Do restrictions on residents' work hours harm patient care?

March 6, 2009

Today's residents face shorter work schedules, which could be tomorrow's problem.

Key Points

As I sat at the light, I realized I was an impaired driver. Ironic. I am the person who refuses to get behind the wheel of my car if I have had even one glass of wine. I am the person who refuses to answer my cell phone when I am driving because I believe cell phones are an unacceptable distraction. I am the driver who, in 34 years, has never been pulled over for any moving violation. And yet I knew for sure at that moment that I was an impaired driver. I finished my drive home that morning, picked up the mail from the day before, unlocked the door to the house, and fell into bed exhausted. I had just finished my latest 30-hour shift at the hospital.

As an associate program director for two different ob/gyn residency programs, I have been responsible for making sure the residents do not violate any of their work-hour restrictions. I have given the required lecture on "resident fatigue" and the dangers it presents to patients and self.

DREAM OR NIGHTMARE?

For those physicians outside of academic medicine, the concept of "work-hour restrictions" may sound like a dream come true-or a nightmare. Or maybe a little of both. As of July 2003, residents may not be on duty more than 80 hours per week. They cannot work for longer than 24 hours, but do have an additional 6 hours to go to lectures or to the clinic (the 24 schedule). They must have 10 hours off between shifts and must have 24 hours away from the hospital every week.

Residents today must fit the same amount of training we received into a workweek that is significantly shorter. Once residents reach their hour restrictions, they are expected to leave the hospital. This also means that on any given night, there are fewer residents available to cover busy services. The Residency Review Committees are quite serious about enforcement of these regulations.

Does fatigue lead to impairment? As reported in an article in the Journal of the American Medical Association (2005;294:1025), 17 hours of continuous sleeplessness equals a blood alcohol level of 0.05 percent. One study found that 24 hours of continuous duty equals a blood alcohol level of 0.1 percent-legally drunk in every state. Another found that interns who are restricted to 63 hours per week, with no shift over 16 hours, make 36 percent fewer serious medical errors than interns working the now-standard 80 hours, with the acceptable 24hour shifts.

Other industries long ago committed to limiting work hours for certain professionals. On more than one occasion, I have had to wait in an airport because the assigned flight crew was nearing its work-hour restriction and a new crew had to take over (maximum flight time for a pilot is 16 hours per day). But we are different. Somehow, this data does not apply to those of us who have already been toughened by the old system. Evidence-based medicine applies to everything but those areas that threaten our sense of invincibility.

The impetus behind work-hour regulations was the now famous Libby Zion case. In 1984, Zion presented to an emergency room with vague symptoms. Because of possible medication interactions, she died in the hospital. An investigation revealed that the residents caring for her had been on duty for 17 hours. The Bell Commission was convened in 1987, the Occupational Safety and Health Administration petitioned the American Medical Association, Senate and House bills were eventually proposed, and resident duty-hour restrictions were born.

One of the facts in the case that is often ignored is that the residents did not have appropriate attending physician supervision throughout the course of mismanagement. Fortunately this has changed, and residents no longer function in a vacuum. As the supervising physician, I am present for every delivery. I am involved in every decision. I cannot leave the hospital, and there are many nights I never see the call room.