When my father was a resident in surgery, he was on call every other night. While things have improved since the time he did his training, the significant work hours that physicians put in while training remains controversial. A number of high profile cases involving mistakes made by doctors who had been without sleep for long periods of time eventually led to changes in work requirements for residents. The Bell Commission, formed after one such case in New York, led to laws changing resident work hours in that state. Later, in 2003, the Accreditation Council for Graduate Medical Education (ACGME) passed new limits for all residents, reducing the maximum hours for most trainees significantly. A 2004 study found that that such reductions could lead to fewer medical errors in intensive care units. Last year, the ACGME passed another rounds of work requirement changes. A number of new regulations are in place, including the following:

  • Residents may only work duty 80 hours per week, averaged over a four-week period. This includes call nights spent in the hospital and moonlighting time.
  • Residents must be given one day off a week, averaged over four weeks.
  • Interns cannot work more than 16 hours in a row.
  • Higher lever residents cannot work more than 24 hours in a row, plus four more for transitions.
  • Interns and intermediate residents must have 8 hours off between work periods, and 14 hours off after 24 hours on.
  • Residents cannot have more than six consecutive hours of night float.
  • Residents cannot be in the hospital for call more than every third night, averaged over four weeks.
I imagine most people will look at these requirements and wonder if the changes are enough. After all, in any other profession, they would be considered extreme, if not unsafe. What’s concerning is that these potentially sleep-deprived workers are the ones responsible for making complex, life-saving decisions, often on the fly. These are people we’d want to be well rested and at their most refreshed. A systematic review and meta-analysis of the effect of the 2003 ACGME duty hour standards found that, “patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved.” The authors of that study cautioned, though, that the effect on education is unclear. Some will take exception with this report. They will point to the fact that many of the studies included in this meta-analysis showed no improvements. They will also point to the fact that individual outcomes in some of these studies actually worsened. None of this is wrong. Moreover, changes to the work hour requirements can cost a great deal of money. Interns and residents are, after all, reasonably cheap labor in the medical environment. Any work that is taken from them and given to more expensive personnel will necessarily raise the cost of care. A study from last year estimated that the new work requirements could cost the United States up to $1.64 billion, depending on what level practitioner was used to do the work residents would no longer be allowed to do. Of course, this could still be an underestimate. In an editorial accompanying last year’s studies, physicians asked if these newer regulations are an unfunded mandate on teaching hospitals. The truth of the matter is that they may be. But it’s important to remember that teaching hospitals also receive the benefit of cheap labor that interns and residents often supply. There are valid arguments to be made on both sides of this debate. I often hear older physicians bemoaning the work ethic of newer physicians who are unwilling to put in the insane hours of their predecessors. They’re not wrong. I’m one of them. I don’t want to work the hours that my father did. I’m willing to accept the fact that this means I’ll make less money, or that I may never be the master clinician that he was. I also know that I am rarely as sleep deprived as he was, and research shows that being less sleep deprived makes you less likely to commit mistakes. There’s a larger point here, though, that sometimes gets missed in the discussion. When I was on every third night in residency, and incredibly tired, I was a much more unpleasant person. I was less empathetic, I was less happy, and I was less attentive to detail. There’s no question that that made me less of a physician. As we continue to debate the economics of resident work hours, and the hard outcomes that might come from changes, we shouldn’t lose sight of the fact that new requirements that help residents to be better human being might also translate into their being better physicians.  

–Aaron Carroll

Dr. Aaron E. Carroll is an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll