I knew from the beginning that residency would be one of the biggest challenges in a career in medicine and reading Dr. Pauline Chen’s article “The Impossible Workload for Doctors in Training” put into mathematical terms what I had been sensing all along. In what other profession do you go through four years of undergrad and four years of $60K/year medical school, only to end up working 100 hour weeks for less than minimum wage, singly covering the work of 10 to 12 colleagues? And even worse, why is it okay for us to put people’s lives in the hands of exhausted residents who can’t think their clearest because they haven’t slept for days? Going through this year in clerkships I have seen how grueling residency programs are, and a sadly, a lot of the trainees I spoke to said that if they could go back and do it all over again, they would not choose a path in medicine again.
So how did it get to this point?
Let’s be clear, in some ways we have evolved. In the days of Dr. William Halsted, the founder of graduate medical education as we know it, residents were expected to work 362 days a year and to live in the hospital. That is not the case anymore (whew!). Since 2003, the Accreditation Council for Graduate Medical Education (ACGME), which oversees residency training programs, has been scrutinizing the best way to structure residents’ time in the hospital. In 2003 the ACGME instituted the 80 hour work week cap and in 2011 imposed a 16 hour limit per day on intern work hours (intern = first year of residency). How did these changes actually affect residents over the years?
The NEJM published a study in 2012 analyzing residents’ responses to survey questions related to patient care, resident education, and resident quality of life (ACGME goals in their hour restrictions). They found that overall, nearly 50% of residents disapproved of the changes. 62% of interns reported a positive change with hour restrictions, but almost 50% of more senior residents thought life was considerably worse. Half of residents surveyed said that in actuality their hours didn’t change at all.
A recent commentary in JAMA on this issue explained it quite clearly. We are imposing all these regulations without actually decreasing workload, but rather, re-distributing it to other residents. The authors had two suggestions to fix this problem: 1). Increase residents to handle the workload and 2). Shift workload from residents to nonresident providers (nurses, phlebotomists, staff, etc.). Both of these approaches might actually improve patient care because residents will have time to think through clinical diagnoses and decisions rather than taking a shotgun approach of excessive testing when under time pressure. This would reduce the number of shift changes where a whole new team comes in everyday to take care of the patients without any continuity of care. Residents will also have more time to actually attend educational activities and learn and reflect on their training. As for the second approach, it would be great to have additional support to do things like paperwork (mountains of it), contacting outside hospitals or providers, liaising with the social workers, etc.
From what I’ve seen, the hours restriction does seem to be mainly helping interns sleep but it decreases their continuity of care for their patients, takes away from educational time, and increases errors due to daily hand-offs of patients between teams. Because interns are working 16 hours at a time, residents are picking up all of the extra work and simply logging “80 hours” no matter how many extra hours they are actually working. (How else could they get all the work done and still be “under 80 hours”?) As a future resident, I’d really appreciate having actual work hour restrictions, but not at the expense of patient care and my learning. We need more hands to do all the work, and taking residents away with work hour restrictions just doesn’t solve the problem. As Dr. Goitein wrote in the Jama article, “It is time to address the disease, not just the symptom.”