A year ago, the Accreditation Council for Graduate Medical Education (ACGME) changed the rules governing the schedules of medical residents. The new work hours were intended to curb resident fatigue, which the Institute of Medicine (IOM) had previously concluded was contributing to medical errors and accidents. But the new duty hours have actually exacerbated fatigue, jeopardized resident education, and endangered patient care at our nation’s teaching hospitals.
Up until the current guidelines took effect in July of 2011, medical residents could work up to 80 hours per week and 30 hours continuously. The new rules, while maintaining the 80-hour schedule, have limited the maximum shift for first-year residents to 16 hours. Senior residents may work 28 hours straight.
Research published in the New England Journal of Medicine highlights that these mandates have failed to achieve what they were intended to. The study’s authors contacted every institution in the country that sponsors an ACGME-accredited residency program, and ultimately 6,202 residents at 123 different institutions completed a twelve-question survey. Of those surveyed, 43 percent indicated that resident work schedules had actually worsened, and 50 percent said that quality of life for senior residents had deteriorated, compared with 30 and 14 percent, respectively, who noted improvement in these areas. Forty-one percent of residents believed that the new guidelines have worsened their education, while only 16 percent believed the changes have benefited resident learning. The survey also indicated that some residents were concerned that patient care was suffering. Overall, 48 percent of residents disapproved of the changes, with only 23 percent approving.
At first blush, these findings may seem counterintuitive, but upon closer inspection, they make perfect sense. Residency programs still have the same number of workers with the same collective responsibilities, but the first-year residents are more limited in the shifts they may work. Consequently, second-year residents and above are increasingly given the most grueling schedules.
Before the changes went into effect, the first year of residency was very physically demanding — but as residents entered senior roles and took on more responsibility, the physical burden subsided in exchange for the intellectual challenge of managing sick patients with complicated problems. The reduction in physical stress granted the senior house staff time to think, read, and learn from patients.
The new duty hours have turned this commonsense approach to residency on its head. Now the residents with the most clinical responsibility are also the most physically taxed. As a result of the new work-hour mandates, senior residents are substantially more fatigued and have significantly less time and energy to read and learn from their patients. This does not just hurt the quality of resident training. It’s actually dangerous.
Medical residents currently care for the sickest and poorest patients. These mandates are impeding their ability to offer the best care. And by compromising the education and training of young doctors, these duty hours could jeopardize the quality of medical treatments provided to all patients.
The goal of these new regulations was to improve patient care, education, and quality of life for residents. As a resident working under this new regimen, I know that it has substantially missed the mark on all three parameters. The ACGME should revert to the old work-hour structure until a more practical and sustainable solution can be reached. If it fails to take the initiative to do this, then Congress and the Department of Health and Human Services should consider stepping in.
Resident fatigue is a real problem — patients should be protected from tired, overworked residents. But the ACGME’s cure is worse than the disease.
— Jason D. Fodeman, M.D., is an internal-medicine resident and a senior fellow in health-care studies at the Pacific Research Institute.