Hold on a second: On the harms of residency work-hour restrictions

by Allan Joseph

Let’s start here: I’m only a first-year medical student. I don’t claim to have inside knowledge into how residency works. But when I saw this widely-shared New Yorker article by cardiologist Lisa Rosenbaum decrying restrictions on resident work-hours, I was struck by how many in the medical field took Dr. Rosenbaum’s argument at face value. I think she makes some valid points, but I worry that in blaming new regulations for every problem, the medical profession misses a critical opportunity to examine its own weaknesses.

Take the article’s opening anecdote, about a mistake made by “Resident B,” who had taken responsibility for a colon-cancer patient from “Resident A.” Dr. Rosenbaum attributes the error to the fact that Resident A was forced to leave the hospital due to work restrictions — but as we see in the article’s own words, the error came from somewhere different (emphasis added):

So when [Resident B] arrived, [Resident A] handed her a fresh list, which now included an instruction to pull the abdominal drain. 

A few hours later, [Resident B] entered the patient’s room, saw the kidney drain coming from the patient’s back, and assumed it was the one to pull.  

This error was absolutely preventable within the context of the work-hour restrictions. Sure, Resident A wouldn’t have made the mistake if he had been there, but Resident B had to make a faulty assumption to make that error. That’s not the regulations’ fault — it’s due to a problem in coordinating care. The patient was going to be in the hospital for several days, perhaps even weeks. Unless you wanted Resident A to be in the hospital for the duration of the patient’s care, the handoff was going to happen somewhere. And if that’s the case, the handoff had to be better.

I’m not saying that work-hour restrictions don’t contribute to poor handoffs. They almost certainly do. But they can’t be the only cause. The American healthcare system is rife with care-coordination problems, due in no small part to physicians’ historical role as “their own bosses” and resulting distrust of administrative solutions. It doesn’t help that paperwork issues with nascent electronic-health-record (EHR) systems add roadblocks to effective coordination, but again, that doesn’t mean we need to get rid of restrictions, it means we need to get better EHR systems.

There are issues with the work restrictions that do need to be addressed. For the physician-in-training, residency is supposed to be learning experience: see as many cases as you can and learn from each and every one of them. Work-hour limitations do reduce your caseload over a typical three- or four-year residency program, but perhaps physicians could improve their training through longer residency programs. Morning rounds should be a sacred time, and there should be enough flexibility in the system to allow residents to complete proper handoffs. But none of those issues require a wholesale repeal of the regulations. They simply require improvement of that which exists. If patients really are more comfortable with rested physicians, and we can improve the system to the point that education and care are at least as good as they were before, then why shouldn’t we put patients’ wishes first?

There are always solutions to the problems brought about by changes like new regulations, new EHR systems, and new reimbursement systems. But instead of looking to move forward and lead a new generation of innovation, physicians tend to look backwards and bemoan the loss of what once was. Rather than training in an environment that sees and addresses the flaws in the practice of medicine, a new generation of physicians is training in a culture that would simply rather blame new regulations and cruel administrators for all of its issues. We can analyze work hour restrictions’ effects on clinical and educational outcomes, but we can’t use them as a scapegoat for all that ails academic medicine.

Our profession is not perfect, and neither are residency work restrictions. But instead of blaming external factors for all of our problems, why can’t we improve the regulations and our own care? We’d produce better physicians in the process — and that’s an outcome we can all agree on.

_____________________________

Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

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3 thoughts on “Hold on a second: On the harms of residency work-hour restrictions

  1. Shawn Martin says:

    Nice observations on the challenges of over-regulation versus no-regulation. This is not an easy issue and the impact on patient care should remain central. I would challenge the idea that we can simply extend training years. The financial impact of such a policy is prohibitive for all practical purposes. The challenge is how do we train more physicians in less time, at a lower cost, while improving quality, and increasing patient satisfaction? The answer is probably worth an award or two!

  2. Cedric Dark says:

    Revisit your comments after your first call as an intern.

    The 2nd iteration of ACGME work-hour restrictions makes life too easy for residents, contributes to more handoffs, and doesn’t lead to better rested residents. They should go back to the original 80-hour work week limits in my opinion.

    I’ve seen many residents graduate, then take hospitalist jobs, and – because attendings don’t have work hour limits – don’t know how to handle the caseload.

  3. littleredmed says:

    You are right that one anecdote can’t be used to draw conclusions about work hours, and that the handoff was not the only factor that lead to the accident. But the New Yorker article focuses on YEARS of data, including the randomized controlled trial at Johns Hopkins they describe. That study, among others, suggests very strongly that the workplace restrictions themselves do cause increased errors and decreased resident satisfaction.

    I’m only a 4th-year student, but I will say that many residents I have talked to are very unhappy with the new regulations. During my medicine rotation, I spent several nights with the overnight intern. Along with the resident on night float, he was responsible for caring for the entire patient load that 2 teams of 2 interns each cared for — 4 interns’ worth of patients for 1 intern overnight. It was scary; though the patient had information from each of the interns regarding what to look out for overnight, and of course he was only responsible for responding to immediate concerns and not directing the overall course of patient care, he was very unfamiliar with each of the patients’ histories and hospital courses and it was frightening when issues did arise. He was also responsible for admitting patients overnight, which would then immediately be handed off to another intern in the morning as he had to go home due to the work restriction hours. It was a terrible system.

    Having said all of that, the work hour restrictions are definitely not the only cause of poor communication among teams and during transitions, and you’re absolutely right that we as (future) members of the medical community need to work to improve communication during transitions. But it is undeniable that there is a certain amount of difficulty inherent in transfer of care, and that reduced work hours contribute to an increased number of transitions.

    Thanks very much for an interesting article!

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