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Resident Work-Week Regulations: Historical Review and Modern Perspectives
ORIGINAL REPORTS
Resident Work-Week Regulations: Historical Review and Modern Perspectives Kirk D. Dimitris, MD, Benjamin C. Taylor, MD, and Richard A. Fankhauser, MD Department of Orthopedic Surgery Mount Carmel Health System, Columbus, Ohio KEY WORDS: work week resident ACGME duty hours COMPETENCY: Patient Care, Medical Knowledge
INTRODUCTION The meaning of the term “resident” physician dates back to the post-World War II (WWII) era when physicians-in-training actually lived in the hospital. These physicians were on call at all times, frequently working 100 hours per week or more. Time off from work could only be granted by requesting time away from the hospital.1 Over the following decades, conditions improved. However, it was common for junior surgery residents to work amounts similar to their counterparts of years past. In March 1984, an event took place that would forever change the way physicians are trained. Libby Zion, who was a healthy 18-year-old college student, was admitted to a hospital in New York City with a fever of 105.8°F. A medical intern who was unsupervised and in the 18th-hour of consecutive work ordered Demerol (Sanofi-Synthelabo, Inc.) for the patient, which was contraindicated with the antidepressant Libby was taking. Libby Zion died of malignant hyperthermia within hours.2 Libby’s father, Sidney, who is a former federal prosecutor and journalist for The New York Times, filed suit for wrongful death. The suit alleged that the house staff was overworked, exhausted, and unsupervised, which led to substandard care. The civil case dragged on for over 10 years, and the hospital was eventually cleared of liability, because they did not depart from “the accepted medical practice.”2 In 1989, the Grand Jury in the case formed the Bell Committee, which was headed by Dr. Bertrand Bell, to investigate the effects of resident working conditions on patient care. Based on their work, the 405 Bell Regulations were accepted by the New York legislature, which limits New York State medical residents to 80 hours of work per week, with no more that 24 consecutive hours of work while on call.3
Correspondence: Inquiries to Benjamin C. Taylor, MD, Department of Orthopedic Surgery, Mount Carmel Health System, Columbus, OH 43222; fax: (614) 234-1701; e-mail: [email protected]
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Initially hospitals did not take the work-hour restrictions seriously. Without funding, it was impossible to enforce the rules. In 1998, a survey by the New York State Health Department found all New York hospitals were grossly noncompliant, with 77% of surgery residents working over 95 hours per week. Each offending hospital was fined $20,000. The 2000 New York Health Care Reform Act stiffened the penalties for noncompliance. Still, in 2001, 54 New York hospitals were found to have work-hour violations.4 In 2001, the federal legislature proposed the Patient Physician Safety and Protections Act to the House of Representatives, calling for a national 80-hour workweek. The bill failed. With increased threats of legislated government regulation of duty hours, the ACGME developed the current work-hour rules, which went into effect on July 1, 2003.5,6 To maintain accreditation, programs must comply with the ACGME’s rules and regulations. Each year, the ACGME, in conjunction with the Residency Review Committee (RRC), conducts over 2100 site visits of residency programs. Each accredited program is visited an average of once every 3.7 years, with a maximum interval of 5 years. Typically, 8% (168) of programs receive “adverse actions” taken against them after a site visit. These actions can include probation, a formal warning, or withdrawal of accreditation. If a program loses its accreditation, then it loses its residents.7
SLEEP DEPRIVATION AND RESIDENT PERFORMANCE One of the greatest concerns with the grueling work hours are the effects of sleep deprivation on resident job performance and medical errors. More than 50 studies have been published that specifically address the effects of sleep deprivation on resident performance; most studies were conducted before the 80-hour workweek regulations were instituted.8 Many studies have documented the fact that most residents experience periods of acute sleep deprivation while on call, in addition to a baseline chronic sleep deprivation. Their sleep is more fragmented, with decreased time in REM sleep and disrupted circadian sleep/wake cycles.8 Howard et al9 studied physiologic and subjective sleepiness in anesthesia residents before and after a 24-hour call period and
Journal of Surgical Education • © 2008 Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery
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also during a period of extended sleep. They found that prior to being on call, residents had shorter than normal sleep-latency times. After being on call, these latency times were similar to values consistent with sleep apnea and narcolepsy. Furthermore, residents were wrong 74% of the time when asked whether they fell asleep during the latency tests. They concluded that these residents were suffering from acute-onchronic sleep deprivation.9 Sleep deprivation and job performance have also been well studied in other occupations that involve demanding, high-risk environments (eg, pilots, air traffic controllers, and nuclear power plant workers). Accident investigations on multiple occasions identified fatigue as a contributing factor to many well-known accidents.10 Wu et al11 interviewed 145 residents about their medical mistakes, and they found that 59 (41%) cited fatigue as a cause of their most serious mistake; 32% of those mistakes led or contributed to a patient’s death. Lockley et al12 investigated work hours and attention failures in medical residents during intensive care unit rotations and found that residents had fewer errors when shifts were limited to 16 consecutive hours as compared with 24- to 30-hour traditional calls. Smith-Coggins et al13 studied simulated patient triage and intubation skills of emergency medicine residents and found a significant increase in errors in both skills with sleep deprivation. Jakubowicz et al14 looked at the effects of a 24-hour call period on the performance of simulated endoscopic surgery and found no significant increase in the number of errors that occurred after being on call. The speed of the procedure was slightly improved but at the expense of accuracy. Davydov et al15 investigated work hours and medication errors. During 24-hour call shifts, no correlation was observed between the number of consecutive hours worked and the frequency or severity of prescribing errors (interns committed 70% of the errors). Stone et al16 found no difference in surgery residents’ American Board of Surgery In-Training Exam (ABSITE) scores when comparing the scores of residents who were on call the night prior to the examination with residents who were not on call. The National Sleep Foundation conducted a public opinion poll in 2002 to determine the public’s thoughts about sleep deprivation among medical personnel.17 Of those persons polled, 86% stated they would feel anxious to receive care from a doctor who had been working for 24 consecutive hours. Seventy percent claimed they would ask for a different doctor, and 60% believed their care would not be adequate in this scenario. Dawson and Reid18 found that 24 hours of sleep deprivation impairs cognitive psychomotor ability to the same level as a blood alcohol level of 0.1%. Some states have even passed Maggie’s Law, under which drowsy drivers (24 hours without sleep) who cause a motor vehicle fatality may be charged with vehicular homicide. Marcus and Loughlin19 surveyed attending physicians and residents about sleep loss and driving a vehicle. As compared with medical faculty, they found residents were more likely to report falling asleep at the wheel (49% vs 13%), a greater num-
ber of accidents (20% vs 8%), and citations (25% vs 18%), most of these accidents occurring after being on call. This study was supported by 1 that showed emergency room residents were 6.7 times more likely to have “fall asleep” motor vehicle accidents compared with preresidency. Again, most of these occurred after being on call.20 Gaba and Howard21 summarized the current literature on sleep loss and clinician performance/patient care. They concluded that although it is difficult to prove that sleep deprivation impairs clinical performance, most studies do show impairment. Veasey et al22 also summarized more than 30 studies of sleep deprivation and performance and found that both shortterm and chronic sleep loss reduce vigilance, verbal processing, and complex problem-solving abilities in general. These cognitive deficits are minimal among sleep-deprived surgical residents, but there is more pronounced decrement in fine motor skills. Nonsurgical residents were thought to be more prone to cognitive errors when sleep deprived.
