The Accreditation Council for Graduate Medical Education (ACGME), the body that oversees medical and surgical residency programs at teaching hospitals nationwide, recently increased the number of consecutive hours — to 28 — that first-year medical residents (known as “interns”) are allowed to work. This upends the 2011 decision to cap shift length at 16 consecutive hours, an attempt to make work conditions more humane and reduce medical errors. Preventable hospital errors kill upwards of 250,000 Americans each year — the third leading cause of death in the United States.
Those in favor of this new ruling argue that patient safety is jeopardized during “handoffs” when residents pass patient care responsibilities on to the incoming team, and that the more changes during a shift, the more opportunity for miscommunication, which is potentially worse for patient safety. Proponents also cite a commitment to resident education as a primary motive, contending that trainees need to be in the hospital for prolonged periods of time to observe how disease and clinical management evolve. In fact, the ACGME recently tailored its language, changing “duty hours” to “clinical experience and education”.
Those who oppose the policy argue that sleep deprivation is far worse for patient safety, given its adverse impact on judgment and decision making. The decision to re-expand intern work hours is based on initial and incomplete data from clinical trials researching how work hours ultimately impact patient outcomes. Given the vast array of inputs that influence one’s health outcome, each of which is near impossible to isolate for independent analysis, it is no wonder that such trials have produced equivocal results. Yet numerous studies do confirm that chronic sleep deprivation — epitomized by medical training — causes progressive decline in attention to detail, compromises performance, poses serious and preventable hazards such as motor vehicle accidents, and increases the rate of medical errors. This is not to mention the miserable workforce and toxic work culture often created from being overworked and sleep deprived in a stressful environment.
Re-expanding intern work hour limits is a hazardous step backward in the evolution of medical training for multiple reasons. Indisputably, working while sleep deprived contributes to burnout and compromises patient safety. Greenlighting this increased number of consecutive hours sanctions residents to work beyond their biological limits, and perpetuates the fallacy that doctors are somehow superhuman. In turn, this reinforces the power divide between patients and doctors while creating an unrealistic expectation of performance for both parties.
Given the litany of medical research on the importance of sleep, it is ironic and hypocritical, that we physicians, stewards of health and standard-bearers of scientific truth, do not heed our own evidence. Pilots for commercial airlines have a 10-hour minimum rest period with 8 hours of uninterrupted sleep between flights. Physicians’ tasks are no less life threatening and yet, we tolerate our young doctors ordering potentially lethal medications, performing invasive procedures, and coordinating patient care while under slept. The American public — our patients — generally lacks awareness of how many hours doctors work and, when surveyed, strongly favors stricter work hour restrictions for U.S. resident physicians.
Moreover, the idea that more time in the hospital translates to more opportunities for learning is overstated. The priority to educate residents invariably comes second to the hospital’s economic imperative to keep heads in beds by admitting and discharging patients. Increasingly, this involves less direct patient care and more clerical work mired in documentation, inefficient communication, and administrative tasks. Medical residency is an informal training in how to function in a dysfunction system, with morsels of dedicated medical education sprinkled on top.
The real danger, however, in this decision to relax the restrictions on resident work hours is the inherent implication that there must be a fixed choice between more handoffs or longer shifts. This underscores our strong need for innovative solutions to update our antiquated training system. As the nature of physician work rapidly changes in our complex health care system, hours worked is no longer an appropriate proxy for the value of patient care. Nor is it the only lever for change. Increasing the number of hours in a shift, regardless of whether this is intended to enhance education or to accommodate the administrative burdens of a wasteful health care system, is a mitigating strategy that misses the root of the problem: we, the frontline workers, are inundated with an impossible cognitive load — more data, endless communications, and increasing systemic pressures — that diminishes the rewards of practicing medicine and often detracts from true patient care.
To truly improve health, our dated training process must evolve in tandem with the shifts in health care delivery, the changes in disease burden, and the evolution of the demography and needs of our patients. We must implement processes that are more efficient, borrow from Lean principles, and adopt best practices from other industries, such as human factors engineers at NASA, that will decrease redundancy, streamline algorithmic workflows, and free us to do the human work of doctoring. Residents must be empowered to improve the quality of patient care while understanding the economic forces and incentives in the larger system. They must be taught techniques to engineer patient-centered care and given the institutional support to deliver care in a logical, safe, and efficient manner. This demands constructive collaboration with our colleagues and allied health professionals to provide effective team-based care. Ultimately, we must look beyond the confines of our exam rooms and out into our communities. Health starts at home — where and how we live day to day. Physicians need formal training in leadership, coalition building, and advocacy to improve the health of the populations we serve. In order to practice these new skills that now constitute effective doctoring in modern health care, residents need a collective voice to help redesign the medical training model.
Sadly, as these imperatives clamor for our attention, as the future of the health care system hangs in the balance, and as our patients look to us for healing and hope, our discussion remains fixated on work hours — a debate that is just as unimaginative as it is outmoded. How we train determines how we sustain ourselves, how our system evolves, and ultimately, how we care for our patients. The real danger in this decision to relax the limits on resident work hours is that it stifles our creativity, constricts our imagination, diverts our focus, and dilutes our collective energy to reconsider and revamp our training process, as our current health care climate demands.