wonders about the educational value of having residents attend lectures in their 30th consecutive hour at the hospital. Of most concern, however, are provisions that allow programs to average the weekly hours and call nights over a four-week period. Under such a system, a resident theoretically could be scheduled to work 114 hours in any given week.
Although ACGME's new policy represents progress from their previous position of loose, specialty-dependent guidelines, it is unclear if this new regulation would lead to significant and meaningful improvement in the health and safety of residents and patients. Many therefore advocate an alternative avenue for reform—involvement and oversight by the federal government. Numerous newspapers have weighed in on the side of government intervention, including an editorial from The New York Times:
“Despite the tough talk, the council faces an inherent conflict of interest. Its board is dominated by the trade associations for hospitals, doctors, and medical schools, all of which benefit from the cheap labor provided by medical residents…codifying the rules into law would be a sensible step to increase the pressure for vigorous enforcement.”23
Furthermore, there is precedent for government regulation of resident work hours. New Zealand, Australia, and Ireland, as well as Great Britain and other members of the European Community, have recently mandated work weeks for “young doctors” that are far shorter than 80 hours. Progress has been made in these countries through collaboration between organized medicine and the respective governments.24
In the United States, precedent is established for safety regulation in other industries. For example, the Department of Transportation (DOT) has successfully regulated work hours in the transportation industry, using evidence-based regulations that are modified as new scientific information becomes available. In response to accident studies conducted in the 1980s, the DOT spent more than $30 million on fatigue research and resolved to “modify the appropriate Codes of Federal Regulations to establish scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements.”25
We come now to a key point: involvement of the government would assure a source of funds for transition to a safer system. There is debate about how much it would cost to limit residents' hours and shifts,2,5,26–28 but there is no doubt that reform will cost a significant amount of money. The parent organizations of the ACGME cannot pay this bill, nor can teaching hospitals afford it.
Policymakers and the public are willing to pay for safe hospitals, as evidenced by recent monies directed toward patient safety research by agencies such as the National Institute for Occupational Safety and Health and the Agency for Healthcare Research and Quality.29 If the federal government invests in this effort, however, policymakers and the public will demand that organized medicine relinquish regulatory authority. This is not an unfair request; the use of public dollars to fund graduate medical education should require public accountability.
Furthermore, if we are to regulate work hours in the name of safety and quality, it is critical that policy in this area be coupled with ongoing research that will guide the most cost-effective ways to improve safety and learning in teaching hospitals. Neither the ACGME nor any of the other private bodies currently engaged in the oversight of hospitals has the funding or structure to link research to regulation. Only the federal government has this capacity.
Medicine has been held back by the reluctance of the profession to allow the government to do its job. In the 1999 Institute of Medicine Report, “To Err Is Human”, the authors note, “Other industries that have been successful in improving patient safety, such as aviation and occupational health, have had the support of a designated agency that sets and communicates priorities, monitors progress in achieving goals, directs resources toward areas of need, and brings visibility to important issues. Although various agencies and organizations in health care may contribute to some of these activities, there is no focal point for raising and sustaining attention to patient safety. Without it, health care is unlikely to match the safety improvements achieved in other industries.”30
In light of the profession's long legacy of failure to improve resident working conditions, we believe it is time for the federal government to intervene and ensure the safety of both residents and the public. Rather than being feared by organized medicine, this development should be welcomed for bringing stability, funding, and research to graduate medical education, and for rebuilding the trust of the public in our nation's academic medical centers.
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2. Knickman JR, Lipkin M Jr, Finkler SA, Thompson WG, Kiel J. The potential for using non-physicians to compensate for the reduced availability of residents. Acad Med. 1992;67:429–38.
3. Committee of Interns and Residents: study and written testimony submitted to the Massachusetts Coordinating Committee by the Boston City Hospital House Officers' Association. Boston, Massachusetts. April 1988.
4. Jacques CH, Lynch JC, Samkoff JS. The effects of sleep loss on cognitive performance of resident physicians. J Fam Pract. 1990;30:223–9.
5. Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward?. N Engl J Med. 1988;318:771–5.
