As fourth-year medical students apply to residency programs, policymakers continue to scrutinize guidelines that regulate the number of hours these soon-to-be-graduates will be able to spend working in the hospital. The Accreditation Council for Graduate Medical Education (ACGME) limited resident duty time to 80 hours per week in 2003, a radical move in light of the 100-plus hours many house staff were used to working. Since then, however, the medical community has been engulfed in a debate over the implications of these guidelines for patient safety, medical education, and health care costs.
The impetus for the ACGME’s resident duty hour restriction dates back to 1984, when Libby Zion, the 18-year-old daughter of a prominent New York City journalist and lawyer, died tragically in a teaching hospital shortly after being admitted. Though her physician care team initially reported that the cause of her death was unclear, her father concluded otherwise. He was convinced that his daughter’s death was a result of an insidious hospital system problem: the interns and residents who took care of her were overworked and overextended, he claimed.
According to him, they were also short on both sleep and senior supervision.
Initially, the controversy triggered ineffectual duty hour restrictions in New York State. Yet as public awareness of the significance of medical errors grew—awareness that was bolstered by the Institute of Medicine’s report on the burden of medical errors—the ACGME entered the fray and made duty hour restrictions and compliance a requirement for accreditation.
Advocates of the reforms argue that they improve the safety of patients and the quality of life of residents and reduce risks that otherwise severely sleep-deprived residents might face. Several studies, for example, have demonstrated that sleep deprivation leaves residents more vulnerable to motor vehicle accidents, low-birthweight baby deliveries, and depression. Opponents believe that the restrictions have excessively increased the frequency of patient handoffs—transition points when the primary responsibility for the care of a patient passes from one resident to another—and that this disruption in care endangers lives. Some also argue that the regulations divert time away from medical education, thereby compromising training.
In two recent studies published in the Journal of the American Medical Association, Kevin Volpp and his colleagues evaluate the impact of duty hour reforms on health outcomes in Medicare patients and patients in Veterans Affairs hospitals. They find that these reforms yielded a small benefit in VA hospital patients but had virtually no effect on Medicare enrollees. Their evidence is some of the strongest available on the relationship between work hours and patient safety. Overall, however, the relationship remains unclear.
I spoke to a few members of the HMS Class of 2004 to hear their perspectives on the impact of work hour restrictions on hospital life. These recent graduates are some of the first to train within the reforms. A common theme that emerged was that they all appreciated the improvements in resident quality of life but had concerns about the effect of handoffs on patient safety.
Nikhil Wagle, an internal medicine resident at Brigham and Women’s Hospital and one of the architects behind the hospital’s redesign of resident duty schedules, thought the benefits of the new regulations needed to be weighed against potential challenges. “An increase in the number of patient handoffs can increase medical errors,” he said, “and the reforms may have disproportionately shifted time away from educational activities for house staff.”
Alden McDonald, a cardiology fellow at the Texas Heart Institute who trained at Massachusetts General Hospital, also highlighted improvements in resident quality of life as a boon but echoed Wagle’s concern about handoffs. “Shorter work hours mean a tradeoff must be made between having a resident who knows the patient well but has worked longer and is tired versus having a resident who is less familiar with the patient but well rested.” He emphasized, though, that the reforms could improve patient safety but would require ongoing review.
General surgery resident at BWH Joan Ryoo also emphasized the challenges inherent in patient handoffs but underscored another important issue. “Though the restrictions are based on evidence from studies performed observing trainees, there is a tension or contradiction for residents that is represented by work hour restrictions that apply only to trainees. Trainees are training to be attendings, but attendings do not function, practice, or work under the same restrictions.”
Rollin Hu, a neurosurgery resident at MGH, was more outspoken about the drawbacks of patient care settings that relied heavily on overworked residents. “It is unrealistic to expect human beings who have been awake and working for over 30 hours straight or who have been working 100-hour weeks without days off to perform with the same level of judgment and ability as a more well-rested person,” he said. “In my own experience, work hour limitations have certainly improved our ability to treat patients with the expected level of competence.”
The resident duty hour issue continues to unfold, and the results of formal research studies are as diverse as the opinions of medical and surgical residents. In the meantime, this year’s residency applicants can expect to work fewer hours than their colleagues did only a decade ago, but they do so in an environment of controversy, evaluation, and change.
Joseph Ladapo is a Harvard medical student and a PhD student in health policy.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
