Should medical residents’ work hours be increased?

This month, the Accreditation Council for Graduate Medical Education will decide whether interns should be allowed the same 28-hour shifts senior residents work instead of the current, 16-hour shift maximum.

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Kelsey Pendleton, MD, family medicine resident at St. Margaret Hospital in Pittsburgh, is one of many residents, physicians and watchdog groups not in favor of lifting the restrictions.

“My first year in a surgical residency was part of a pilot program in Pittsburgh that was studying whether 30-hour interns was just as safe or not as safe as interns who work 16 hours at a time,” Pendleton says. “I did several 30-hour calls.  Around hour 20, I found myself making more mistakes caught by pharmacists, and I definitely wasn’t thinking things through. I started taking the easy route out because I was so exhausted. It was terrifying.”

The experience was so scary, Pendleton switched after that first year to a family practice residency, where the longest shifts she’s worked are 14 to 16 hours. “At the time, I was making simple mistakes, putting in information meant for one patient for another,” Pendleton says. “I’m not in favor of leaving it up to residents to decide if they are too tired to work or not. We’re in a prideful industry where people don’t want to admit their weaknesses, whether it is pressures from superiors or peers, or self-pride. People don’t want to say no. There needs to be limits.”

Sammy Almashat, MD, MPH, researcher and preventative medicine physician at Public Citizen’s Health Research Group, says the idea of no restrictions scares the public, too.    Nearly 90 percent of respondents in a public opinion poll are opposed to lifting the work hour restrictions. “The guidelines themselves are abusive,” Almashat says. He believes that the hours will not be restricted unless the general public calls for change.

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Pamela Wible, MD, family practice physician and author of Physician Suicide Letters, points out that other professions that affect public safety have work-hour restrictions. Pilots can only fly eight hours at night or nine hours during the day due to Federal Aviation Authority restrictions, while truck drivers can only drive for up to 11 hours out of a 14-hour shift maximum, according to Federal Motor Safety Administration rules. Both of those professions are restricted to a maximum of 60-hour work weeks. “We need to call this what it is: human rights violations or abuse,” Wible says, adding that every day she receives dozens of calls from both residents and physicians who are struggling with extreme work hours with no room for bathroom or lunch breaks. The morning of this interview, Wible had already fielded seven phone calls from physicians.

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“This is a very sick culture, and I don’t know any doctor who has not been injured by this,” Wible says.

The reason for the proposed changes at ACGME is to provide continuity of care, says Thomas J. Nasca, MD, MACP, in a news release. “Residents must prepare in real patient care settings for the situations they will encounter after graduation,” Nasca says in the news release. The potential change underscores that residents’ responsibility to their patients supersedes any duty to the clock or schedule and that hours worked is only one component of providing safe, quality care to patients.

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The ACGME task force, which is recommending the change, reviewed research, evidence and testimony before removing the time limit “noting a commitment to avoiding disruption of team-based care and to facilitate seamless continuity of care.”

In a letter to the graduate medical community, Nasca points out that long hours, night hours and managing challenging situations over extended hours are circumstances physicians encounter after graduation. “Just as drivers learn to drive under supervision in real life, on the road, residents must prepare in real patient care settings for the situations they will encounter after graduation,” Nasca wrote.

Frances Southwick, DO, family practice physician and author of Prognosis: Poor, was in the last class of interns before the current restrictions were put in place in 2011, and she remembers her program director coming in, complaining about the new restrictions. “He was angry and contemptuous, saying that the studies showed no change in the number of medical errors made by (interns working longer hours), that the only real change was in the number of car accidents residents get into after shifts,” Southwick says. “I remember thinking ‘That doesn’t matter to you?’ The whole discussion was strange.”

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During her first year of residency, Southwick herself attempted suicide, and she also knows of many residents who had attempted suicide, daydreamed about suicide or began self-injury practices. “I think one of the most disturbing parts of this is I had one of the best programs in the country,” Southwick says. “I don’t think it’s the fault of anyone in my program. It’s a system problem. Had the restrictions been in place when I was a resident, it would have given me that tiny buffer to where I wouldn’t have gotten so far down the rabbit hole as I did.”

Southwick says while administrators may have griped about the restrictions, the only actual changes to the program was a different schedule for residents and the hiring of one nurse practitioner for one half-day per week.

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Southwick also points out that while the lifting of 16-hour work shifts is being talked about the most, another big change in the ACGME residency training requirements is removing the need for 10 hours off between shifts if you work 24 hours straight. “You could work 23 hours and have one and a half hours off before having to head back in,” she says.  “Residents can’t speak up because they don’t have enough time, and they are so indoctrinated that they have no say in their work hours that they don’t even try.”

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Wible says that another reason why residents do not speak out against the hours is that any investigation into it could jeopardize the accreditation of their residency program, which could impact their ability to get hired.

Though the ACGME has stopped taking public comment on the issue, Almashat recommends emailing Nasca at tnasca@acgme.org, contacting local members of Congress to pressure OSHA to institute physician work limits and to write letters and opinion pieces for publications. “Don’t remain silent about this,” Wible says.  “Because some day, you might have to be cared for by somebody who hasn’t slept or eaten in 28 hours. We all have something to lose by this. There is absolutely no reason this should be going on in 2017.”