Resident Angst

Reform meets controversy in new medical school rules

They roam the airwaves of prime-time TV, and the University Medical Center's hushed hallways. Charts in hand, stethoscopes draped around their necks, they are doctors-in-training, and they're required to work shifts that put the rest of us to shame—up to 80 hours a week for some, often in 24-hour stretches.

Over time, this hardcore training has become enshrined in medical culture as a precious rite of passage. But that rite may be coming to an end. Starting in July, the 24-hour shifts will be shortened to 16 hours for first-year residents, and "strategic napping" will be "strongly suggested" for those working around the clock.

It's the first update in resident-duty hours since stringent standards—such as capping the work week at 80 hours—were first enacted by the American College of Graduate Medical Education in 2003. Medical training programs, including the one at the University of Arizona, are accredited by the ACGME.

But this change has rekindled a long-simmering controversy, particularly among teaching hospitals such as the University Medical Center, which rely heavily on the relatively low-cost work done by residents typically earning $45,000 to $50,000 per year.

Key to that debate is whether the extraordinarily long shifts—and exhausted medical residents—put patients at greater risk. "When we talk about resident work hours, what we're really talking is patient safety," says John Brockman, national president of the American Medical Student Association, based in Reston, Va. "To think that residents and medical students alike can work up to 30 hours in a shift is crazy. We believe that residents shouldn't work shifts over 16 hours—when you look at the data, their performance drops off markedly after 16 hours."

Studies have supported Brockman's position. For instance, a report by the Institute of Medicine in 2008 urged the ACGME to institute stricter resident-hour guidelines, concluding that "patient safety in hospitals remains a very serious problem."

Another study, spearheaded by researchers at the University of California, substantiated the so-called "July Effect." It refers to a suspected increase in patient harm during the month when medical-school graduates begin their residencies; the California study suggests that medical errors jump by 10 percent over that one-month period.

Yet another study found that residents were involved in up to one-third of all such mistakes.

Meanwhile, proponents of long resident-duty hours cite their own studies showing little detrimental effect. They tout the intensive learning that lengthy shifts provide, and note that shortened shifts will only prolong the residencies.

The UA medical school has 31 residency- training programs. Among them, most residents work fewer than 80 hours a week, says Dr. Rebecca Potter, associate dean for graduate medical education. "It depends on the specialty and the level of training. In surgery you're going to find more of them working the maximum of 80 hours a week. In some of our fellowships, they're working 40 to 50 hours a week."

She says those exacting hours are sometimes necessary to gain the needed, cumulative experience. "For instance, surgery is a five-year program. (Residents) have to see so many cases of different things. So if we decrease their work hours, we're going to have to increase the length of training."

Still, she says, "Most of the (surgery residents) don't average 80 hours a week."

Another factor is the constant ebb and flow of hospital life. "It depends upon what's going on in the hospital," Potter says, calling pediatrics a case in point. "When it's 'RSV' season—which is respiratory syncytial virus—in the wintertime and there are a lot of sick babies in the hospital, residents are going to work closer to their 80 hours a week. And when the hospital is slower—when there are not as many acute things going on—they're going to work fewer hours. It's fluid."

But are residents still able to provide proper care when they hit those upper limits? "That is the debate," Potter concedes. "If you ask different people, you will get different answers."

Conrad Clemens is the UA's program director for pediatrics, a specialty education program known for its interminable resident shifts. While acknowledging this critical conflict—he calls it the "million-dollar question"—Clemens argues that even exhausted residents are up to the task. "I've been doing this for close to 20 years now, and I honestly feel that, even though a resident may be tired, they do an excellent job throughout that whole long shift. The cognitive things tend not to be affected by working a little bit longer."

Clemens says the lengthy shifts are dotted with breaks and even occasional naps. He also considers them a benefit for patients, who get to see the same doctor throughout the day. "It sounds stark to say, but would one rather have a doctor who's a little more tired, but knows you well as a patient, compared to a doctor who is fresh, but doesn't know you from Adam? That's the real debate. And I don't think there's an easy answer."

Either way, he says that ACGME requirements established in 2003 made medical school's notorious boot-camp mentality a relic of the past. "Now a program can't say, 'I'm going to work you 120 hours.' That's actually not legal anymore. There still may be older faculty members who still have that mindset, but you're in a system now where that is no longer able to be done."

Regardless, there are many who think grueling resident shifts offer a preparation no other experience can provide. Among them is a doctor we'll call Susan. She finished her residency at the UA in June, but requested anonymity due to media policies at the Tucson-area hospital where she now works as an internist.

Susan contends that those long shifts—including her routine, 70-hour weeks as a resident—were arduous but invaluable. "I don't think anyone functions well after 24 hours on the job," she says. "But I felt it was reasonable. It was right on the edge, but it was reasonable.

"To be honest, when you're alone at night and it's your first year of training, that's when you learn how to be a confident, decision-making physician, and learn to take care of your patients effectively."

Likewise, she worries about how the coming changes will affect those who follow. "Everyone I've spoken to has deep concerns," says Susan. "Are they going to come out as confident as we did?"

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