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More Information on Medical Resident Work Hours

Petition to Reduce Medical Resident Work Hours

September 2, 2010

PART 5: Arguments Against Reducing Work Hours

 The following arguments are often made against reducing housestaff hours: (1) continuity of patient care will be disrupted; (2) long hours are necessary in order to sufficiently train physicians; (3) training under conditions of fatigue and sleep deprivation prepares resident physicians to function should these conditions arise in future practice; and (4) long hours promote favorable character attributes in physicians, such as discipline, endurance, responsibility, self-reliance, confidence, collegiality, and humility. The signers of this petition believe that two important questions must be asked: What is the incremental gain on any of these measures of working a 24-hour shift versus a 16-hour shift, and what are the risks against which these incremental benefits are being weighed? The risks have been reviewed in this petition, and have been shown to be substantial to both patients and physicians. On the other hand, there are no data supporting the claims of proponents of the current situation.

The continuity-of-care argument claims that (1) long continuous hours worked by an individual physician are necessary for the delivery of good care to his or her patients, and that (2) long, continuous hours are necessary for the physician to receive adequate training. First, it is inevitable that there will be breaks in the continuity of care for patients. Attending physicians, for example, are scheduled to go home after shifts much shorter than those worked by resident physicians. Resident physicians, on the other hand, have been traditionally expected to subordinate their needs to the “ideal” of spending as much time with their patients as possible. Studies increasingly demonstrate serious harm to resident physicians as a result of these long hours. But there is no evidence to support the contention that eliminating extended shifts leads to lower care quality. Quite the contrary, both the randomized controlled trials cited in the prior section, and a host of cohort studies, have demonstrated that eliminating 24-hour shifts improves the quality of care. In a systematic review of the literature, Levine et al. found that in seven out of 11 published studies, eliminating or reducing shifts of longer than 16 hours led to improvements in patient-care quality and safety;[1] in no studies did care quality deteriorate as a result of shortened hours. Decisions regarding how to schedule resident physicians — both with respect to patient care and resident physician well-being — must be based upon scientific evidence, not unsubstantiated arguments.

Second, resident physicians need not spend 30 continuous hours at a hospital in order to learn from their patients. Most diseases are seen a number of times in the course of multi-year residency programs, and resident physicians can also learn from the experience or reports of other resident physicians. With rational redesign of programs, it is possible to preserve or improve education despite reducing hours of work. In the Levine et al. systemic review, in nine out of 14 studies, educational outcomes did not change with reduction or elimination of shifts greater than 16 hours; in four out of 14 they actually improved; in only one out of 14 studies did any measure of education worsen (and that particular measure was a subjective rating by senior physicians).[2]

The profession of medicine is a continuous learning process, with many opportunities for necessary skills to be obtained throughout a physician’s career. With the rapidly changing nature of medicine, the ability to develop a well-balanced life with a well-established ability to continue to learn are at least as important as any experience to be gained between the 80th and 100th hour of a work week. Moreover, much of a resident physician’s time is spent on non-educational activities. In a time-motion study of internal medicine resident physicians at two urban hospitals in New York City, Knickman found that 19% of internal medicine resident physicians’ time was spent on activities that could be done by nurses, laboratory technicians, or other staff.[3] A meager 3.1% of their time was actually spent exclusively seeing patients. This raises the question of why more ancillary staff is not hired to allow resident physicians added time for educational activities and to reduce work hours. Green has argued that the real reason is that it is economically more favorable for hospitals to use resident physicians as inexpensive labor to complete necessary tasks than to hire ancillary personnel who require higher salaries.[4] It has been calculated that substituting ancillary staff to provide services currently provided by resident physicians would cost hospitals approximately $58,000-$78,000 annually (in 1993 dollars) per resident physician, because resident physicians’ salaries per hour actually worked are so low.[5] A more recent study put the annual labor costs of implementing the 2008 IOM recommendations at $1.6 billion (in 2006 dollars).[6]

The argument that, by training long hours, resident physicians will learn to function under the harsh conditions of real-world practice is false. Very few physicians work such long hours after residency. In fact, according to a very recent survey, the trend in the last decade has been “a steady decrease in hours worked per week … for all physicians”.[7] U.S. physicians work an average of about 50 hours per week. In addition, on-call shifts occur less frequently. Being “on-call” for an attending physician is different than for a resident physician. While the resident physician must be physically present in the hospital, the attending physician usually has the luxury of taking call from the comfort of his or her own home. The attending physician must be available to come into the hospital if there were an emergency, but that rarely happens. In fact, the culture fostered in some residencies is one that discourages resident physicians from bothering the attending physician overnight. If the resident physician cannot handle a patient and has to ask for help from the attending physician, it is considered by some attending physicians and/or some resident physicians to be a sign of weakness.

