Viewpoint: Is it time for physicians to have an 80-hour attending workweek?

January 1, 2010

I recall I took some comfort in that adage during my residency. However, such bravado was representative of a different era, a time when 36-hour calls, 120-hour workweeks, and 1 weekend off a month were seen as rites of passage crucial to the creation of competent physicians.

Key Points

The belief that those were suitable conditions for medical training began to change in the late 1980s, particularly in the face of the high-profile death of Libby Zion in New York City. Zion's father was a politically well-connected former New York Times reporter who argued convincingly that the medical errors that contributed to his daughter's death were in part the result of overworked, overtired residents. In response, New York State implemented resident work-hour reforms in 1989, creating an 80-hour maximum workweek and 24-hour maximum calls. The rest of the country followed suit, albeit belatedly, when the American Council for Graduate Medical Education (ACGME) in July 2003 implemented a maximum of 80 hours of on-duty work per week (averaged over a 4-week period), 24-hour call cycles (with additional 6 hours for didactics, handoffs, or outpatient duties), and a minimum of 10 hours off between shifts.1

In the August 2009 issue of the American Journal of Obstetrics and Gynecology, Steven Clark presents physiologic and empiric evidence connecting sleep deprivation with impaired practice.2 Although data demonstrating diminished performance in sleep-deprived physicians are largely obtained outside of actual work conditions, such as in simulations using psychometric testing, multiple studies have shown that sleep deprivation contributes to poor interpretive skills, delayed and dysfunctional decision-making, and psychomotor performance impairment. Relating sleep deprivation to an indisputable condition of impairment, Clark points out that at 17 hours of wakefulness, a person's performance is equivalent to one who has a blood alcohol level of .05%, and at 24 hours, it is comparable to .10%, above the legal limit defining intoxication in all US states.

In light of the evidence, it is difficult to argue against some controls in resident work hours. Furthermore, regulatory efforts by the Accreditation Council for Graduate Medical Education (ACGME) are unlikely to go away, so our compliance is mandatory. In fact, the Institute of Medicine has advocated for a further reduction in trainee work hours, including mandatory protected in-house sleep time for shifts continuing beyond 16 hours.3

Yet, the dirty secret in medicine is that although we restrict the hours of our trainees, which has become a very public issue in the interest of safety, there is no similar accountability for those providers who supervise them-the attending. In fact, attending physicians make up a far larger portion of the workforce and are the individuals with the ultimate clinical responsibility. According to the US Department of Labor, many physicians and surgeons work long, irregular hours. More than one-third of full-time physicians and surgeons worked 60 hours or more a week in 2006.4 Although fatigue is a potential concern in all fields of medicine, it is a particular concern in obstetrics, where overnight calls sandwiched between full work days and entire weekend shifts are a regular occurrence. A survey of Houston ob/gyns identified 62% who worked more than 80 hours per week.5