RESIDENT EDUCATION AND TRAINING One of the most controversial topics when considering the new resident work-hour restrictions is the idea of resident education. Will our physicians be less experienced when they complete residency? Chung et al23 assessed the operative experience of surgical residents at The Cleveland Clinic both before and after the work-hour restrictions and found that the residents performed fewer operations (55 per week vs 68 per week), saw fewer consultations (19 per week vs 36 per week), and attended fewer conferences (3.5 per week vs 5.7 per week). After the work-hour restrictions went into effect, the authors concluded that for many surgery programs, reducing the work hours cannot be done without reductions in educational components.23 Jarman et al24 studied potential missed operative experience because of being on-call in a general surgery residency program for years PGY 1⫺4. Before instituting a night-float system, a resident would miss an average of 202 surgical cases over 4 years of residency. By implementing a night-float call system, that number decreased to 107. Spencer and Teitelbaum25 reviewed operative logs of University of Michigan surgery residents both before and after the work-hour restrictions were implemented. Both junior and senior residents did not experience a decrease in the number of operative cases. They did, however, attend significantly less outpatient clinics (17% vs 66% of clinics covered).25 Another study that involved University of California-Irvine surgery residents by Gelfand et al26 found that although educational didactics decreased after the new work-hour restrictions (2.5 hours/week vs 4.8 hours/week), operating room hours, clinic time, and duration of rounds showed no difference. The Residency Review Committee analyzed general surgery resident case logs across the country from 1997 to 2004.27 They found no decrease in the average number of cases per resident in the 2003–2004 year and concluded that the new work-hour restrictions did not affect surgical volume for residents. One
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study of a surgery program in New York suggested that resident education had improved.9 After the new work hours, residents reported more time to read and prepare for cases. ABSITE scores were also higher than in previous years. Baskies et al28 reviewed orthopedic case logs before and after the implementation of the ACGME rules; no difference in case numbers was noted for postgraduate years 2 through 4, whereas fifth-year residents increased their case numbers by 73.6 cases per year. However, a similar review of different orthopedic surgery residents in their second and third postgraduate years over the same period revealed a decrease in case load of 21.5%.29 Zuckerman, et al30 surveyed 48 orthopedic surgery residents and 39 faculty members. Junior residents’ hours decreased from 89 to 74 per week, whereas senior residents’ hours increased from 61 to 68 hours per week. Senior residents thought their education, ability to make clinical decisions, and overall training had been impacted negatively. Junior residents and attending physicians/faculty members were more neutral. Senior residents also believed that resident work ethic had suffered because of the new work-hour regulations.30 Most articles agree on the following possible drawbacks of the new work-hour restrictions when it comes to resident education and training: • Fewer operations performed • Fewer consults/outpatient clinic patients seen, which means decreased diversity, intensity, and continuity of patient interactions. This reduction may lead to gaps in clinical skills not reflected on in-service or board examinations. • Inability to cover surgeries on patients admitted while on call • Decreased continuity of care • Resident lifestyle One goal of the work-hour restrictions is to improve residents’ lives outside the hospital. Numerous studies examined the effect of the new work-hour restrictions on residents’ lives both before and after the regulations were instituted. Prior to the 80-hour workweek, researchers assessed the lifestyles of pregnant ob-gyn residents.30 These studies showed that female residents often worked well over 80 hours per week throughout their pregnancy. When compared with matched controls, these residents had an increased frequency of preterm labor, preeclampsia, and fetal growth restriction. McCue32 in 1985 studied resident burnout and stress among medicine residents. More than 35% of residents experienced at least 1 of the following during their residency: depression, drug abuse, marital separation, suicidal thoughts, or actions. Zaré et al33 performed a multicenter study of the psychological well-being of surgery residents at 4 hospitals before the 80-hour workweek regulations took effect. Residents were matched to societal normal populations. All measures of stress and psychological distress were significantly greater among the residents than in controls. More than one third of general surgery residents met criteria for clinical psychological distress.33 Sargent et al34 surveyed 21 orthopedic surgery residents and 25 orthopedic faculty members to measure stress and burnout lev292
els, psychiatric morbidities, and so on. Residents showed high levels of burnout (upper one third for emotional exhaustion and depersonalization). Faculty showed much lower levels of burnout and significantly higher levels of personal achievement and job satisfaction. In addition, 33% (n ⫽ 7) of residents and 8% (n ⫽ 2) of faculty showed significant psychiatric morbidity. They concluded that prior to the new work-hour restrictions, a disparity among stress levels, burnout, psychiatric morbidity, and overall mental health existed between orthopedic residents and faculty.34 Gelfand et al26 measured levels of resident burnout in surgery both before and after the work-hour regulations and found no change; burnout was still high even with the new restrictions. Arnold et al35 studied medical students’ perceptions of a career in surgery both before and after the work-hour restrictions. Although students’ perceptions of a surgeon’s lifestyle improved significantly after the work-hour regulations, students showed no increased interest in surgery as a career.35 Whang et al4 surveyed over 300 general-surgery residents in New York about their lifestyle after the implementation of the 80-hour workweek. The study found that 64% felt more rested with the new work-hour regulations, 66% felt quality of life had improved outside the hospital, and 55% felt the quality of their work had also improved. In addition, 35% of residents thought the new rules hurt the quality of their training, whereas 22% said the quality of their training had improved, 47% said they had significantly more time to study and read for cases, and 51% agreed that they were missing too many learning opportunities. Senior residents were found to be not as receptive of the changes. One senior resident was quoted as saying “interns/ junior residents have fewer skills as physicians, tire easily, and are not committed to caring for patients if it conflicts with their work hours.”4 This interesting “division among the ranks” was also reported by a study of orthopedic surgery residents.30 Several reasons for this include the fact that as junior residents’ hours decreased to below 80 per week, senior residents’ hours increased. Senior residents may also feel victimized by the new rules, as they did not benefit from them when they were junior residents. Finally, senior residents may have internalized the culture of surgery.4
