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The Trouble With Shortening Residency Hours
By Alexander Ende |
It is 6 a.m. on December 1, 2002, and Jane Wilson, MD, a first year surgery resident, has completed her evaluation of an undergraduate student who was admitted to the hospital from the emergency room with fever and abdominal pain. Jane has been on duty for almost 24 hours. She has performed an examination, ordered blood tests and x-rays, and carefully explained to the frightened student that he has appendicitis. The senior surgeon, Jane explains, is on his way to the hospital, and surgery will start around 9 a.m., or sooner if a team can be assembled and an operating room is available. "Will you be there during my operation?" the student asks. "Of course," Jane says, "I'll be there." In fact, Jane thinks to herself, hardly noticing her own sense of fatigue, I'd better be there. This will be only my second appendectomy and I really need the experience.
Now it is 6 a.m. on December 1, 2003, one year later, and John Levin, MD, a first year resident in Jane's program, admits a similar patient and, like Jane, is hoping to be present in the operating room to be sure his patient receives proper care and to assist in the surgery. But John knows that this will not be possible. His training program, like all accredited residency programs in the United States, is now governed by a strict set of regulations, which requires that residents not work more than eighty hours per week, and that shifts not exceed 24 consecutive hours. Unlike Jane, who stayed with her patient well into the following day, John leaves the hospital at 10 AM for a well-deserved period of rest. He appreciates the respite, and knows he will be more alert tomorrow than he would have been if he had worked through the night and into the following day. But he also regrets the lost opportunity to be part of his patient's surgery. And he wonders how his experience as a first year resident will compare with Jane's.
John is not alone in questioning the tradeoff between, on the one hand, allowing residents to remain with their patients so that they can learn by observing the complete episode of an acute illness, which may not fall within a 24-hour on-call period; and on the other hand, ensuring that residents get adequate rest. The rationale for limiting duty hours is clear. Medical care will be less error-prone if residents receive adequate rest than if care is delivered by fatigued residents who have been up all night. No one can argue against patient safety, and no one can argue that medical personnel do not need rest like other professionals entrusted with public safety. But the problem is not so simple. In order to become fit to practice independently, medical residents must receive ample exposure to acute illness, which, of course, does not adhere to hourly limits. Furthermore, the expense of replacing the work performed by residents will have to be borne by financially stressed teaching hospitals. Finally, many physicians fear the new regulations will make residents more like shift-workers and less like self-sacrificing professionals, an attitude change that poses threats to patient safety that are arguably more substantial than those posed by residents' fatigue.
From its inception after World War I, residency has been a particularly intense form of apprenticeship, with residents commonly working in excess of 100 hours per week. Such long hours have been viewed as vital to the success of two objectives: residents receive experience in their specialty and learn from more seasoned physicians, while providing financially stressed hospitals with skilled care providers for relatively little pay. While the Accreditation Council of Graduate Medical Education (ACGME) has not been entirely silent on the subject of residency working conditions since its founding in 1981, until recently it has not formally interfered with the role of residents in teaching hospitals. The physicians that make up the governing body of ACGME have generally taken the view that residency training has a history of long hours that reflects the profession's commitment to service, even if that means sacrifice on the part of the trainees. The question of whether fatigue is a factor contributing to medical errors was never examined in any formal studies.
Though the hazards of sleep deprivation have always been a recognized issue in medicine, it is only recently that residents' hours have been formally regulated. In contrast, commercial aviation has since the 1930's imposed strict regulations on the number of hours a pilot can fly a plane. Although residents work longer hours than commercial pilots and arguably have the potential to do just as much Ð though perhaps less spectacular Ð harm, little was heard about the possibility that fatigued residents placed patients at risk. When the National Transportation Safety Board (NTSB) investigates accidents, it always considers whether fatigue was a contributing factor: to the NTSB, the link between accidents and operator fatigue is quite real. As David Gaba wrote in The New England Journal of Medicine, "if the same analyses [the NTSB makes of transportation accidents] were applied to accidents involving the care of patients in teaching hospitals, fatigue on the part of clinicians would almost always be cited as a contributing factor." In 1989, in New York, that was about to change.
The path to litigation began in 1984 with the highly publicized death of an eighteen-year-old girl who was admitted to a prominent New York City teaching hospital. While the circumstances surrounding her death in the early morning hours were never entirely clarified, the girl's father, influential New York journalist Sidney Zion, blamed the residents on call. In a public trial broadcast on television, Zion accused the residents and doctors at New York Hospital of negligence, and explicitly identified fatigue among the residents as a major factor in his daughter's death. Soon after, the New York State Department of Health established regulations to limit residents' hours. These statewide regulations, which were first imposed in July 1989, "essentially provided for an 80-hour workweek averaged over a four-week period, at least one scheduled 24-hour work free period per week...together with around-the-clock supervision by attending physicians."
