The battle lines were drawn a decade ago, but the controversy is far from being over. A recent article in The Wall Street Journal returns to the question, 'Should Medical Residents be Required to Work Shorter Shifts?' (February 19, 2013). Here are some of the rules now governing their work schedules:
- An 80-hour weekly work limit, averaged over 4 weeks
- A minimum of one day off every week, averaged over 4 weeks
- A 16-hour limit on continuous duty for first-year residents
- A 24-hour limit on continuous duty for other residents
- In-house call no more than once every 3 nights, averaged over 4 weeks
To keep their accreditation, residency training programs must report regularly to the Accreditation Council for Graduate Medical Education (ACGME) to show they they are following the rules. "I think we should challenge the whole idea of having a central committee dictate work limitations for all residency programs,'' says Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons.
But, they don't comply with the guidelines anyway, says Dr. Steven Lockley, sleep medicine specialist at Harvard Medical School. "A study by our research team [at Harvard] found 85% of residency programs were non-compliant with the work-hour rules."
A survey done by the ACGME found only 5% non-compliance.
So what about patient safety? "When hours are reduced," says Dr. Lockley, "medical error rates fall enormously." No other simple solution comes as close as a way of cutting errors. "He adds that longer shifts affect physicians health and safety as well." In surveys conducted by our group, residents working 24 or more hours in a row reported sticking themselves with needles 60% more often, as compared with [those working] shorter shifts."Yes," says Dr. Orient, "people do tend to make more mistakes when tired. But the bigger reason for mistakes by physicians-in-training is lack of experience." Dr. Orient believes that shorter shifts short-change the learning experience:"Many physicians, myself included, think new physicians are less well-trained. They have seen fewer patients and have done fewer procedures. [Consequently], future patients may pay the price when the less-experienced physician is working without close supervision."
It's almost impossible to take a neutral stance on this issue. As might be expected, older physicians are more likely to see the so-called 'shift-work culture' as a threat to the traditional doctor-patient relationship in which doctors are customarily available outside "office hours." Younger physicians are more likely to see patient care as "the collective responsibility of the team, rather than primarily the responsibility of their doctor." Since this controversy is in part driven by differing attitudes between generations, it will take a while before it's resolved.
Ken Teufel is the Medical Director for Interim Physicians