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THE NEW RULES OF RESIDENCY:
Work hours are about to get shorter // And learning opportunities fewer // But will better-rested residents really improve care?

Residency Hour Limits: On the Clock

By Linda Keslar // Photographs by Jessica Dimmock // Spring 2011
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Jessica Dimmock for Proto

In a Dec. 26, 2007 letter to The Journal of The American Medical Association, Bertrand Bell, the physician who chaired a 1987 New York State commission on residency training for doctors, described the startlingly offhand calculation used to decide how long residents could work without endangering patients or themselves. The Bell Commission was created in the wake of the death of a young woman in a New York City hospital, under the care of two unsupervised and apparently overworked residents. The commission’s recommendation of an 80-hour workweek not only became state law in 1989 but, in 2003, also formed the basis of national rules mandated by the Accreditation Council for Graduate Medical Education.

“The specific ‘80-hour week’ was actually determined by a colleague on my porch,” Bell wrote in his letter to JAMA, “and was based on the following informal reasoning: There are 168 hours in a week. It is reasonable for residents to work a 10-hour day for five days a week. It is humane for people to work every fourth night. If you subtract the 50-hour workweek from 168 hours, you end up with 118 hours. If you then divide 118 by four (every fourth night), it equals 30. If you then add 50 to 30, then eureka, that equals an 80-hour week.”

Informal reasoning, indeed. Yet now, in a further attempt to safeguard patients and residents, ACGME is instituting additional limits. This July, new standards for the nation’s 114,115 physicians-in-training go into effect, restricting the number of consecutive hours that interns (first-year residents) may work without sleep, from the customary 30 hours to 16 hours. Meanwhile, more experienced residents will be limited to 24-hour shifts, and they’ll be urged to pursue “strategic napping.”

How these tighter restrictions will affect the many teaching hospitals that depend on residents as a vital resource remains to be seen. “I don’t think anyone would argue against the notion that well-rested trainees can and will provide better care,” says John Co, director of graduate medical education at Partners HealthCare, which has more than 1,700 residents and clinical fellows at Massachusetts General Hospital and Brigham and Women’s Hospital in Boston. “But the question is, how do you implement that in practical terms?”

Perhaps more crucially, medical educators worry that the reduced shifts will provide an insufficient educational experience. “I’m concerned whether residents will see enough patients,” says Craig Brater, a physician and dean of the Indiana University School of Medicine, which has more than 1,000 residents. “Will residencies need to be longer?”

Others are worried that shorter hours might even increase medical errors if the change results in patients being handed off more frequently from one resident to another. And so far, there has been little conclusive evidence to validate Bell’s on-the-porch estimate or to gauge the impact of the 2003 reforms. “We’re making a very big, expensive change in residency programs, and the problem is we don’t have enough high-quality data from real residency programs to know how to do this and improve outcomes,” says Vineet Arora, a physician and associate professor at the Pritzker School of Medicine of the University of Chicago.

For soon-to-be residents, that adds up to an uncomfortable level of uncertainty. “If I’m in the hospital less, I’m afraid I’m going to learn less,” says Celine Goetz, who this summer will start her residency at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. “I interviewed with a dozen residency programs, and the subject of the new rules came up in every one. Every institution seems to have a different philosophy about the changes, and many emphasized that no one really knows what the impact will be for medical education. My class is going to be the guinea pigs.”

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Lost in the Shuffle

Looking ahead to shorter resident hours causing more frequent patient handoffs, hospitals are working to ensure vital information is communicated to the next shift.

A Matter of Time

Doctors' hours have risen, then fallen, since the practice of residency was adopted in 1889.

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hed-dossier

1. Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care, by Kenneth M. Ludmerer (Oxford University Press, 1999). An examination of the exponential growth of U.S. medical schools and their future challenges, such as the potential negative impact of resident work-hour limits on education and care.

2. “Resident Duty Hours: Enhancing Sleep, Supervision and Safety,” Institute of Medicine, December 2008. The most comprehensive consideration to date, wielding influence on the new Accreditation Council for Graduate Medical Education standards.

3. “Interns Overestimate the Effectiveness of Their Hand-off Communication,” by Vivian Y. Chang et al., Pediatrics, March 2010. There is proof positive, the authors say, that vital patient information isn’t fully conveyed in most cases during the transfer of care between physician trainees, and that the increased frequency of such handoffs, the result of resident work-hour limits, jeopardizes care.

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