The True Cost of Resident Work-Hour Restrictions

Work restrictions intended to limit residents' fatigue and stress, and as a result reduce medical errors, have associated labor costs of nearly $1.6 billion per year, according to a new study in the New England Journal of Medicine. That figure includes costs associated with handing off excess work from resting residents to substitute providers.

The researchers based their assumptions on Institute of Medicine recommendations to improve adherence to the ACGME's 80-hour work week, encourage naps during extended shifts, and limit shifts without naps to 16 hours. They also tried to measure costs associated with preventable adverse events and the total societal costs of the restrictions.

Their ultimate conclusion was that the effectiveness of the IOM's recommendations is unknown. "If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high," they wrote.

But are those the only costs tied to work restrictions?

It has taken me a while to wrap my head around the controversy of the 80-hour resident workweek. I confess, in my mostly Monday-Friday, mostly 40-50-hour work world, 80 hours seems like an admirable and exhausting commitment. When I first began learning about resident work restrictions I assumed that it was a no-brainer. Of course residents are going to become fatigued and make more errors if they're working 120 hours a week on little sleep.

I still think resident exhaustion is worth addressing, but some recent conversations with physicians and administrators have opened my eyes to some of the long-term negative impacts of the 80-hour workweek.

The work restrictions seem to be gradually and not-so-subtly changing physician culture. Physicians have traditionally been known for basing the amount of hours they work on the amount of work that needs to be done. Many doctors take pride in not leaving the hospital until all their patients are cared for.

As residents get accustomed to limited shift work in their training, however, they are increasingly looking for similar scheduling arrangements in their post-residency careers. Physicians, particularly those early in their careers, are shying away from private practice in favor of employment arrangements with set schedules. They are favoring specialties like dermatology that are known for both high compensation and a controllable lifestyle.

"One of my concerns is that a lot of the doctors in training are now going to this have mindset that I only have to work so many hours and I'm gone, it's somebody else's problem," says John Jeter, MD, CEO of Hays Medical Center, a 153-staffed-bed community hospital in Kansas. "That's not how it works. You can't abandon patients and partners."

This is particularly troubling at a time when severe physician shortages are being projected. There are also concerns that residents working fewer hours aren't getting the training they need and the length of residencies may have to be extended, slowing the development of much-needed new doctors, Jeter says.

So what's the solution? Work residents to exhaustion and risk preventable errors? Continue with the restrictions and lose physician productivity?

"There has got to be some in-between where there are still many opportunities to learn what needs to be learned without it being an unhealthy environment," says Jeter. "I'm not sure we've found the balance."