Rest for the Weary

Work Limits to Change Medical Training for Residents, Teaching Hospitals  

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Cover Story -- November 2002

By  Ken Ortolon
Senior Editor

Michael Ready, MD, recalls his internship year as one of nearly never-ending fatigue. Being on call every third night and frequently working 36-hour shifts eventually wore him down.

"I remember thinking to myself toward the end of the year that I was tired of being tired," said the third-year family practice resident from Bryan. "It almost seemed more like a hazing than an educational process."

Grueling work hours have been part of postgraduate medical training for decades, sort of a "rite of passage" into the medical profession. Many physicians say stress and fatigue are part of a trial by fire that prepares residents for the demands of private medical practice.

Dr. Ready recalls fighting to stay awake and seeing others lose similar battles. Another resident says he sometimes had trouble deciphering his own handwriting. Yet another admits he made mistakes with patients because of fatigue.

But the era of workweeks that sometimes exceed 120 hours for some residents is about to end. The Accreditation Council for Graduate Medical Education (ACGME) has mandated new limits on residents' weekly work hours. All U.S. residency programs must comply with the new guidelines by July 2003 or risk losing their accreditation.

While the council says the new guidelines will result in more alert doctors functioning more efficiently, others say they will drive up health care costs and jeopardize the quality of medical training.

Some fear limiting residents' training hours may end up jeopardizing patient safety in the long run. "As we cut down on the number of hours and exposure to clinical cases, the proficiency of a doctor who has fewer exposures and fewer hours is not going to be of the quality that we had in the former years," said Kenneth Mattox, MD, chief of staff and chief of surgery at Ben Taub General Hospital in Houston.

Coping With Fatigue

Residents say they recognize the need to work long hours to ensure continuity of care and learn their craft. Maurice Sholas, MD, PhD, who recently completed his residency in physical medicine and rehabilitation in San Antonio, sometimes worked more than 100 hours a week during some rotations. But he says people don't go into medicine "to punch in and punch out on the clock." Residents expect to work hard, he says.

"A lot of professionals are forced to work hours that are much longer than 9 to 5," said Dr. Sholas, now a fellow in pediatric rehabilitation at the Rehabilitation Institute in Chicago. "That's not to say it's all peaches and cream and gravy, but it is the reality that we are hired in a sense to learn but also to do a job."

But Dr. Sholas and other residents say fatigue does detract from both learning and patient care. Dr. Ready recalls a passage from a book, MD: Doctors Talk About Themselves (Delacorte Press, 1988), in which a urology resident recounted falling asleep during an operation because of fatigue. Dr. Ready says he hasn't witnessed a similar incident in his family practice residency, but adds that fatigue does take its toll.

"After you've been on call for more than 24 hours and the new day starts again, you may have didactic lectures in the afternoon. You sit there fighting to find a way to stay awake. You nod off while someone's lecturing and you wonder, 'Is this learning or is it just a ritual you have to go through?'"

Dr. Ready says he's seen residents fall asleep while making rounds. "I've seen people just dog tired. They'll lean up against a wall for a second and just nod off. I'd find myself falling asleep at morning report. I'd find myself closing my eyes a little bit longer than I should on rounds."

Ben Leeah, MD, chief resident in the Department of Family Medicine at Texas Tech University Health Sciences Center in Amarillo, says long hours during his internship and residency have "toughened" him and made him a better doctor. But, he remembers times when he was so tired he couldn't read his own writing or make sense of his notes or dictation.

"When I was an intern working internal medicine at the VA Hospital here in Amarillo there were times when I basically couldn't function because of fatigue," Dr. Leeah said. "When it's 4 in the morning and you haven't slept in 24 hours -- and you probably haven't eaten that well either -- you really do begin to question and double check and, of course, you start working slower, as well. You're not as efficient, you have to repeat a lot of things, you have to stop and think about what you're going to do, you have to look up medicines for fear of prescribing the wrong dose.

"There were a couple of times when I probably gave a patient with congestive heart failure too much fluids, or maybe I didn't notice some subtle EKG changes until the patient's cardiac enzymes started creeping up and I went back and looked at the EKG again, maybe losing a couple of hours because it was early in the morning and I was sleep deprived," said Dr. Leeah.