Moreover, it is important to recognize that in those cases when attending physicians do remain awake overnight, they have been found to cope with sleep deprivation no better than trainees, despite years of experience with it. In a retrospective study of surgical and obstetrical complications over a 10-year period, Rothschild et al. found that attending physicians obtaining less than a six- hour opportunity to sleep overnight had three times as many complications in the operating room as compared with those who had more than a six-hour opportunity to sleep.[8] The notion that resident physicians should experience sleep deprivation in their training to prepare them for those times in the future when they may experience it again thus appears misguided. Studies in medicine, other occupations, and the laboratory do not support the notion that one can learn to cope with sleep deprivation. Indeed, emerging studies strongly indicate that chronic sleep deprivation greatly magnifies the ill effects of acute sleep deprivation, leading to as much as a 10-fold worsening in the effects of acute sleep loss.[9]

In sum, whereas there is evidence that physical and mental harm comes to resident physicians and that performance decreases with sleep deprivation and fatigue, there is no evidence to suggest that reducing work hours would decrease the quality of patient care, that 80 hours per week is insufficient to train resident physicians, or that resident physicians are better prepared for the future because they trained more than 80 hours per week. Moreover, there is positive evidence that medical errors decrease with reduced work schedules[10] and that resident physicians’ performance and moods get better with rest,[11] both of which translate into better patient care. If policy is to be based on evidence and not opinion, the federal government is obligated to protect resident physicians and their patients by reducing resident physician work hours. It is quite clear that public opinion strongly supports reducing resident work hours.[12] In a telephone survey of 1,200 people using random digit telephone dialing, researchers found that 81% believed that reducing resident physician work hours would be very or somewhat effective in curtailing the problem of medical errors. Further, only 1% approved of shifts lasting more than 24 hours.

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[1] Levine AC, Adusumilli J, Landrigan CP. Effects of Reducing or Eliminating Resident Work Shifts over 16 Hours: A Systematic Review. Sleep 2010; 33: 1043-53.

[2] Levine AC, Adusumilli J, Landrigan CP. Effects of Reducing or Eliminating Resident Work Shifts over 16 Hours: A Systematic Review. Sleep 2010; 33: 1043-53.

[3] 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. Academic Medicine 1992;67:429-38.

[4] Green MJ. What (if anything) is wrong with residency overwork? Annals of Internal Medicine 1995;123(7):512-7.

[5] Stoddard JJ, Kindig DA, Libby D. Graduate medical education reform. Service provision transition costs. Journal of the American Medical Association 1994;272:53-8.

[6] Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009 May 21;360(21):2202-15.

[7] Staiger DO, Auerbach DI, Buerhaus PI. Trends in the work hours of physicians in the United States. JAMA. 2010 Feb 24;303(8):747-53.

[8] Rothschild JM, Keohane CA, Rogers S, Gardner R, Lipsitz SR, Salzberg CA, Yu T, Yoon CS, Williams DH, Wien MF, Czeisler CA, Bates DW, Landrigan CP. Risks of Complications by Attending Physicians after Performing Nighttime Procedures.  JAMA 2009; 302:1565-72.

[9] Cohen DA, Wang W, Wyatt JK, Kronauer RE, Dijk D, Czeisler C, Klerman EB. Uncovering residual effects of chronic sleep loss on human performance. Science Translational Medicine 2010;2(14):14ra3.

[10] Gottlieb DJ, Parenti CM, Peterson CA, Lofgren RP. Effect of a change in house staff work schedule on resource utilization and patient care. Archives of Internal Medicine 1991;151(1):2065-70.

[11] Berkoff K, Rusin W. Pediatric house staff’s psychological response to call duty. Developmental and Behavioral Pediatrics 1991;12:6-10.

[12] Blum AB, Raiszadeh F, Shea S, Mermin D, Lurie P, Landrigan CP, Czeisler CA. US public opinion regarding proposed limits on resident physician work hours. BMC Med. 2010 Jun 1;8:33.

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