Be a Doctor! The Hours are Great!




Residency training in the United States has historically been a period of abusive hours and intense training. Until recently, there was no limit to the number of hours per week a resident could work. In fact, that has something to do with why they’re called “residents” in the first place: they practically lived in the hospitals in which they worked.

Then came the Libby Zion case, in which a young woman died while under the care of overtired residents. Suddenly America realized that it probably wasn’t a good idea to have inexperienced doctors taking care of really sick people on less than three hours of sleep per night. Enter the Accreditation Council for Graduate Medical Education (ACGME) which is charged with accrediting residency programs nationwide. As of 2003, the ACGME limited the number of hours a resident could work per week to 80, 88 if you were training to be a surgeon and then only under extenuating circumstances. If you were listening carefully at that time, you may have heard the cries of outrage from practicing physicians across the country. How could residents possibly learn enough in 80 hours a week? And after all, if we had to do it, then so should they!

As it turns out, however, caps on resident working hours were nothing new, having been in place across the Atlantic for quite some time. In the United Kingdom, for example, the resident work week is capped at 56 hours per week. And as of August 1, 2009, it’s dropping to 48.

As a program director, I believe I can provide my residents with the training that they need in 80 hours per week over the course of three years. 56 hours per week would take some very creative scheduling. But if I were limited to 48 hours per week, I don’t think that adequate training would be possible, at least not in three years. The British Medical Association seems to realize that and has written a paper outlining several options to address this problem, including extended training. Most options, however, entail added staff and costs. Moreover, most practicing physicians work more than 48 hours per week, according to a 2003 JAMA article. Any resident trained in a 48 hour work week environment would be in for a rude awakening once released into the “real world”.

Fortunately, I don’t have to worry about a foreshortened resident work week just yet. But if the ACGME is taking any cues from the training of British physicians, I may be in for a rude awakening myself in a few years.

References

Maintaining the quality of training in the craft specialties: managing EWTD implementation. British Medical Association. 2009.

E. Ray Dorsey, David Jarjoura, & Gregory W. Rutecki (2003). Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students. JAMA, 290 (9), 1173-1178

  • I’m amazed that this kind of professional hazing is only now being phased out. Sure, doctors and other professionals might end up working 80 hour weeks, but sleep deprivation as an enhanced learning technique is not a hypothesis I’m aware of an any other profession except the military–where evidence-based decision making on the fly is equally crucial. Time to let doctors and soldiers in training get some sleep.

  • residentwife

    Um… plenty of residents still work on 2 hours of sleep. I know my husband does and did so last night. The hours are obscene even still. How do I know? When your husband comes home so sleep deprived he acts as if he is drunk – then he is not getting enough sleep. Spouses of medical residents across the nation can tell you what really happens to these individuals after working Q2 for a week straight, to just go into a “regular” work week, or what happens when they don’t get a days off work, but their day “off” is one where they worked 7p- 9:00 a.m. and slept half the day. Normal people would call 8 hours a day, a normal work day, not a day off. The system, however no longer completely ludicrous, is still – obscene. It changes good people into people you don’t recognize, until they are no longer in training, and come to.

  • residentwife

    Oh, and not to mention, surgical residents often break the hours, regularly. And… they are told to fudge their hours and do so all the time. Neuro Surgery is notorious for this. Every one knows this, why is this myth of a hard 80 hours still being spoken of like it’s true.

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  • Anocow

    I am not a physician, but I used to work ridiculous hours during grad school, getting by on 2 to 4 hours of sleep a night for 2 years straight. I had two major car accidents during this period, falling asleep at the wheel on both occasions. The first incident had me drowsing briefly into sleep for a few seconds, while driving at 80mph on the freeway. I ended up rolling my car, missing several vehicles including a school bus narrowly and landed in a ditch on the side of the road. The second incident had me falling asleep and plowing into the back of a parked car. Both incidents resulted in the vehicle driven by me being totaled. I count myself extremely fortunate not to have hurt either myself or anyone else on either occasion.

    The second incident was the wake up call that the first should have been, and I’ve made sure that I never drive sleep-deprived after it. On the slightest hint of sleepiness, I get off the road.

    The idea that doctors are allowed to operate while under a similar degree of sleep deprivation is beyond ridiculous to me. There is no way that I would have any doctor who’s had less than 7 hours of sleep in the last 24 come near me, let alone operate. The scary part is that I’ll probably be unable to prevent it.

    I also think that counting resident work hours is the wrong way to go. Its a secondary and often poor measure of the degree of sleep deprivation, which is what you’re trying to estimate. Instead, you should measure the actual amount of sleep they are getting, using an ambulatory sleep sensor that the wearer cannot remove without a supervisor’s (regulatory board’s?) assistance. As soon as hours awake exceed a set number, light changes to red and you need to step away from the patients.

    residentwife: I hope that your husband doesn’t drive when so severely sleep deprived.

  • Anders

    I think the regime you operate under over there is ridiculous. Why the work fetish? Do you need the money? The sleep deprivation is a serious safety concern, and not necessary.

T. A. McNamee, MD

T. A. McNamee, MD, is an associate professor and internal medicine residency program director at Sanford School of Medicine of the University of South Dakota.

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