For most people, talking about a 16-hour workday is outrageous. For doctors in training, it may not be enough.
Training doctors is not easy. It’s not just a matter of learning what is in the books or latest articles. Under the supervision of attending physicians, young doctors learn the art of doctoring by staying with and caring for their patients. Because of the work they do while they are learning, resident salaries are supported through Medicare… mostly. That’s another issue, but not unrelated to the issue of duty hours.
Twenty years ago, it wasn’t unusual for an intern to arrive at 5 or 5:30 in the morning, work all day, stay up all night on call, and then work the following day until evening rounds were finished. That meant 36-hour shifts and many weeks with more than 100 hours in the hospital. It was clear that this wasn’t sustainable, nor was it safe.
After much debate, in 2003, the initial duty hour regulations were put into effect. In a nutshell, residents couldn’t work over 80 hours a week (on average) and they weren’t allowed to stay longer than 24 hours. If they worked all night, they had to go home the next day. In 2011, the regulations were revised. The major change was that interns (residents in their first year of training) could only work 16 hours in a row instead of 24. On the surface, this made sense. Fewer hours should mean more sleep. More sleep should mean rested interns and fewer mistakes.
I wasn’t surprised to read the article published by Time magazine entitled “Fewer Hours for Doctors-in-Training Leading To More Mistakes.” This report, summarizing the on line JAMA Internal Medicine article from this week, noted that “interns working under the new rules are reporting more mistakes, not enough sleep and symptoms of depression.” In the same issue, authors from Johns Hopkins reported the results of a prospective, randomized crossover trial comparing the new regulations (16 hr work day) to a 24 hours work day with the next day off. They showed no significant difference in the number of hours the interns slept per week between the 16 hour and 24 hour shifts. However, there was a marked decrease in educational opportunities, a significant increase in the number of handoffs, and less resident satisfaction with the 16 hour work day. Most importantly, both the interns and the nurses caring for patients felt that the quality of patient care was decreased by the 16 hour duty hour regulation.
Why would there be more mistakes? Patient care is usually transferred in the morning (to the entire team) and in the evening (to the resident covering the patients at night). That’s roughly every 12 hours. When a portion of the team is rotating on a 16-hour schedule, it results in more handoffs (usually to fewer team members). Increasing the number of times information is transferred between doctors means increasing the risk of communication errors.
If they are working fewer hours why are they not more rested? The new regulations almost require a “night float” system to insure that the patients are taken care of. Working nothing but nights for one week a month followed by 16 hour days is not conducive to being rested.
Why are interns depressed? Remember, decreasing intern work hours didn’t change how much work there was to do in a day – and most hospitals didn’t respond by hiring more people to help. Interns worry that they are “dumping” on their colleagues because they are being required to leave earlier than the other residents. Less obviously, they are learning to be professionals but are being treated like they can’t “take” the hours of the residents one year above them. The message is subtle but real. There’s also a perception that the quality of patient care is decreased by the new system – which is reason enough for a young doctor to feel bad.
Education is clearly impacted. These studies document what we have all observed on the wards. Interns working 16 instead of 24 hours admit and follow fewer patients. In the surgical specialties, they participate in fewer cases. They also attend fewer teaching conferences.
The solution to this complex problem isn’t going to be easy. It’s an ongoing struggle to balance service vs. education, fatigue vs. experience and, maybe most importantly, how we pay for the incredibly important mission of training doctors.
I’m working hard to be part of the solution – along with everyone else in medical education. We owe it to the future physicians we will train and the patients they will take care of.