Setting the Limit

For years, medicine has been wrestling with the issue of how many hours a resident should work. In September 2001, responding to concerns that restricted sleep could be detrimental to patient safety and residents' education, safety, and well-being, the ACGME appointed the Work Group on Resident Duty Hours and the Learning Experience to recommend appropriate limits on resident work hours. (See "Current Issues in Work Hours of House Staff Physicians," May 2002 Texas Medicine , pages 13-15.) The ACGME adopted the group's recommendations in June 2002.

The new guidelines prohibit residents from working more than 80 hours per week, averaged over a four-week period. Residency programs can apply to their sponsoring institution's Graduate Medical Education Committee for an increase of up to 10 percent if they can prove additional hours are necessary to complete a resident's education.

The new rules also require that:

  • Residents must have one day in seven free of patient care responsibilities, and they cannot be on call more than every third night, both averaged over a four-week period.
  • On-call duty must be limited to 24 hours, but an additional six hours will be allowed for inpatient and outpatient continuity and transfer of care, educational debriefing, and instructional activities.
  • Residents must receive at least 10 hours of rest between duty periods. When they take call from home and are called into the hospital, any time spent in the hospital must be counted against the weekly duty limits.

The ACGME guidelines are similar to resident work hour limits spelled out in a policy adopted by the American Medical Association House of Delegates in June, as well as legislation introduced in Congress by U.S. Rep. John Conyers (D-Mich.).

The new limit was driven partly by high-profile professional liability cases citing physician fatigue as a significant factor in medical errors. One such case was that of Libby Zion, an 18-year-old New York woman who died in 1984 after being given Demerol, even though she allegedly told her physicians she had taken Nardil, an antidepressant. The two drugs can be fatal when taken together.

Ms. Zion's father, a former federal prosecutor, claimed his daughter received inadequate care at the hands of overworked and undersupervised medical house officers. The case prompted a grand jury investigation that faulted New York's system of residency training and physician staffing. It also prompted legislation that made New York the only state to limit resident work hours by statute.

Dr. Mattox points out that the resident who gave the telephone order for Ms. Zion's medication used fatigue as her defense even though she had been on duty less than six hours. Thus, the case concerned continuity of care, not excessive work hours, he says. Continuity-of-care issues will be compounded with the new ACGME recommendations, he adds. "The area in medicine that creates the greatest problems for us is the hand offs: the hand off from the emergency room to the ICU, the emergency room to the operating room, the operating room to the ICU, one hospital to another. With all of the schemes I have seen, the number of hand offs in individual physician responsibility is going to increase, and we are going to create increased problems of continuity," Dr. Mattox said.

Marvin Dunn, MD, director of residency review committee activities for the ACGME, says incidents like the Zion case "indirectly" influenced the push to limit resident work hours, as did automobile accidents caused by exhausted residents falling asleep behind the wheel while driving home after particularly long shifts.

Recent research into the effects of sleep deprivation on performance has provided a better understanding of the impact of long work hours on a physician's ability to function, and there was wide variation among specialties on how many hours a resident could be required to work.

According to a study published by the British Medical Journal on Nov. 24, 2001 (323:1222-1223), surgeons who do not get enough sleep may be endangering their patients. In the study, 14 surgeons-in-training who slept for less than three hours after working a 17-hour shift made significantly more errors when performing laparoscopic surgery, partly because of a lack of concentration and coordination. They also took longer to perform certain tasks associated with the surgery.

The surgeons used a virtual reality surgery system, not real patients, in the study.

According to a February 2002 report by the American Medical Student Association, the work hour guideline for general surgery residents was defined as "whatever is considered 'appropriate' by residency directors." The residency review committee for ophthalmology, on the other hand, limited residents to an 80-hour workweek.

"Is there some one-size-fits-all standard? The answer to that is no," Dr. Dunn said. "So between those two extremes we wanted to bring this into focus." He says the guidelines are "very reasonable," protect residents and patients, and give adequate time for training.

Difference of Opinion

But not all physicians who supervise residents agree with that assessment. Michael Smerud, MD, chief of radiology at Baylor University Medical Center in Dallas, says the new guidelines will have little impact on radiology residents there because lengthy on-call hours were eliminated years ago.

"Traditionally, you'd come to work on Tuesday morning and you'd work all day," Dr. Smerud said. "If you were on call, everybody else would go home at 5 o'clock but you'd work all Tuesday night and then all day Wednesday. If you were lucky, you'd get out of here at 5 o'clock Wednesday afternoon."

Now, radiology residents at Baylor rotate coverage of the emergency room at night. Residents on the night shift have no additional responsibilities the next day.