PATIENT CARE AND CONTINUITY OF CARE One goal of the resident work-hour restrictions was to improve patient care by providing more rested residents. Several papers have been written concerning continuity of care and overall patient care since the new work-hour regulations. Bailit and Blanchard36 queried the perinatal database for the frequency of perinatal complications (failed induction, labor abnormality, etc) both before and after the 80-hour workweek went into effect. They found no change in complication frequency and concluded that the work hours did not seem to affect patient care either way. Chung et al23 found a decrease in resident continuity of care among Cleveland Clinic surgery residents from 88% to 28%. They concluded that this decrease could
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affect patient care negatively as well as resident learning and create a “shift work” mentality among residents. Zuckerman et al30 found that although orthopedic surgery residents believed patient care had suffered because of the new regulations, they believed patient care errors had actually decreased. Junior residents felt that patient care had improved, and the faculty was more neutral on patient care, even though they thought patient errors had increased. All faculty and residents surveyed believed that continuity of patient care had suffered.30 Although some argue that cross-covering physicians may offer new ideas about treatment options for a particular patient, 1 study found that preventable adverse events were 6 times more likely to occur when a physician from another team was providing coverage.37 Whang et al4 surveyed New York surgical residents and found that although 35% of residents thought that patient care was compromised as a result of the new work hours, 21% responded that patient care had improved, and 44% reported no change. Sixty percent of respondents agreed that continuity of care suffered. Negative impacts on patient care and continuity of care were cited more frequently by senior residents.4 The Harvard Work Hours Health and Safety Group discovered in their longitudinal validated nationwide survey that residents who worked traditional call schedules had twice as many attentional failures on duty overnight, and they made 36% more serious medical errors and nearly 6 times more serious diagnostic errors than when working on a schedule that limited continuous duty to 16 hours.38 Additional review of the data showed residents taking a traditional call made 300% more fatigue-related medical errors that led to a patient’s death when compared with residents who worked no more than 16 continuous hours.39 Note was made, however, that built-in multidisciplinary “checks” in the health-care system help to limit the clinical effect of some of these errors. Many programs instituted a night-float program to unload the call schedule and to comply with work-hour restrictions. Residents cover patients with whom they are not familiar for short time periods. Patient “sign out” to the night-float resident is frequently inadequate. In an editorial, Charap40 stated, “we are suggesting that continuity of care is not important . . . it is one of our most valued tenets . . . we are criticizing them if they want to stay and help their sickest patients in acute crisis.” This system harbors a resident “shift work” mentality.
FACULTY With limitations in resident work hours, some concern has been raised regarding a potential increase in faculty work hours. Winslow et al41 examined faculty hours in surgical subspecialties (general, neurosurgery, orthopedic, and otolaryngology) both before and after the work-hour regulations went into effect. Initially, 70% of faculty thought that their work hours would increase. This sentiment was more common among general surgeons (84%) when compared with subspecialists (57%). Furthermore, 87% predicted that reducing resident work hours
would compromise surgical education. Forty-six percent viewed the changes as harmful to the faculty, and 50% thought patient care had suffered. Despite their concerns, Winslow et al found that faculty hours did not increase with resident workhour restrictions. Malangoni et al42 studied faculty hours both before and after the work-hour restrictions and found that faculty call actually decreased by 21% because of call amalgamation, and faculty hours did not increase, nor did productivity decrease. Chandra3 surveyed 9 surgical subspecialties (faculty and residents) on work-hour regulations and found that senior faculty and senior residents were the least accepting of the changes and that 18% of senior residents and faculty were described as “in denial.”3
THE HOSPITAL The impact of the resident work-hour restrictions on the hospital is a purely negative one. For teaching hospitals, the work-hour restrictions are an unfunded mandate. With strict enforcement of the work-hour regulations, violations encounter large fines for hospitals. Work-hour monitoring systems also cost money for the hospital; many hospitals have had to hire physician assistants (PAs) and house officers to manage the increased work load. The number of registered PAs in New York increased by more than 60% from 1997 to 2002.43
SOLUTIONS Many hospitals/programs have devised innovative methods to work with the work-hour regulations, each with specific drawbacks. Night-float systems decompress “in house” call and allow for better and more consistent operative coverage for the primary team. Although no extra cost to the hospital is incurred, 1 drawback is the decreased continuity of care for the night-float resident, with the potential for compromised patient care. A 360-degree evaluation by residents, attending staff, and nursing and resident families of a surgical nightfloat system revealed significant positive responses in all categories with the exception of attending staff’s opinion of clinical care.39 However, studies of the sleep patterns of residents on the night-float rotation reveal that these residents actually get significantly less sleep per night, lower quality sleep, have increased fatigue and decreased vigor scores, and have more episodes of depression.44,45 Other programs have changed to home call for residents, with hours spent away from the hospital not counted toward the resident’s 80 hours. Although this system does not incur any increased cost to the hospital, the residents are not immediately “in house” to manage emergencies (codes/traumas). The same drawback is realized when 1 resident covers multiple hospitals in an effort to amalgamate hospitals into a common call schedule. Some hospitals have hired PAs, nurse
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practitioners, and house officers in an effort to deal with the increased work load. Although this process may decompress some “scut” work and allow for a more concentrated surgical experience, it costs the hospital money and does take away from some educational experiences for the resident. One final common method used is the creation of nonteaching services. This method decreases resident learning opportunities and increases the workload for staff/faculty. The bottom line is that hospitals and residency programs must work with the 80-hour workweek, have a plan in place, and not try to work around the regulations.
