Written for Dr. Mark McLaughlin, MD
The Controversy Over Resident Work Restrictions
It all started in 1984 when 18-year-old Libby Zion went to the emergency room at New York Hospital with flu-like symptoms.
The two young medical residents—physicians in training—who cared for Zion couldn’t determine the cause of her illness. They prescribed a medication that caused serotonin syndrome, a lethal interaction with a drug that she had been taking. Later that day, Zion died of cardiac arrest.
Her family claimed she died because the residents made poor decisions due to the fact that they were sleep-deprived from working 36-hour shifts. On the night of Zion’s death, one of the residents was responsible for 40 patients.
The case became a high-profile legal battle. The residents and their supervising physicians weren’t found guilty of negligence, but they were reprimanded by the State of New York.
Work Restrictions Established
In 1987, after studying the issue of resident work hours, a New York State commission passed a law limiting resident work hours to 80 hours a week.
The Accreditation Council for Graduate Medical Education (ACGME) followed suit in 2003 by mandating that in all medical resident training programs, residents could work no more than 24 consecutive hours.
In my opinion, these well-intentioned laws have caused harm to medicine. They’re a perfect illustration of the fact that management of medicine by non-medical entities is a bad idea.
Let’s look at both sides of this issue. Those who disagree with limiting the number of work hours claim that doctors in training need to work long shifts to observe the entire course of an illness and treatment.
People on this side of the argument contend that if work hours are limited, residents might not be prepared for real-life situations in which doctors must work very long shifts.
On the other side of the coin, those who agree with resident work restriction make the seemingly obvious point that well-rested doctors are more alert, they learn their profession better and make fewer medical errors.
A number of research studies reveal, however, that limiting resident work hours doesn’t improve performance, it actually does the opposite. Work restrictions cause residents to make more mistakes, not fewer.
A study published in the Journal of Neurosurgery in 2014 examined the effect of resident work restrictions on complications, mortality, length of stay and costs. It compared the outcomes of neurosurgical procedures before and after work restrictions were enacted. More than 90,000 patients were studied.
The researchers’ conclusion was straightforward: “The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose.”
In a survey of 377 neurosurgery residents published in the December 2011 edition of Neurosurgery, most of those surveyed “believe that the new standards will have a negative effect on their residency training.”
Neurosurgery published a study in 2012 that evaluated more than 21,000 patients who underwent surgery for brain cancer and found that, after resident work restrictions were enacted, “At teaching hospitals, the complication rate increased from 14% to 16%.”
According to a survey of 2,300 residents published in JAMA Internal Medicine in 2013, even though residents worked fewer hours, the reduction “has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being but has been accompanied by an unanticipated increase in self-reported medical errors.”
Problems from Restricted Hours
The JAMA study also found that while residents didn’t work as many hours, they were still expected to do the same amount of work as before the restrictions were put in place. Compressing the same workload into a smaller amount of time can increase the risk of medical errors.
Shorter shifts also mean more “handoffs” in which a doctor transfers the care of a patient to another doctor who isn’t as familiar with the patient’s medical history. Handoffs are notorious for causing miscommunication and opportunities for medical errors.
Problems due to work restriction often occur with highly complex medical procedures. Those procedures demand long, arduous residencies so young physicians can obtain the experience and skill to perform them well.
Reducing the work week to 80 hours for these specialties can reduce hours in surgery by 25%. Since residencies aren’t extended by 25% to compensate for this, many residents gain less experience—and less skill—than before.
I believe the proper approach to resolving this issue is to reassess work hour restrictions based on the specific medical specialty involved. Changes can be made to ensure that residents in training for highly complex specialties work enough hours to gain the experience and skill they need to provide the highest level of care for their patients.