How many hours does it take to sufficiently train a clinician?
For much of the twentieth century, absurdly long working hours were a hallmark of residency in the United States. This arrangement largely existed outside of the realm of public consciousness until the mid-1980s before a catalytic event occurred: a college freshman, Libby Zion, died at New York Hospital while under the care of two overworked residents. Through the efforts of her father, the journalist Sydney Zion, the public soon came to learn that doctors-in-training routinely made clinical decisions in the midst of brutally long shifts with little or no sleep.
In response to her death, New York adopted the Bell regulations in 1989, which limited residents to 80-hour work weeks and capped the length of individual shifts to no more than 24 hours. In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) followed suit, implementing the duty hour restrictions nationwide.
It should be pointed out, however, that the ACGME’s primary aim in adopting the resident duty hour restrictions was not to reduce resident working hours. Rather than viewing long working hours as a threat to the public health that should be curtailed, the ACGME sees them as an essential component of a future clinician’s training. “Long hours,” as stated on its website, “are a component of medical residency and preparation for an occupation that requires hard work and dedication.”
Then why did the ACGME adopt duty hour limits? The ACGME website explains that in 2003, “with the threat of federal legislation to place a limit on resident hours, it was important to create common standards, while emphasizing that accreditation offers greater flexibility and sensitivity to specialty considerations than regulatory or legislative approaches.”
So, there it is: The threat of federal legislation is what finally forced the ACGME’s hand to do the right thing. Once the threat was removed and the glare of the public was diverted, critics of the new rules pounced. In an ironic twist, they began to argue that shorter resident work hours, instead of longer ones, were the actual threat to patient well-being.
Why is that? There is evidence that the duty hour reforms have been broadly successful in reducing resident work hours. A 2010 study in JAMA that examines population survey data between 1976 and 2008 derived from the U.S. Census Bureau had findings to support this claim. After steadily rising from 60.8 hours in 1976-1978 to 65.7 hours in 1996-1998, the average number of hours worked per week by American medical residents dropped 9.8% to 59.3 hours per week in 2006-2008.
The reduction of resident work hours has been a positive development for the profession. With American medicine already grappling with a devastating moral injury crisis, anything that can be done to help improve the lives of American clinician should be pursued wholeheartedly. A large body of evidence suggests that working longer hours breeds burnout. A recent burnout survey found that 57% of clinicians working greater than 71 hours per work reported burnout, compared to 36% of those working 31-40 hours per week.
Critics, however, have seized on these findings to point out that reduced working hours lead residents to see fewer patients. As a result, these commentators say, residents have less experience managing difficult cases, jeopardizing patient safety. This viewpoint is by no means isolated despite the reality that most sleep-deprived residents rarely gain much of anything from seeing another patient in their 100th hour of work in a week.
A 2007 study published in JAMA Surgery examines the views of all teaching faculty at a single academic center. Authors found that one-third of respondents believed that patient care worsened after the duty hour restrictions were implemented.
The results of a recent study published in BMJ directly challenge these persistent and misguided views. The study authors examined a variety of patient outcomes in a random sample of Medicare beneficiaries treated by an internist between 2000 and 2012. The study found that there was, in fact, no difference in patient mortality, patient readmissions, or inpatient spending among doctors trained before and after the ACGME’s duty hour rules came into effect. In an article published in the Harvard Business Review describing the results of the study, author Anupam Jana, MD, PhD concludes that an “80-hour work week seems sufficient for training a doctor.”
However, by focusing on internists the study left open the question of whether an 80-hour work week is sufficient to train doctors from other specialties like surgery, in which repetition is key to achieving good patient outcomes. Prior data has shown that high-volume surgeons tend to have better clinical outcomes. It is understandable then that many critics of the duty hour rules exist within the fields of surgery.
Yet most surgical residents will surprisingly agree that the ACGME duty hour restrictions should be loosened. To try to get a sense of why they hold such views, I recently discussed the issue with several of my surgical colleagues. Most of them, it turns out, felt that an 80-hour work week is insufficient.
“It’s the sheer volume of specialties you have to be decently proficient in,” one general surgery resident told me in a representative response. “Transplant, thoracic, colorectal, bariatrics, surgical oncology, breast, general surgery, trauma, pediatrics — you have to be good enough to run a service in all of these and have a certain number of cases in each specialty to graduate.”
After hearing a number of similar responses, I realized that the discussion about the sufficiency of the 80-hour work week in surgery was missing the point. Instead, the real problem is that modern surgical residency has become too complex. While there are certainly benefits to becoming familiar with a wide variety of surgical subspecialties, expectations set for graduating surgical residents still today are grossly excessive. Most attendings, it should be noted, specialize to some degree. Surgical residents should have some ability to do so, too.
No one, whether in medicine or not, should be expected to consistently exceed the ACGME’s duty hour restrictions. Requiring workers to toil 80 hours per week compromises their mental health, damages their physical health, and leaves them with less time to develop and maintain personal relationships. It is, simply put, inhumane.
If surgical residents believe that the current duty hour limitations do not allow for sufficient preparation to practice as an attending, perhaps the problem is not with the duty hours themselves. Rather, we should consider that the requirements of the job itself may simply be unrealistic. A broad rethinking of the surgical residency is urgently needed.
Kunal Sindhu, MD is a resident clinician in New York City. You can follow him on Twitter @sindhu_kunal.
Dr. Sindhu is a 2019-2020 Doximity Fellow.
Illustration by April Brust