REFERENCES 1. Queenan JT. Work-hour limitations: Let us solve our own
problems. Obstet Gynecol. 2004;103:611-612. 2. Robins N. The Girl Who Died Twice: Every Patient’s
Nightmare. The Libby Zion Case and the Hidden Hazards of Hospitals. New York: Delacorte Press; 1995. 3. Chandra RK. The resident 80-hour work week: how has it
affected surgical specialties? Laryngoscope. 2004;114:13941398. 4. Whang EE, Mello MM, Ashley SW, Zinner MJ. Im-
THE FUTURE With work hours being limited to 80 hours per week, one must ask: What does the future hold? Some have hinted at decreasing work hours even more to 60 per week, whereas others have talked about limiting faculty hours. Beginning in August 2004, medical residents in England have been limited to 58 hours per week; their work hours will decrease to 56 by 2007 and to 48 by 2009. Furthermore, shifts (including call shifts) are limited to no more than 13 consecutive hours. Also, a resident physician’s salary is not cheap in England, with the average salary of $144,000.1 A systematic review of over 1000 resident physicians in 16 specialties revealed that as much as 35% of awake time on duty was spent delivering care of marginal to no educational value and that 16% was spent in other noneducational objectives.46 These data show that it is valuable not only to review the number of hours worked, but also it is just as important to assess the quality of hours worked when considering attempts at workhour reform.
CONCLUSIONS Studies show that prior to the 80-hour workweek, residents suffered from significant sleep deprivation, which could lead to decreased cognitive performance and the potential for compromised patient care. Substantial concerns about decreased learning opportunities and operative experience have been raised. It seems that continuity of patient care is compromised by the work hours and that patient care does not seem to be improved. Many studies show that residents’ operative experience does not seem to suffer; however, they commonly attend fewer clinics/ didactics. As far as quality of life during residency, the work hours are more embraced by junior residents and less well received by senior residents and faculty. The hospital is negatively affected from an economic standpoint. Faculty hours did not increase after the new work-hour restrictions. An evidencebased approach is needed to minimize the well-documented risk that current work-hour practices confer on resident health and patient safety while optimizing education and continuity of care. 294
plementing resident work hour limitations: lessons from the New York State experience. Ann Surg. 2003; 237:449-455. 5. Tami TA. Special features topic: the effects of limited
work hours on surgical training in otolaryngology - head and neck surgery. Curr Opin Otolaryngol Head Neck Surg. 2004;12:217-221. 6. ACGME website. Available at: http://www.acgme.org.
Accessed November 19, 2007. 7. Steinbrook R. The debate over residents’ work hours.
N Engl J Med. 2002;347:1296-1302. 8. Daugherty SR, Baldwin DC Jr. Sleep deprivation in se-
nior medical students and first-year residents. Acad Med. 1996;71(suppl 1):93-95. 9. Howard SK, Gaba DM, Rosekind MR, Zarcone VP. The
risks and implications of excessive daytime sleepiness in resident physicians. Acad Med. 2002;77:1019-1025. 10. Mitler MM, Dement WC, Dinges DF. Sleep medicine,
public policy, and public health. In: Kryger MH, Roth T, Dement WC (eds). Principles and Practice of Sleep Medicine, 3rd ed. Philadelphia, Pa: WB Saunders; 2000:580588. 11. Wu AW, Folkman S, McPhee SJ, Lo B. Do house of-
ficers learn from their mistakes? JAMA. 1991;265: 2089-2094. 12. Lockley SW, Cronin JW, Evans EE, et al. Effect of reduc-
ing interns’ weekly hours on sleep and attentional failures. N Engl J Med. 2004;351:1829-1837. 13. Smith-Coggins R, Rosekind MR, Buccino KR. Rotating
shift work schedules: can we enhance physician adaptation to night shifts? Acad Emerg Med. 1997;4:951-961. 14. Jakubowicz DM, Price EM, Glassman HJ, et al. Effects
of a twenty-four hour call period on resident performance during simulated endoscopic sinus surgery in an accreditation council for graduate medical educationcompliant training program. Laryngoscope. 2005;115: 143-146.
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15. Davydov L, Caliendo G, Mehl B, Smith LG. Investigation
30. Zuckerman JD, Kubiak EN, Immerman I, Dicesare P.
of correlation between house-staff work hours and prescribing errors. Am J Health Syst Pharm. 2004;61:11301134.
The early effects of Code 405 work rules on attitudes of orthopaedic residents and attending surgeons. J Bone Joint Surg Am. 2005;87:903-908.
16. Stone MD, Doyle J, Bosch RJ, Bothe A Jr, Steele G Jr.
31. Gabbe SG, Morgan MA, Power ML, Schulkin J, Williams
Effect of resident call status on ABSITE performance. American Board of Surgery In-Training examination. Surgery. 2000;128:465-471.
SB. Duty hours and pregnancy outcome among residents in obstetrics and gynecology. Obstet Gynecol. 2003;102: 948-951.
17. National Sleep Foundation. Sleep in America poll,
32. McCue JD. The distress of internship. Causes and preven-
2002. Available at: http://www.sleepfoundation.org/ site/c.huIXKjM0IxF/b.2417355/k.143E/2002_Sleep_ in_America_Poll.htm. Accessed November 19, 2007.
tion. N Engl J Med. 1985;312:449-452. 33. Zaré SM, Galanko J, Behrns KE, Koruda MJ, Boyle LM,
Farley DR, et al. Psychological well-being of surgery residents before the 80-hour work week: a multi-institutional study. J Am Coll Surg. 2004;198:633-640.
18. Dawson D, Reid K. Fatigue, alcohol and performance
impairment. Nature. 1997;388:235. 19. Marcus CL, Loughlin GM. Effect of sleep deprivation on
driving safety in house staff. Sleep. 1996;19:763-766.
34. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL.
Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2004;86:1579-1586.
20. Kowalenko T, Kowalenko J, Gryzbowski M, Rabinovich
A. Emergency medicine residency related auto accidents—is sleep deprivation a risk factor? Acad Emerg Med. 2000;7:451.
35. Arnold MW, Patterson AF, Tang AS. Has implementa-
tion of the 80-hour work week made a career in surgery more appealing to medical students? Am J Surg. 2005;189: 129-133.
21. Gaba DM, Howard SK. Patient safety: fatigue among
clinicians and the safety of patients. N Engl J Med. 2002; 347:1249-1255.
36. Bailit JL, Blanchard MH. The effect of house staff work-
ing hours on the quality of obstetric and gynecologic care. Obstet Gynecol. 2004;103:613-616.
22. Veasey S, Rosen R, Barzansky. Sleep loss and fatigue in
residency training. JAMA. 2002;288:116-127.
37. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH.
23. Chung R, Ahmed N, Chen P. Meeting the 80-hour work
week requirement: what did we cut? Curr Surg. 2004;61: 609-611.
Does house staff discontinuity of care increase the risk of preventable adverse events? Ann Intern Med. 1994;121: 866-872.
24. Jarman BT, Miller MR, Brown RS, et al. The 80-hour
38. Lockley SW, Landrigan CP, Barger LK, Czeisler CA; Har-
work week: will we have less-experienced graduating surgeons? Curr Surg. 2004;61:612-615.
vard Work Hours Health and Safety Group. When policy meets physiology: the challenge of reducing resident work hours. Clin Orthop Relat Res. 2006;449:116-127.
25. Spencer AU, Teitelbaum DH. Impact of work-hour re-
strictions on residents’ operative volume on a subspecialty surgical service. J Am Coll Surg. 2005;200:670-676.
39. Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler
Wilson SE, Williams RA. Effect of the 80-hour work week on resident burnout. Arch Surg. 2004;139:933-940.
CA, Landrigan CP; Harvard Work Hours, Health and Safety Group. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(suppl 11):7-18.
27. Bland KI, Richardson JD, Britt LD. Brief communication
40. Charap M. Reducing resident work hours: unproven as-
of the Residency Review Committee-Surgery (RRC-S) on residents’ surgical volume in general surgery. Am J Surg. 2005;190:345-350.
sumptions and unforeseen outcomes. Ann Intern Med. 2004;140:814-815.
26. Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ,
41. Winslow ER, Berger L, Klingensmith ME. Has the 80-
hour work week increased faculty hours? Curr Surg. 2004; 61:602-608.
28. Baskies MA, Ruchelsman DE, Capeci CM, Zuckerman
JD, Egol KA. Operative experience in an orthopaedic surgery residency program: the effect of work-hour restrictions. J Bone Joint Surg Am. 2008;90:924-927.
42. Malangoni MA, Como JJ, Mancuso C, Yowler CJ. Life
29. Weatherby BA, Rudd JN, Ervin TB, Stafford PR, Norris BL.
The effect of resident work hour regulations on orthopaedic surgical education. J Surg Orthop Adv. 2007;16:19-22. Journal of Surgical Education • Volume 65/Number 4 • July/August 2008
after 80 hours: the impact of resident work hours mandates on trauma and emergency experience and work effort for senior residents and faculty. J Trauma. 2005;58: 761-762. 295
43. Philibert I, Friedmann P, Williams WT. ACGME Work
45. Cavallo A, Jaskiewicz J, Ris MD. Impact of night-
Group on Resident Duty Hours. Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA. 2002;288:1112-1114.
float rotation on sleep, mood, and alertness: the resident’s perception. Chronobiol Int. 2002;19:893902.
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Journal of Surgical Education • Volume 65/Number 4 • July/August 2008
Resident Work-Week Regulations: Historical Review and Modern Perspectives Kirk D. Dimitris, MD, Benjamin C. Taylor, MD, and Richard A. Fankhauser, MD Department of Orthopedic Surgery Mount Carmel Health System, Columbus, Ohio KEY WORDS: work week resident ACGME duty hours COMPETENCY: Patient Care, Medical Knowledge
INTRODUCTION The meaning of the term “resident” physician dates back to the post-World War II (WWII) era when physicians-in-training actually lived in the hospital. These physicians were on call at all times, frequently working 100 hours per week or more. Time off from work could only be granted by requesting time away from the hospital.1 Over the following decades, conditions improved. However, it was common for junior surgery residents to work amounts similar to their counterparts of years past. In March 1984, an event took place that would forever change the way physicians are trained. Libby Zion, who was a healthy 18-year-old college student, was admitted to a hospital in New York City with a fever of 105.8°F. A medical intern who was unsupervised and in the 18th-hour of consecutive work ordered Demerol (Sanofi-Synthelabo, Inc.) for the patient, which was contraindicated with the antidepressant Libby was taking. Libby Zion died of malignant hyperthermia within hours.2 Libby’s father, Sidney, who is a former federal prosecutor and journalist for The New York Times, filed suit for wrongful death. The suit alleged that the house staff was overworked, exhausted, and unsupervised, which led to substandard care. The civil case dragged on for over 10 years, and the hospital was eventually cleared of liability, because they did not depart from “the accepted medical practice.”2 In 1989, the Grand Jury in the case formed the Bell Committee, which was headed by Dr. Bertrand Bell, to investigate the effects of resident working conditions on patient care. Based on their work, the 405 Bell Regulations were accepted by the New York legislature, which limits New York State medical residents to 80 hours of work per week, with no more that 24 consecutive hours of work while on call.3
Correspondence: Inquiries to Benjamin C. Taylor, MD, Department of Orthopedic Surgery, Mount Carmel Health System, Columbus, OH 43222; fax: (614) 234-1701; e-mail: [email protected]
