THCB

Growing Up in the Era of Work-Hour Restrictions

Danielle Jones

In 2008, the IOM study on resident work hours came out and in the years that followed the Accreditation Council for Graduate Medical Education (ACGME) subsequently implemented a gamut of “recommendations.”

As a medical student, I remember thinking it was a much needed change – why wouldn’t it be a good idea to improve patient safety and decrease resident fatigue?

Alas, as a newly minted intern growing up in the era of work-hour regulations, it’s become apparent that many of these changes may actually make life harder without achieving their main goal of improving patient care.

The 80-hour work week cap is fine; it’s been in effect on its own since 2003 and overall it seems to have made residency more humane. Most programs have found reasonable ways to limit work hours to this full-time-times-two amount, at least when hours are averaged over four-week periods.

However, the additional bullet point “recommendations” from 2010 seem to play out very differently in real life than they do on paper. Many of them seem to be arbitrary lines drawn in political sands hiding behind a facade of patient safety, but that’s another blog for another time.

So, what do the bullet point regulations look like in the hospital?

They look like: Interns can’t work 24-hour shifts. 

So, what used to be a two-and-a-half shift weekend turns into a four shift weekend. At a four intern/year program like mine, that means instead of two people splitting the weekends and having a post-call day after 24 hours on, one intern is committed to night-float six nights/week for a month while the remaining three interns take the three leftover weekend shifts.

The result: Fewer hours at a time in the hospital, but more working days in a row and more days/month away from your family.

Is that worse than working a 24-hour shift? I’m not sure it is. It’s certainly not better, though, and I’ve yet to see convincing data that it’s made drastic improvements in patient care; I have seen a few mildly convincing reports that it’s potentially done the opposite. What it has definitely done is make scheduling and coverage more stressful and taxing.

I tend to agree with this recent JAMA article suggesting limiting hours without changing workload is completely counterproductive. I do, however, consider myself incredibly lucky to be a resident at a humane program that takes care of its residents.

The regulations seem to be put into place without regard to specialty or program size, which could be the fundamental flaw. What works for primarily clinical specialties like Family Practice and Pediatrics may never work for primarily surgical specialties like General Surgery or for mixed surgical specialties like Ob/Gyn and Orthopedics. In politics and in medicine, blanket regulations, while easier to create, track and implement, rarely achieve proposed goals on a global level.

I guess it won’t matter for me too long – come July 1, 2014 I move up in the ranks to “2nd year” and am suddenly capable of working a 24-hour shift…yet another arbitrary line those bullet points draw in the proverbial sand.

What do work hour restrictions look like in your hospital?

Danielle Jones, MD is a a fellow of The American Resident Project, where the following post first appeared. 

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Not a Provider

The era of work hour limitations has resulted in incompetent surgeons with insufficient training and decision making skills.

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Perry

“However, the additional bullet point “recommendations” from 2010 seem to play out very differently in real life than they do on paper. Many of them seem to be arbitrary lines drawn in political sands hiding behind a facade of patient safety, but that’s another blog for another time.” Such is the way of regulations. The problem is, once it’s a reguation, it’s very hard to undo, even if it’s a bad idea. I trained about (gulp) 30 years ago in a Family Practice residency. While we had no limitations, we did try to make call somewhat humane. What we found… Read more »