6. American Medical Student Association. Work hour stories from the front lines. 2001. Available at www.amsa.org/hp/reswork.cfm.
7. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358–67.
8. Collier VU, McCue JD, Markus A, Smith L. Stress in medical residency: status quo after a decade of reform?. Ann Intern Med. 2002;136:384–90.
9. Clever LH. Who is sicker: patients—or residents? Residents' distress and the care of patients. Ann Intern Med. 2002;136:391–3.
10. Kowalenko T, Kowalenko J, Rabinovich A, Gryzbowski M. Emergency medicine resident-related auto accidents—is sleep deprivation a risk factor?. Acad Emerg Med. 2000;7:1171.
11. Marcus CL, Loughlin GM. Effect of sleep deprivation on driving safety in housestaff. Sleep. 1996;19:763–6.
12. Klebanoff MA, Shiono PH, Rhoads GG. Outcomes of pregnancy in a national sample of resident physicians. N Engl J Med. 1990:323:1040–5.
13. Grunebaum A, Minkoff H, Blake D. Pregnancy among obstetricians: a comparison of births before, during, and after residency. Am J Obstet Gynecol. 1987;157:79–83.
14. Valko RJ, Clayton PJ. Depression in the internship. Dis Nerv Syst. 1975;36:26–9.
15. Reuben DB. Depressive symptoms in medical house officers. Effects of level of training and work rotation. Arch Intern Med. 1985;145:286–8.
16. Steele MT, Ma OJ, Watson WA, Thomas HA Jr, Muelleman RL. The occupational risk of motor vehicle collisions for emergency medicine residents. Acad Emerg Med. 1999;6:1050–3.
17. Samkoff JS, Jacques CH. A review of studies concerning effects of sleep deprivation and fatigue on residents' performance. Acad Med. 1991;66:687–93.
18. Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Laparoscopic performance after one night on call in a surgical department: prospective study. BMJ. 2001;323:1222–3.
19. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes?. JAMA. 1991;265:2089–94.
20. Defoe DM, Power ML, Holzman GB, Carpentieri A, Schulkin J. Long hours and little sleep: work schedules of residents in obstetrics and gynecology. Obstet Gynecol. 2001;97:1015–8.
21. O'Connell, A. Medical errors report opens way for hours, staffing reform. CIR News March 2000. Accessed on September 18, 2002, at www.cir-docs.org/news/5hoursnewspage.htm.
22. Accreditation Council for Graduate Medical Education. Proposed common duty standards for programs. June 2002. Report of the ACGME Work Group on Resident Duty Hours. Accessed on September 18, 2002, at www.acgme.org/new/wkgreport602.pdf.
23. Sleep-deprived doctors. New York Times. June 14, 2002:A36.
24. Sharfstein JM. Asleep on the job. The New Republic. June 21, 1999:17.
25. National Transportation Safety Board. Evaluation of U.S. Department of Transportation efforts in the 1990s to address operator fatigue. Safety Report NTSB/SR-99/01. May 1999.
26. Purdum TS. New York hospitals fear harm in plan to reduce specialization. New York Times. January 24, 1994:A1.
27. Pereira-Ogan G, Nash DB. Putting a price tag on training new doctors. J Am Health Policy. 1994;4:19–25.
28. Stoddard JJ, Kindig DA, Libby D. Graduate medical education reform. Service provision transition costs. JAMA. 1994;272:53–8.
29. Lamberg L. Long hours, little sleep. Bad medicine for physicians-in-training?. JAMA. 2002;287:303–6.
30. Institute of Medicine (U.S.) Committee on Quality of Health Care in America. To err is human: building a safer health system. Kohn LT, Corrigan J, Donaldson MS, eds. Washington, D.C. National Academy Press. 2000.
This department features essays written by medical students and family practice residents. Contributing editors are Sumi M. Sexton, M.D., who is an assistant editor for AFP; Jennifer Reidy, M.D., a resident at the Lawrence Family Practice Residency Program; and Laurie MacDonald, M.D., a resident at the Georgetown University/Providence Hospital Family Practice Residency Program.
Copyright © 2002 by the American Academy of Family Physicians.
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