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I can still vividly recall the unique feeling of utter exhaustion that would creep up on me in the middle of a hectic day in the clinicusually at about 2 pmafter a brutally busy and sleepless night on call as a resident. One afternoon, I fell asleep while using an old-fashioned fetoscope (translation for the "under-45" crowd: fetal acoustic stethoscope) to listen for a fetal heart beat. Post-call, I remember sleeping soundly at the theater, sometimes in the company of other residents. My co-residents and I had a particularly restful nap during what I'm toldat least by our spouses or significant others, who looked on in dismaywas a wonderful rendition of Handel's "Messiah" by the Philadelphia Philharmonic.
Amusing anecdotes aside, I do not recall making an error because of exhaustion, but I may have been too tired to know that I was making one. On the other hand, some of my most memorable cases occurred at 2 am: abdominal pregnancies, ruptured livers, breech deliveries, shoulder dystocias, ruptured uteri, cesarean hysterectomies, septic shock, DIC, etc. In retrospect, residency was the time when my clinical judgment was honed and my ability to swiftly and correctly react to a crisis was developed. Thus, it is with mixed emotions that I confront the new Accreditation Council for Graduate Medical Education (ACGME) regulations to restrict resident work hours.
The history of resident work hour legislation can be traced back to the unfortunate case of Libby Zion, an 18-year-old woman admitted to New York Hospital on the evening of March 4, 1984, with a high fever. Ms. Zion did not survive until the morning, allegedly because the severity of her condition was not recognized in a timely fashion, she was not monitored closely enough, and her treatment was inappropriate given the prescription and non-prescription substances she may have recently ingested. Most importantly, it was alleged that resident fatigue contributed to the situation. Ms. Zion's death received intense local and national public scrutiny because of the efforts of her father, Sidney Zion, a former prosecutor and New York Times writer.
Because the very safety of care at all New York hospitals was called into question, the district attorney impanelled a grand jury to investigate the circumstances of Libby Zion's death. Neither the hospital nor the physicians were found to be criminally liable. Without benefit of trial, however, the system of resident education in New Yorkwhich was no different than elsewhere in the United Stateswas found to be guilty.
Then-New York State Commissioner of Health Dr. David Axelrod charged an ad hoc committee with analyzing the grand jury's findings. Chaired by Dr. Bertrand Bell, the panel issued a highly publicized set of recommendations, including the following:
If these recommendations look familiar to you, it is because the ACGME recently adopted these limitations on resident work hours almost verbatim. With relatively minor modifications, these restrictions will apply to all specialties and all geographic areas effective in July. Most residency program directors, including my indefatigable one at Yale, are now desperately struggling to craft rotation schedules for adequately training house staff under these conditions. I know their goal is to do so without compromising either patient care or resident education, but will that be possible?
Is there evidence that long resident work hours adversely impact patient care, or conversely, that an 80-hour workweek will not seriously impair clinical competence? And of even greater concern, how can we be sure that an 80-hour workweek will not reduce surgical proficiency?
Resident work hours have become an area of active research since the changes that occurred in New York State in the 1980s. In one survey of physicians-in-training, 41% cited fatigue as a cause of a serious mistake.1 Other studies have found that extreme physician fatigue affects memory, concentration, and language skills.2-4 This research confirms what is obvious to some: Resident physicians are not somehow immune to the effects of sleep deprivation. Unfortunately, the body of available literature does little to help us understand the impact of reduced hours on either "cognitive" or surgical training. At least one study has shown that New York ob/gyn residents' performance on Council for Residency Education in Obstetrics and Gynecology examinations did not improve after the 80-hour week was implemented, and recently there have been concerns about the impact of the restrictions on the performance of general surgery residents.5,6 This latter report concluded that patient care was actually negatively affected by the reduced work hours!6
Today's residents must assimilate an exponentially growing body of basic science and clinical data and deftly use that knowledge to make evidence-based decisions in patient care. After the Human Genome Project is completed and in the wake of the coming revolution in genomics and proteomics that holds the promise of allowing us to predict and prevent many common disorders, this body of requisite information will expand at an even more accelerated pace. Given national demographic, social, and economic trends, future physicians will also have to focus, as never before, on geriatrics, ethics, and the ABCs of managed care. Despite this additional training burden, residents in obstetrics and gynecology will still need to devote a significant amount of their time to developing their surgical and obstetrical skills. Each graduating resident still should be able to expertly perform a hysterectomy transvaginally and transabdominally while also mastering the art of operative vaginal delivery and grasping how to recognize and deal with complications of labor, vaginal delivery, and cesarean birth. But now, because of limitations on work hours, residents will have to learn all these things in a shorter period of time.
I became an attending physician in New York shortly after the implementation of Dr. Bell's recommendations, and over the course of 12 years, I did see some positive changes. Residents were routinely able to fully avail themselves of formal didactics, had the energy to actively engage in research, and most importantly, had the clarity of thought to be able to continuously assess their decisions. The grueling and sometimes demoralizing "boot camp" approach to training was gone, and as I was fond of saying, a "peppy and positive" attitude took its place. But I also noticed some problems. Much of the major surgical and decision-making experience that had previously occurred early in residency was now delayed. Residents were a bit less comfortable in making difficult decisions, even with the active support of the attending staff. Residents seemed to have lost complex operative vaginal skills and their overall surgical skills appeared to have deteriorated. In short, residents are now a bit less prepared for and less confident about the rigors of independent practice.
An extremely sleep-deprived resident obviously is more likely to make a poor decision, but a well-rested yet incompletely trained resident may not perform much better. At this point, the residency work-hours debate has not moved to a discussion of narrowing the scope of training so that essential elements can be mastered nor is there talk of extending the training period in most programs. Neither is an ideal solution. In the former situation, the resident is responsible for less; in the latter, the cost of additional training, both in dollars and in a potentially smaller pool of interested applicants, must be considered. Nor has the ACGME considered separate work-hour requirements for "cognitive" versus surgical disciplines (for example, 80 vs. 95 hours).
Regrettably, data have not been able to drive the ACGME's deliberations. I have yet to see evidence that New York hospitals are significantly safer since Dr. Bell's committee issued its report. I have also not seen a detailed assessment of how the new ACGME guidelines will better protect patients, if at all. Like all things in medicine, the risks of this "treatment" must be weighed against its benefits, and I do not think we have enough information to make an informed choice. Since the choice has already been made for us, we can only judge over time whether the cure was worse than the disease.
1. Daugherty SR, Baldwin DC, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions. JAMA. 1998;279:1194-1199.
2. Hart RP, Buchsbaum DG, Wade JB, et al. Effect of sleep deprivation on first year residents' response times and memory. J Med Educ. 1987;62:940-942.
3. Rubin R, Orris P, Lau SL, et al. Neurobehavioral effects of the on-call experience in housestaff physicians. J Occup Med. 1991;33:13-18.
4. Robbins J, Gottleib F. Sleep deprivation and cognitive testing in internal medicine house staff. West J Med. 1990;152:82-86.
5. Kelly A, Marks F, Westhoff C, et al. The effect of the New York State restrictions on resident work hours. Obstet Gynecol. 1991;78(3 Pt 1):468-473.
6. Barden CB, Specht MC, McCarter MD, et al. Effects of limited work hours on surgical training. J Am Coll Surg. 2002;195:531-538.
Charles J. Lockwood, MD
Charles Lockwood. Editorial: The 80-hour resident work week: cure or curse?.