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Initially hospitals did not take the work-hour restrictions seriously. Without funding, it was impossible to enforce the rules. In 1998, a survey by the New York State Health Department found all New York hospitals were grossly noncompliant, with 77% of surgery residents working over 95 hours per week. Each offending hospital was fined $20,000. The 2000 New York Health Care Reform Act stiffened the penalties for noncompliance. Still, in 2001, 54 New York hospitals were found to have work-hour violations.4 In 2001, the federal legislature proposed the Patient Physician Safety and Protections Act to the House of Representatives, calling for a national 80-hour workweek. The bill failed. With increased threats of legislated government regulation of duty hours, the ACGME developed the current work-hour rules, which went into effect on July 1, 2003.5,6 To maintain accreditation, programs must comply with the ACGME’s rules and regulations. Each year, the ACGME, in conjunction with the Residency Review Committee (RRC), conducts over 2100 site visits of residency programs. Each accredited program is visited an average of once every 3.7 years, with a maximum interval of 5 years. Typically, 8% (168) of programs receive “adverse actions” taken against them after a site visit. These actions can include probation, a formal warning, or withdrawal of accreditation. If a program loses its accreditation, then it loses its residents.7
SLEEP DEPRIVATION AND RESIDENT PERFORMANCE One of the greatest concerns with the grueling work hours are the effects of sleep deprivation on resident job performance and medical errors. More than 50 studies have been published that specifically address the effects of sleep deprivation on resident performance; most studies were conducted before the 80-hour workweek regulations were instituted.8 Many studies have documented the fact that most residents experience periods of acute sleep deprivation while on call, in addition to a baseline chronic sleep deprivation. Their sleep is more fragmented, with decreased time in REM sleep and disrupted circadian sleep/wake cycles.8 Howard et al9 studied physiologic and subjective sleepiness in anesthesia residents before and after a 24-hour call period and
Journal of Surgical Education • © 2008 Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery
1931-7204/08/$30.00 doi:10.1016/j.jsurg.2008.05.011
also during a period of extended sleep. They found that prior to being on call, residents had shorter than normal sleep-latency times. After being on call, these latency times were similar to values consistent with sleep apnea and narcolepsy. Furthermore, residents were wrong 74% of the time when asked whether they fell asleep during the latency tests. They concluded that these residents were suffering from acute-onchronic sleep deprivation.9 Sleep deprivation and job performance have also been well studied in other occupations that involve demanding, high-risk environments (eg, pilots, air traffic controllers, and nuclear power plant workers). Accident investigations on multiple occasions identified fatigue as a contributing factor to many well-known accidents.10 Wu et al11 interviewed 145 residents about their medical mistakes, and they found that 59 (41%) cited fatigue as a cause of their most serious mistake; 32% of those mistakes led or contributed to a patient’s death. Lockley et al12 investigated work hours and attention failures in medical residents during intensive care unit rotations and found that residents had fewer errors when shifts were limited to 16 consecutive hours as compared with 24- to 30-hour traditional calls. Smith-Coggins et al13 studied simulated patient triage and intubation skills of emergency medicine residents and found a significant increase in errors in both skills with sleep deprivation. Jakubowicz et al14 looked at the effects of a 24-hour call period on the performance of simulated endoscopic surgery and found no significant increase in the number of errors that occurred after being on call. The speed of the procedure was slightly improved but at the expense of accuracy. Davydov et al15 investigated work hours and medication errors. During 24-hour call shifts, no correlation was observed between the number of consecutive hours worked and the frequency or severity of prescribing errors (interns committed 70% of the errors). Stone et al16 found no difference in surgery residents’ American Board of Surgery In-Training Exam (ABSITE) scores when comparing the scores of residents who were on call the night prior to the examination with residents who were not on call. The National Sleep Foundation conducted a public opinion poll in 2002 to determine the public’s thoughts about sleep deprivation among medical personnel.17 Of those persons polled, 86% stated they would feel anxious to receive care from a doctor who had been working for 24 consecutive hours. Seventy percent claimed they would ask for a different doctor, and 60% believed their care would not be adequate in this scenario. Dawson and Reid18 found that 24 hours of sleep deprivation impairs cognitive psychomotor ability to the same level as a blood alcohol level of 0.1%. Some states have even passed Maggie’s Law, under which drowsy drivers (24 hours without sleep) who cause a motor vehicle fatality may be charged with vehicular homicide. Marcus and Loughlin19 surveyed attending physicians and residents about sleep loss and driving a vehicle. As compared with medical faculty, they found residents were more likely to report falling asleep at the wheel (49% vs 13%), a greater num-
ber of accidents (20% vs 8%), and citations (25% vs 18%), most of these accidents occurring after being on call. This study was supported by 1 that showed emergency room residents were 6.7 times more likely to have “fall asleep” motor vehicle accidents compared with preresidency. Again, most of these occurred after being on call.20 Gaba and Howard21 summarized the current literature on sleep loss and clinician performance/patient care. They concluded that although it is difficult to prove that sleep deprivation impairs clinical performance, most studies do show impairment. Veasey et al22 also summarized more than 30 studies of sleep deprivation and performance and found that both shortterm and chronic sleep loss reduce vigilance, verbal processing, and complex problem-solving abilities in general. These cognitive deficits are minimal among sleep-deprived surgical residents, but there is more pronounced decrement in fine motor skills. Nonsurgical residents were thought to be more prone to cognitive errors when sleep deprived.