Robert Alpern, MD, dean of The University of Texas Southwestern Medical School at Dallas, says most other specialties will see little impact from the 80-hour limit. "I think there will be some inconveniences, but I also think there will be advantages to getting some sleep."

He shares Dr. Mattox's worry about the work limits' effect on continuity of care. "The biggest concern I've had with these limitations is that you end up chopping up the care of the patients, which is never good," Dr. Alpern said. "So you have one doctor admitting a patient, another doctor seeing him the next day, and maybe a third doctor taking care of him next. That's not good for patient care or for resident education."

Cost and Quality

Dr. Mattox, who also is professor of surgery and vice chair of the Department of Surgery at Baylor College of Medicine, has two other major concerns with the new limits: added costs for the teaching hospitals and reduced quality in residency training programs.

No one has estimated the cost of complying with the guidelines, but Dr. Mattox says the New York experience should provide a good example. When that state limited resident work hours in 1989, state officials estimated it would cost $220 million a year for hospitals to comply.

Dr. Mattox says a recent survey at Ben Taub indicates residents are spending 10 to 30 percent of their work hours on nonclinical tasks, such as locating laboratory results and x-rays, transporting patients, performing clerical work, and providing case management.

"If we no longer have the residents to do those hospital activities, then somebody is going to have to do them," he said. "The hospital will have to hire secretaries, case managers, transportation orderlies, translators, chaperones, and other individuals to replace the residents who have basically been cheap labor in the past, or those tasks are not going to get done, or the time for a patient to see a physician is going to increase."

If residents' time is so valuable, Dr. Ready, the family practice resident, asked, "then why is any amount of it spent performing tasks of minimal educational value?"

Kirk Calhoun, MD, senior vice president and chief medical officer for Parkland Memorial Hospital in Dallas, says teaching hospitals also are going to need more physicians or other health care professionals to fill the void left when resident work hours decrease.

"We expect that we are going to have to find some alternative ways to provide the type of care that we've provided in the past," said Dr. Calhoun. "Those alternatives are likely to be more costly and may involve the use of hospitalists to see patients, as well as the use of other types of providers, such as nurse practitioners, physician assistants, and others."

Dr. Calhoun, who also is associate dean for clinical affairs at Parkland for UT Southwestern, says the larger services should be able to comply with the new requirements with little inconvenience. Smaller programs, such as neurosurgery, which have fewer house staff, will find the new guidelines much more burdensome, he says.

"For the smaller programs, identifying what process changes need to take place to meet the requirements is going to be more challenging. But we will work with those departments to achieve what is necessary."

Even if the programs can comply, he worries about the impact on the medical training his residents will receive.

"I know the arguments about people being unable to learn when they're tired," Dr. Calhoun said, "but I'm concerned about doctors not getting the necessary experience because they're not present with patients during times of key decision making."

Dr. Mattox concurs. "There is a certain volume of exposure that is needed before we have a finished doctor." He worries that 80 hours per week -- or even 88 hours if a program can get the 10 percent extension -- will not be enough, particularly in the surgical specialties. If programs cannot adapt, Dr. Calhoun says, the length of some residencies may have to be extended, particularly in those specialties that require physicians to perform a certain number of procedures to become eligible for board certification.

Given the fact that Medicare pays a large portion of the tab for graduate medical education and that funding is tight, lengthening residency programs may not be an option, Dr. Mattox says. Instead, he fears that training programs will be cut short.

"We may have to start training a thoracic heart surgeon after only one or two years of general surgery training, whereas in the past a heart surgeon went into heart surgery after five years of general surgery," he said.

Dr. Dunn of the ACGME says these economic, patient care, and training concerns are legitimate, but he believes they can be overcome.

"These are touchy issues that everyone is going to be monitoring very carefully with the understanding that there may be modifications in the future if this compromises the education. If the education is compromised, it's a shallow victory."

Meanwhile, Dr. Ready thinks the changes will be good for medicine.

"It's going to have a tremendous impact on fatigue," he said. "After you've pulled a 24-hour shift and you're starting over again in the morning, you start working a lot slower. You're not very productive, and anything you learn during the time when you're fatigued will be much more difficult to retain.

"We can't think of ourselves as supermen. We know about the cognitive slippage that takes place after about a 30-hour period. I don't think many of us would feel terribly comfortable flying in a plane with a pilot who had been up for 30 hours straight," Dr. Ready said.

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.

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