Don't Ask Me to Work 80 Hours...
I work hard. My job—like most jobs—requires that I produce quality work even during the most hectic of times. Whether it's of the physical or existential variety, the fatigue resulting from unexpected projects or protracted work hours or numbing repetition just comes with the territory. I confess I'm not above trying to use fatigue as an excuse, mind you—but it's really not an excuse.
Fatigue is a relative term, however. If I were forced to work, say, 80 hours a week, I'd probably last about... a week. My writing would grow less crisp. I'd start missing mistakes in the editing process. I might even doze off in a meeting or two.
Medical residents, of course, don't have that luxury. In fact, they probably view 80 hours as an improvement from years past. Historically, residents have trudged through 100-hour weeks and at times worked 36 hours straight. And even in their most bleary-eyed state, residents have always been expected to maintain their focus on quality and ensuring patient safety. If I'm tired and the quality of my work slips, we print a correction. If a resident is tired and the quality of his or her work slips, someone dies.
The Accreditation Council for Graduate Medical Education in 2003 tried to address the issue of fatigue-related medical errors by limiting residents to 80-hour weeks and 24- to 30-hour shifts. Is it working? Many of you may have seen a study, "Effects of the Accreditation Council for Graduate Medical Education Duty Hour Limits on Sleep, Work Hours, and Safety," published in Pediatrics magazine that says, for the most part, no. The study of resident work hours at three pediatric training programs drew some grim conclusions. Some examples:
The rate of medication errors did not change.
The rate of physician ordering errors actually crept up, from 1.06 to 1.38 errors per 100 patient days.
Residents' measured total work hours and sleep hours did not change.
Rates of depression, car wrecks, and accidental needle sticks among residents did not change.
The catch is that while the report was released in August 2008, the data is from 2004, according to the ACGME's Ingrid Philibert, senior vice president for field activities. How much change can really be expected in the year between the ACGME's creation of the restrictions and the collection of the data? Won't we continue to see improvements both in error rates and the quality of residents' lives as organizations adapt to the restrictions?
Maybe. But even accepting the premise that the study's value is limited, the extreme physical and psychological demands placed upon residents—demands rooted in a longstanding medical culture that is accepted as gospel—still seem in conflict with the industry's broader push for improved quality. The theme that patients are arming themselves with more information and becoming savvier about choosing a provider is a ubiquitous one. For the sake of our patients and the sake of our organization, we can't lose focus on quality, say countless hospital leaders. So does the pervading industry philosophy of resident work hours align with that quality emphasis?
Don't get me wrong. The life of a medical resident should be demanding—very demanding. There's just no other way to properly prepare them for what lies ahead. But the provider community should continue to at least evaluate long-accepted truths about medical residents' workloads. "It's a balancing act between the number of hours worked safely from the intern and patient perspectives and ensuring they receive a wide variety and depth of experience to become competent physicians," says Sandeep Jauhar, MD, director of the Heart Failure Program at Long Island (NY) Jewish Medical Center who wrote a memoir of his years as a resident called Intern: A Doctor's Initiation. "It depends on a case-by-case basis about what constitutes too many hours. Some doctors can work well sleep-deprived and others can't.
Jay Moore is a managing editor with HealthLeaders Media. He can be reached at email@example.com.
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