RESIDENT EDUCATION AND TRAINING One of the most controversial topics when considering the new resident work-hour restrictions is the idea of resident education. Will our physicians be less experienced when they complete residency? Chung et al23 assessed the operative experience of surgical residents at The Cleveland Clinic both before and after the work-hour restrictions and found that the residents performed fewer operations (55 per week vs 68 per week), saw fewer consultations (19 per week vs 36 per week), and attended fewer conferences (3.5 per week vs 5.7 per week). After the work-hour restrictions went into effect, the authors concluded that for many surgery programs, reducing the work hours cannot be done without reductions in educational components.23 Jarman et al24 studied potential missed operative experience because of being on-call in a general surgery residency program for years PGY 1⫺4. Before instituting a night-float system, a resident would miss an average of 202 surgical cases over 4 years of residency. By implementing a night-float call system, that number decreased to 107. Spencer and Teitelbaum25 reviewed operative logs of University of Michigan surgery residents both before and after the work-hour restrictions were implemented. Both junior and senior residents did not experience a decrease in the number of operative cases. They did, however, attend significantly less outpatient clinics (17% vs 66% of clinics covered).25 Another study that involved University of California-Irvine surgery residents by Gelfand et al26 found that although educational didactics decreased after the new work-hour restrictions (2.5 hours/week vs 4.8 hours/week), operating room hours, clinic time, and duration of rounds showed no difference. The Residency Review Committee analyzed general surgery resident case logs across the country from 1997 to 2004.27 They found no decrease in the average number of cases per resident in the 2003–2004 year and concluded that the new work-hour restrictions did not affect surgical volume for residents. One
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study of a surgery program in New York suggested that resident education had improved.9 After the new work hours, residents reported more time to read and prepare for cases. ABSITE scores were also higher than in previous years. Baskies et al28 reviewed orthopedic case logs before and after the implementation of the ACGME rules; no difference in case numbers was noted for postgraduate years 2 through 4, whereas fifth-year residents increased their case numbers by 73.6 cases per year. However, a similar review of different orthopedic surgery residents in their second and third postgraduate years over the same period revealed a decrease in case load of 21.5%.29 Zuckerman, et al30 surveyed 48 orthopedic surgery residents and 39 faculty members. Junior residents’ hours decreased from 89 to 74 per week, whereas senior residents’ hours increased from 61 to 68 hours per week. Senior residents thought their education, ability to make clinical decisions, and overall training had been impacted negatively. Junior residents and attending physicians/faculty members were more neutral. Senior residents also believed that resident work ethic had suffered because of the new work-hour regulations.30 Most articles agree on the following possible drawbacks of the new work-hour restrictions when it comes to resident education and training: • Fewer operations performed • Fewer consults/outpatient clinic patients seen, which means decreased diversity, intensity, and continuity of patient interactions. This reduction may lead to gaps in clinical skills not reflected on in-service or board examinations. • Inability to cover surgeries on patients admitted while on call • Decreased continuity of care • Resident lifestyle One goal of the work-hour restrictions is to improve residents’ lives outside the hospital. Numerous studies examined the effect of the new work-hour restrictions on residents’ lives both before and after the regulations were instituted. Prior to the 80-hour workweek, researchers assessed the lifestyles of pregnant ob-gyn residents.30 These studies showed that female residents often worked well over 80 hours per week throughout their pregnancy. When compared with matched controls, these residents had an increased frequency of preterm labor, preeclampsia, and fetal growth restriction. McCue32 in 1985 studied resident burnout and stress among medicine residents. More than 35% of residents experienced at least 1 of the following during their residency: depression, drug abuse, marital separation, suicidal thoughts, or actions. Zaré et al33 performed a multicenter study of the psychological well-being of surgery residents at 4 hospitals before the 80-hour workweek regulations took effect. Residents were matched to societal normal populations. All measures of stress and psychological distress were significantly greater among the residents than in controls. More than one third of general surgery residents met criteria for clinical psychological distress.33 Sargent et al34 surveyed 21 orthopedic surgery residents and 25 orthopedic faculty members to measure stress and burnout lev292
els, psychiatric morbidities, and so on. Residents showed high levels of burnout (upper one third for emotional exhaustion and depersonalization). Faculty showed much lower levels of burnout and significantly higher levels of personal achievement and job satisfaction. In addition, 33% (n ⫽ 7) of residents and 8% (n ⫽ 2) of faculty showed significant psychiatric morbidity. They concluded that prior to the new work-hour restrictions, a disparity among stress levels, burnout, psychiatric morbidity, and overall mental health existed between orthopedic residents and faculty.34 Gelfand et al26 measured levels of resident burnout in surgery both before and after the work-hour regulations and found no change; burnout was still high even with the new restrictions. Arnold et al35 studied medical students’ perceptions of a career in surgery both before and after the work-hour restrictions. Although students’ perceptions of a surgeon’s lifestyle improved significantly after the work-hour regulations, students showed no increased interest in surgery as a career.35 Whang et al4 surveyed over 300 general-surgery residents in New York about their lifestyle after the implementation of the 80-hour workweek. The study found that 64% felt more rested with the new work-hour regulations, 66% felt quality of life had improved outside the hospital, and 55% felt the quality of their work had also improved. In addition, 35% of residents thought the new rules hurt the quality of their training, whereas 22% said the quality of their training had improved, 47% said they had significantly more time to study and read for cases, and 51% agreed that they were missing too many learning opportunities. Senior residents were found to be not as receptive of the changes. One senior resident was quoted as saying “interns/ junior residents have fewer skills as physicians, tire easily, and are not committed to caring for patients if it conflicts with their work hours.”4 This interesting “division among the ranks” was also reported by a study of orthopedic surgery residents.30 Several reasons for this include the fact that as junior residents’ hours decreased to below 80 per week, senior residents’ hours increased. Senior residents may also feel victimized by the new rules, as they did not benefit from them when they were junior residents. Finally, senior residents may have internalized the culture of surgery.4
PATIENT CARE AND CONTINUITY OF CARE One goal of the resident work-hour restrictions was to improve patient care by providing more rested residents. Several papers have been written concerning continuity of care and overall patient care since the new work-hour regulations. Bailit and Blanchard36 queried the perinatal database for the frequency of perinatal complications (failed induction, labor abnormality, etc) both before and after the 80-hour workweek went into effect. They found no change in complication frequency and concluded that the work hours did not seem to affect patient care either way. Chung et al23 found a decrease in resident continuity of care among Cleveland Clinic surgery residents from 88% to 28%. They concluded that this decrease could
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affect patient care negatively as well as resident learning and create a “shift work” mentality among residents. Zuckerman et al30 found that although orthopedic surgery residents believed patient care had suffered because of the new regulations, they believed patient care errors had actually decreased. Junior residents felt that patient care had improved, and the faculty was more neutral on patient care, even though they thought patient errors had increased. All faculty and residents surveyed believed that continuity of patient care had suffered.30 Although some argue that cross-covering physicians may offer new ideas about treatment options for a particular patient, 1 study found that preventable adverse events were 6 times more likely to occur when a physician from another team was providing coverage.37 Whang et al4 surveyed New York surgical residents and found that although 35% of residents thought that patient care was compromised as a result of the new work hours, 21% responded that patient care had improved, and 44% reported no change. Sixty percent of respondents agreed that continuity of care suffered. Negative impacts on patient care and continuity of care were cited more frequently by senior residents.4 The Harvard Work Hours Health and Safety Group discovered in their longitudinal validated nationwide survey that residents who worked traditional call schedules had twice as many attentional failures on duty overnight, and they made 36% more serious medical errors and nearly 6 times more serious diagnostic errors than when working on a schedule that limited continuous duty to 16 hours.38 Additional review of the data showed residents taking a traditional call made 300% more fatigue-related medical errors that led to a patient’s death when compared with residents who worked no more than 16 continuous hours.39 Note was made, however, that built-in multidisciplinary “checks” in the health-care system help to limit the clinical effect of some of these errors. Many programs instituted a night-float program to unload the call schedule and to comply with work-hour restrictions. Residents cover patients with whom they are not familiar for short time periods. Patient “sign out” to the night-float resident is frequently inadequate. In an editorial, Charap40 stated, “we are suggesting that continuity of care is not important . . . it is one of our most valued tenets . . . we are criticizing them if they want to stay and help their sickest patients in acute crisis.” This system harbors a resident “shift work” mentality.
FACULTY With limitations in resident work hours, some concern has been raised regarding a potential increase in faculty work hours. Winslow et al41 examined faculty hours in surgical subspecialties (general, neurosurgery, orthopedic, and otolaryngology) both before and after the work-hour regulations went into effect. Initially, 70% of faculty thought that their work hours would increase. This sentiment was more common among general surgeons (84%) when compared with subspecialists (57%). Furthermore, 87% predicted that reducing resident work hours
would compromise surgical education. Forty-six percent viewed the changes as harmful to the faculty, and 50% thought patient care had suffered. Despite their concerns, Winslow et al found that faculty hours did not increase with resident workhour restrictions. Malangoni et al42 studied faculty hours both before and after the work-hour restrictions and found that faculty call actually decreased by 21% because of call amalgamation, and faculty hours did not increase, nor did productivity decrease. Chandra3 surveyed 9 surgical subspecialties (faculty and residents) on work-hour regulations and found that senior faculty and senior residents were the least accepting of the changes and that 18% of senior residents and faculty were described as “in denial.”3
THE HOSPITAL The impact of the resident work-hour restrictions on the hospital is a purely negative one. For teaching hospitals, the work-hour restrictions are an unfunded mandate. With strict enforcement of the work-hour regulations, violations encounter large fines for hospitals. Work-hour monitoring systems also cost money for the hospital; many hospitals have had to hire physician assistants (PAs) and house officers to manage the increased work load. The number of registered PAs in New York increased by more than 60% from 1997 to 2002.43
SOLUTIONS Many hospitals/programs have devised innovative methods to work with the work-hour regulations, each with specific drawbacks. Night-float systems decompress “in house” call and allow for better and more consistent operative coverage for the primary team. Although no extra cost to the hospital is incurred, 1 drawback is the decreased continuity of care for the night-float resident, with the potential for compromised patient care. A 360-degree evaluation by residents, attending staff, and nursing and resident families of a surgical nightfloat system revealed significant positive responses in all categories with the exception of attending staff’s opinion of clinical care.39 However, studies of the sleep patterns of residents on the night-float rotation reveal that these residents actually get significantly less sleep per night, lower quality sleep, have increased fatigue and decreased vigor scores, and have more episodes of depression.44,45 Other programs have changed to home call for residents, with hours spent away from the hospital not counted toward the resident’s 80 hours. Although this system does not incur any increased cost to the hospital, the residents are not immediately “in house” to manage emergencies (codes/traumas). The same drawback is realized when 1 resident covers multiple hospitals in an effort to amalgamate hospitals into a common call schedule. Some hospitals have hired PAs, nurse
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practitioners, and house officers in an effort to deal with the increased work load. Although this process may decompress some “scut” work and allow for a more concentrated surgical experience, it costs the hospital money and does take away from some educational experiences for the resident. One final common method used is the creation of nonteaching services. This method decreases resident learning opportunities and increases the workload for staff/faculty. The bottom line is that hospitals and residency programs must work with the 80-hour workweek, have a plan in place, and not try to work around the regulations.
REFERENCES 1. Queenan JT. Work-hour limitations: Let us solve our own
problems. Obstet Gynecol. 2004;103:611-612. 2. Robins N. The Girl Who Died Twice: Every Patient’s
Nightmare. The Libby Zion Case and the Hidden Hazards of Hospitals. New York: Delacorte Press; 1995. 3. Chandra RK. The resident 80-hour work week: how has it
affected surgical specialties? Laryngoscope. 2004;114:13941398. 4. Whang EE, Mello MM, Ashley SW, Zinner MJ. Im-
THE FUTURE With work hours being limited to 80 hours per week, one must ask: What does the future hold? Some have hinted at decreasing work hours even more to 60 per week, whereas others have talked about limiting faculty hours. Beginning in August 2004, medical residents in England have been limited to 58 hours per week; their work hours will decrease to 56 by 2007 and to 48 by 2009. Furthermore, shifts (including call shifts) are limited to no more than 13 consecutive hours. Also, a resident physician’s salary is not cheap in England, with the average salary of $144,000.1 A systematic review of over 1000 resident physicians in 16 specialties revealed that as much as 35% of awake time on duty was spent delivering care of marginal to no educational value and that 16% was spent in other noneducational objectives.46 These data show that it is valuable not only to review the number of hours worked, but also it is just as important to assess the quality of hours worked when considering attempts at workhour reform.
CONCLUSIONS Studies show that prior to the 80-hour workweek, residents suffered from significant sleep deprivation, which could lead to decreased cognitive performance and the potential for compromised patient care. Substantial concerns about decreased learning opportunities and operative experience have been raised. It seems that continuity of patient care is compromised by the work hours and that patient care does not seem to be improved. Many studies show that residents’ operative experience does not seem to suffer; however, they commonly attend fewer clinics/ didactics. As far as quality of life during residency, the work hours are more embraced by junior residents and less well received by senior residents and faculty. The hospital is negatively affected from an economic standpoint. Faculty hours did not increase after the new work-hour restrictions. An evidencebased approach is needed to minimize the well-documented risk that current work-hour practices confer on resident health and patient safety while optimizing education and continuity of care. 294
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