How many hours should medical residents work?
Hospital care is a 24-hour-a-day enterprise, but the question of which doctor should be there — and how long he or she should already have been there — is among the most controversial and unsettled in medicine. It’s a question that comes up almost daily among my peers, and my own feelings about the issue often depend on whether I’m trying to grasp details about a new patient or struggling to stay awake at the end of a very long shift.
Credit Tom Fitzsimmons
In 2003, at the genesis of the modern patient safety movement, the Accreditation Council for Graduate Medical Education mandated that residents work no more than 80 hours per week. In 2011, it limited individual shifts for first-year residents to 16 hours. Since then, research has been mixed on whether reducing the length of shifts or total number of hours worked has improved resident health, medical education or patient outcomes.
This year, two large national trials, known as iCompare and First, aim to shed new light on the issue. Researchers randomized first-year residents at internal medicine or general surgery programs across the country to work either 16-hour shifts, the current maximum, or longer shifts of 28 hours or more. Shortly after the iCompare trial began, two advocacy groups sent an open letter to the Office for Human Research Protections, calling the trial “unethical” and arguing that it exposes patients to dangerously sleep-deprived residents while exposing residents to a greater risk of car accidents, needlestick injuries and depression.
These trials come at a critical time, amid mounting evidence of serious mental health concerns for medical trainees. A recent study found that almost one-third of residents exhibit symptoms of depression; other studies show that almost 10 percent of fourth-year medical students and 5 percent of first-year residents admitted to having suicidal thoughts in the previous two weeks — with higher rates among minorities.
And yet, it’s not clear whether more restrictive work hours will make things better for residents or patients. When residents work fewer hours, there are more patient “handoffs” — when a patient is transferred from one doctor to another. The process makes it more likely that important details are overlooked, and intimate familiarity with a patient’s recent clinical course is often left behind. And residents may not even be reporting their hours accurately. Whistle-blower protections are lacking, and the penalty for work hour violations is loss of program accreditation, which could hurt the resident reporting the problem.
In the face of uncertainty, we need more data — and we’re starting to get it. Results from the First trial, published yesterday, found no significant differences in patient outcomes, resident satisfaction or educational quality when surgical trainees worked longer shifts. (Results from iCompare, which is looking at internal medicine residents, are expected in June.)
But I worry about how to interpret the results of trials like these, and what positive or negative findings may mean for residency training discussions going forward. In a profession driven by evidence, data is useful. But it’s important to recognize data’s limitations.
Many patient-care metrics we use to evaluate the impact of duty hour restrictions — mortality, procedural complications, adverse events, readmission rates — are crude. They might make sense for hospitals and health systems designed to increase efficiency and insulate patients from human fallibility. But they fail to capture the nuances of care delivered at the doctor-patient level. Good patient care is about more than surgical infection rates and medication errors. At the end of a long shift, am I the kind of doctor — and person — I want to be? Do I make time to sit with a suffering patient? Do I snap at a well-meaning colleague?
Well-being is similarly difficult to study. Research suggests that one’s judgment of happiness and life satisfaction is surprisingly fickle. For example, people interviewed on sunny days report being more satisfied with their entire lives than those interviewed on rainy days. So if you ask me about my training program after a particularly bad 16-hour shift, I’m likely to rate it worse than during a particularly good 30-hour shift.
Medical educators also worry that work hour restrictions force residents to see fewer patients and miss important educational experiences. At the same time, we allow residents to spend hours scheduling appointments, faxing medical records, gathering vital signs, obtaining prior authorization, and completing many other nonclinical tasks. We don’t learn to do these tasks in medical school; we shouldn’t be spending our time on them as residents. If we’re concerned about resident education, let’s focus on increasing quality time spent on direct patient care and educational activities.
The right answer on how many hours residents should work may be more nuanced than we’ve been willing to accept. It isn’t the same today as it was 20 years ago, as the complexity of caring for patients and medical technology continue to evolve. It varies by subspecialty — discontinuity may have graver consequences for neurosurgery, say, than for radiology. And it hinges more on the character of work than the length of it — I’d spend twice as long at a patient’s bedside if I could spend half as long at a computer.
Ultimately, the answer may be as philosophical as it is empirical. What kind of doctors do we want to be? What kind of doctors do patients want us to be? And does what we can’t measure still matter in a profession that’s now judged and motivated by what we can?
Dhruv Khullar, M.D., MPP is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.