he 1984 case of Libby Zion, an 18-year-old college freshman who died in a New York hospital while being treated by overworked and tired medical residents, was a key event behind changes in rules guiding residents’ work hours that have been developed over the past 25 years.1
In those days, residency was brutal. There was no cap on admissions or duty-hour restrictions, and many residents were overworked, stressed, and sleep deprived, a combination of factors that could create a dangerous situation. But it was a scenario that was considered part of “normal,” necessary medical training. The Zion case brought public attention to the issue of residents’ work hours and how it affects patient care.
In the last decade, two important regulations have been instituted: in 2003 the Accreditation Council for Graduate Medical Education (ACGME) issued a set of guidelines limiting time for residents to 80 hours per week.2 Recently, in April 2010, ACGME adopted new federal regulations further limiting work hours for resident physicians. There were several changes that became effective July 1, 2011: constant supervision of PGY1, duty hours that are now down from 24 hours per shift to no longer than 16 hours, and frequency of call no more than every third day, or a maximum of six nights in a row.3
Nationwide surveys have been conducted to evaluate the opinion of both residents and program directors about the new work-hour regulations.4,5 Expectations and perceptions about the new regulations are divided. While concerned about achieving a good balance between preventing exhaustion among the residents and thus enhancing their patients’ safety and wellbeing, directors of residency programs are concerned that the reduced hours would have a negative effect on resident training because less time in the hospital means less “hands-on” experience with patients and procedures. Concerns were raised that with fewer hours on call there would be less exposure to a wider amount of clinical encounters, and in this way the resident would have less practical learning. Others noted the financial costs of reducing resident work hours, and the need to imprint responsibility and professionalism and place patient care as the uppermost aim.
It is my belief that the new rules regarding a change in work hours will be shown to benefit both the patients and residents. Patient care will be improved because well-rested residents are better equipped to perform critical patient care, with rapid decisions and more lucid management at 3 a.m. Residents will have fewer episodes of depression and accidents inside and outside of the hospital, and take better care of their health and personal lives. I believe that when residents have more free time to study at home, they can improve their body of theoretical knowledge. Spending more time with family and being able to deal with personal concerns also gives us a sense of personal fulfillment that carries over to our professional lives and makes us better practitioners.
It makes sense to have more work-hour restrictions for interns, because they are not only the most inexperienced practitioners, but are writing orders under the most stressful conditions—not only because they are just starting to know the system but also because that is an important part of their training. Constant supervision during those critical moments of making a tough decision will benefit the patient, and getting validation of one’s clinical decision by supervisors will build better clinicians for the future. I believe that patients will be able to perceive that physicians are more rested and committed and have a better attitude, which will enhance their confidence and well-being.
On the other hand, time to acquire practical skills will be reduced, and residents will need to take advantage of every single clinical encounter with patients. We are also expected to be ready when the moment comes, after finishing our training and becoming real doctors, that we no longer require a teacher, are able to work in the current healthcare system—very often in less-than-ideal circumstances—and are independent enough to deliver optimal patient care.
A problem that arises with work-hour restrictions will be optimal hand-off of patients’ care. Fatigue-related errors might drop with the new system but the errors related to hand-offs could potentially increase.6 There is also the potential drawback that interns are not going to be prepared to be senior residents due to a lack of exposure to increased amounts of work and challenging situations that will greet them as they advance. Another potential issue would be to have to see the same number of patient in fewer hours, which can compromise quality of care, with potential harm to patients and decreased insight to problems in care.7
In summary, the new work-hour regulations have benefits for the physical and intellectual well-being of the resident, but may have disadvantages with respect to the learning process. As has been said, learning about a disease from a book is like reading about a voyage without being in the ship at all. We need to see patients to learn the true nuances of disease and patient care.8
The current regulations are not perfect; new studies are needed to objectively assess patients’ benefits derived from having more willing, alert, and enthusiastic residents to devote their attention to the Holy Grail of excellent patient care. I believe each doctor must make the most out of his or her new-found free time, and make a personal commitment to harness this opportunity to enhance themselves as clinicians.
It is my belief that in general the new ACGME regulations are in the best interest of our patients, and that we as residents can make our training a success. If we use our time wisely, we will learn to practice medicine as well as was the case with the previous work-hour standards.
1. Lerner BH. A life-changing case for doctors in training. New York Times. August 14, 2011. http://www.nytimes.com/2009/03/03/ health/03zion.html. Accessed September 1, 2011.
2. Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288:1112-1114.
3. Nasca TJ, Day SH, Amis ES Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363:e3.
4. Drolet BC, Spalluto LB, Fischer SA. Residents’ perspectives on ACGME regulation of supervision and duty hours — a national survey. N Engl J Med. 2010;363:e34.
5. Antiel RM, Thompson SM, Reed DA, et al. ACGME duty-hour recommendations — a national survey of residency program directors. N Engl J Med. 2010;363:e12.
6. Joint Commission International Center for Patient Safety. Strategies to Improve Hand-Off Communication: Implementing a Process to Answer Questions. Joint Commission Perspectives on Patient Safety, July 2005, Volume 5, Issue 7.
7. Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300:1146-1153.
8. Gaba DM, Howard SK. Fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347:1249-1255.