Do Hospital Work Limits Hurt Patients?

Feb. 14, 2005 — -- Racquel Daley-Placide, an internal medicine resident, loved staying up with hospital patients throughout the night and caring for them the following day.

"I enjoyed it," said the resident at the University of Oklahoma College of Medicine-Tulsa.

But recently passed regulations have limited residents' weekly duties to 80 hours. And some in the medical field are now questioning the benefit of those reduced hours.

"I was kind of upset about the rule, because I felt like that's what I was there to do," said Daley-Placide. However, she concedes the biggest advantage of the new system is the opportunity to spend time with her 2-year-old daughter.

Her husband, Jon, is a resident in a nearby program. "If Jon's program didn't also follow the 80-hour week, I don't think we could take care of Ashley. We'd probably have to send her to our parents," she said.

Longer Hours, More Mistakes

The standards, implemented in 2003 by the Accreditation Council for Graduate Medical Education, reduce residents' availability for hospital duty. The standards were a response to mounting concern among the public, medical professionals and consumer advocates that residents' long work hours were a threat to patient care.

An October 2004 study in the New England Journal of Medicine found that residents in their first year of training made one-third more serious mistakes during 30-hour shifts than they did in 16-hour periods.

And in January of this year, a study in the same journal found that first-year residents were more than twice as likely to be involved in car accidents after working 24 hours or longer, compared with those working shorter shifts.

"It's completely crazy to schedule people for sleep deprivation and chronic fatigue," said Bertrand Bell, who led a commission that designed New York state's legislation on residency work hours.

The Bell Commission reviewed the grand jury report regarding the accidental death of teenager Libby Zion at New York Hospital, in which the physical exhaustion of a resident was a contributing factor.

"The most important thing in being a doctor is not the hours, but responsibility," Bell said.

Have Rules Caused Staffing Shortages?

But there are concerns that compliance with the ACGME rules may have brought about shorter-staffed wards that may pose risks to patient care.

A 2002 report in the New England Journal of Medicine estimated that the cost of conformity with the ACGME regulations would surpass $1.5 billion. The regulations come at a time when hospitals across the country are facing severe financial constraints and some are unable to fund additional hires.

"You have to have enough money to replace the work performed by residents," explains Ingrid Philibert, director of field activities for ACGME.

"If an institution can't afford to replace a resident, you may hurt patient care by reducing resident hours. The institutions that have money to fund these changes tend to do fairly well. However, the jury is still out on the programs that don't have the money," she explained.

"Hospitals that have resource problems have problems that are not specific to training programs," said Bob Dickler, senior vice president of the Division of Health Care Affairs for the Association of American Medical Colleges. "For these hospitals, changes in duty hours has only complicated their resource problems."

Experience -- The Best Teacher

Some physicians, as well as residents themselves, are concerned that the hourly restrictions make residents ill-prepared to face the demands of practice.

Residents sometimes miss performing surgical procedures in order to cover hospital wards. They also take mandatory leave after an overnight shift, neglecting morning rounds and educational conferences.

"I think it's made them weak and inexperienced," said John Zelem, a general surgeon in Booneville, Miss. "Look at the military. They train for war. They don't say, oh, this is training; let's only make them work 80 hours a week. You have to be sharp.You do it through practice," he said.

"I've always been taught that you should train at a level harder than what you're expected to do in private practice. It prepares you to work under adverse conditions," said Michael Sutherland, a thoracic surgeon and vice chair of the American College of Surgeons' Resident and Associate Society.

A 2003 study published in the Annals of Surgery revealed that 50 percent of New York residents surveyed reported a decreased number of operations in which they participated, and 51 percent felt they missed too many learning opportunities.

Though the resident work standards have garnered mixed reviews, they suggest that the medical community recognized an impending revolution and has attempted to initiate a transformation that may take years to fully implement.

"The culture of medicine changes fairly slowly, but it does change," said Philibert.