The same initiative that resulted in resident regulations in New York has recently pressured the ACGME to take a stand on the issue of residents' work hours at a national level. Much of the rise in public pressure can be traced back to an influential report by the Institute on Medicine, which focused on patient safety and error reduction in hospitals. Soon after the publication of the article, Public Citizen, an advocacy group, petitioned the Occupational Safety and Health Administration (OSHA) to regulate residents' hours nationally. OSHA, aware of the complicated nature of the problem, refused to act on the petition, saying "other knowledgeable groups are taking action on this problem." Yet after Representative John Conyers (D-MI) introduced the Patient and Physician Safety Act on November 6, 2001 to the House of Representatives, the ACGME was forced to create their own regulations or else risk government regulation. Modeled after New York, the ACGME's regulations called for an eighty-hour workweek averaged over four weeks and a maximum of twenty-four hours on-call duty, though with an additional six hours for "continuity and transfer, educational briefing and didactic activities," a period that allows for no direct patient care but does provide extra time for the hand-off between residents that occurs when the new resident on-call takes over. Moreover, the ACGME left little or no leeway for individual disciplines, like neurosurgery, to modify the limitations to meet the needs of their own programs.
Given the similarities between the regulations in New York that began in 1989 and the national regulations set by the ACGME beginning in 2003, New York should be an accurate indicator of the difficulties that might be faced by teaching hospitals across the nation. By the time the ACGME's nationwide regulations went into effect, New York hospitals had been operating under virtually the same regulations for fourteen years. However, recent studies of New York hospitals show that even after the period to adopt the new regulations passed, there is still widespread noncompliance. The studies suggest that the new regulations make acquiring adequate resources to maintain a similar quality of care extremely difficult. In 1998, the Department of Health visited twelve hospitals and found them all non-compliant. In 2001, after the New York Health Care Reform Act of 2000 required the State to conduct annual surveys of its hospitals, a third-party organization conducted a more thorough survey and found 75 of the 118 (63.6%) hospitals it surveyed to be non-compliant. The failure of the New York hospitals to meet the regulations is especially alarming because the New York Department of Health's regulations are nearly identical to the ACGME's regulations. Though the regulations, both in New York and more recently across the country, were created with the universally accepted intention of reducing the risk of medical errors caused by resident fatigue, the failures of New York hospitals to comply with them suggest that they force a change in the organizational structure of hospitals that is unfeasible, or at least problematic.
Though ignoring the regulations did not jeopardize the accreditation of New York hospitals, it did cost them the state funding that comprised a significant portion of their revenue. That teaching hospitals would risk losing this funding suggests that they viewed the regulations as impractical or even dangerous. Even if the hospitals were willing to break the rules, one might at least expect residents themselves to report on noncompliant programs if only to cut down on their grueling workweek. Yet the fact that little was heard from the residents in these New York programs, despite the widespread noncompliance, suggests that the residents themselves valued extra training more than extra rest. Once the ACGME nationalized the regulations in 2003, however, violating the rules meant losing their entire funding for residency training as well as their programs' accreditation. Indeed, soon after the regulations went into effect, Johns Hopkins' internal medicine program lost its accreditation. Though it will have the opportunity to be reaccredited, the negative publicity it has received will surely be a warning for other hospitals to take the regulations seriously.
As teaching hospitals are forced to adapt to the new regulations, one of the most significant concerns is maintaining the same quality of care that they delivered before. Since residents will be doing less work, hospitals must hire physician assistants and nurse practitioners to ensure that their floors remain adequately staffed. Simply taking on more residents is not an option because ACGME Residency Review Committees limit the number of residents in each program. As a result, Dr. John Harding of the University of Pennsylvania pointed out that the new regulations have forced academic medical centers to hire extra nurses and physician assistants. Yet physician assistants and nurse practitioners typically command salaries close to double those of residents and may have a more limited range of skills, adding further costs to budgets that were stretched thin to begin with. According to Dr. Harding, the extra hiring has raised the costs for academic hospitals that were already struggling with tight budgets. And because the extra nurses and practitioners are not licensed to perform the same procedures as doctors, the residents are having to "squeeze their work into 80 hours." As Debra Weinstein pointed out in a recent article in The New England Journal of Medicine, "recent evidence suggests that a reduced ratio of nurses to patients adversely affects care; it is reasonable to assume that a reduction of physicians would have a similar effect."
Perhaps the strongest criticism that has been raised with the ACGME regulations is that they do not account for the curricular requirements that are unique to each specialty. In applying the same rules to specialties as different as psychiatry and orthopedic surgery, the ACGME has created a "one size fits all" solution to a diverse set of training problems. The solution is particularly challenging for the surgical specialties, in which residents need to gain extensive hands-on experience while they are still in a supervised setting. When residents leave their training that supervision ends. This raises the question: will there be a cost to patient safety in the future if residents go through training working more humane hours, but getting substantially less experience in some procedures?
Dr. Rosemarie Fisher, the program director for internal medicine at Yale, pointed out that specialties requiring experience with complex procedures like cardiothoracic surgery are having to send residents out of the operating room once their twenty-four hour period is up. Though using mannequins and computer simulations may be a possibility in the future, Dr. Fisher said such simulations are unrealistic now, and are unlikely to replace actual experience. Her concern raises an important question: though the limits on working hours may benefit residents' abilities to care for patients in the hospital during training, what about after training? Depending on residents' specialties, they may not have sufficient time in the hospital to gain the experience they need to achieve a high level of competence. Indeed, the 1998-1999 national survey of residents reporting their own work hours showed broad ranges by specialty of residents who reported working over eighty hours per week. Looking at second-year residents, the percentage of residents who reported working over eighty hours per week ranged from 100% in neurological surgery (they reported working 110.6 hours per week on average) to 5.1% in pathology (they reported working 56.7 hours per week on average).
Also, now that residents are forced to leave the hospital even in the middle of an operation, many doctors fear that contemporary residency training programs will not instill in their trainees the professional sense of dedication crucial to physicians' relationships to their patients. Once a resident completes his graduate training, he will be expected to be available when patients call or when illness arises. Physicians have learned the dedication that makes them available at all hours and encourages them to place the needs of the patient above their own through their experiences as residents. With the new circumscribed hours, will that process be assured? As New England Journal of Medicine editor Jeffrey Drazen argues, "long hours have also taught a central professional lesson about personal responsibility to one's patients, above and beyond work schedules and professional plans. Limits on hours on call will disrupt one of the ways we have taught young physicians these critical values." Especially today, as the spread of HMOs places increasing pressure on doctors to limit their time with patients, intense residency programs are crucial in preserving the professional attitude that ensures quality health care.
If leaving a patient in the middle of a critical time can harm a physician's sense of dedication, it can also potentially harm the patient's health. Medical care is complex, and one variable that has been traditionally eliminated by long duty hours is the "hand-off," where information is passed along from one provider to the next. In a system that places strict limits on the time a resident can spend in the hospital, hand-offs are more frequent. Since subtleties of a physician's observations, including intimate knowledge of how the patient may have responded to a medication at one dosage, the patient's level of stress, or even the patient's preferences, are not always reliably transmitted in the written message that a resident hands to his colleague when a shift ends, critical information may be lost. Furthermore, many teaching hospitals will have to rely more on nurse practitioners and physician assistants. Apart from the strain this will place on hospital budgets, the increased reliance on paraprofessionals raises concerns over providing patients with a less competent medical team. Residents have been through four years of medical school and may already have three or even four years of specialized experience. Though many paraprofessionals are highly skilled, they may not share this level of expertise.
The ACGME devised the new regulations in order to prevent government regulation that threatened to be even stricter and less sensitive to the needs of teaching hospitals and specialties. This urgency likely contributed to the blunt nature of the regulations and to their unintended consequences. In particular, the ACGME seems to have been pressured to promulgate regulations that were similar to those proposed by the advocacy group Public Citizen and to the regulations imposed in New York. While there is much that is sensible in an eighty-hour workweek for professionals entrusted with as much responsibility as physicians in training, there are serious unintended consequences as well. Dr. Larry Smith, who as the program director at Mt. Sinai in New York has been working under the regulations since 1989, believes an eighty-hour weekly limit makes sense but would get rid of all the other regulations. In many ways, his proposal seems to make more sense than the ACGME's regulations, since it would allow residents to stay through the end of an operation or while their patient was critically ill even if they have been working for twenty-four hours.
Though some form of regulation is warranted, and has received support by both the public and the medical profession, the recent regulations have provoked much criticism because of the unintended and counterproductive consequences they are likely to produce. Since the regulations were specifically designed to improve residents' ability to deliver care, and do not address the training needs that make up an equally important part of graduate medical education, teaching hospitals will be forced to restructure their training programs. As Dr. Smith points out, there is much that is sensible in an eighty-hour limit. Indeed, as both the public and the health industry have agreed, it is a goal worth striving for. But teaching hospitals have depended on a system that frequently called on residents to work in excess of 100 hours per week for two of their primary functions: caring for patients and training young physicians. As they adapt to new rules and regulations, it will be critical that those two functions continue, and that unintended consequences are not allowed to undermine the benefits of changes that are long overdue.
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