Medical residents work long hours despite rules

To reduce errors by doctors in training, medical educators have capped how long they can work. But enforcing the limits can be a challenge.

More than 10 years after she was a internal medicine resident, Dr. Vineet Arora still thinks about how her shifts used to end.

She says the best shift change was one that didn’t require her to transfer single patient to the next bunch of residents. “A good sign out was ‘nothing to do,’ ” she recalls. “When I trained, you worked here until your work was done.”

But things have changed a lot since then. Now, Arora is the associate director of the University of Chicago’s internal medicine residency program. And the residents she supervises aren’t allowed to work indefinitely long shifts.

Rules implemented nationally in 2003, and tightened last year, put a hard cap on the length of residents’ shifts: no more than 16 hours for first-year residents or interns, and no more than 28 hours in one shift for others.

The rules came down from the Accreditation Council for Graduate Medical Education, which was responding to a series of front page headlines about overworked residents and interns making life-threatening mistakes. The most famous of these was the Libby Zion case, in which an 18-year-old died at New York Hospital in 1984 while under the care of a first-year resident working a 36-hour shift.

 

 

New Rules On Medical Residents’ Hours Spur Debate

 

While the rules may have changed, the situation inside many hospitals hasn’t budged as much as you might have expected.

A 2008 study of three hospitals found that 87 percent of interns reported working past their shift limits. Two other studies, from 2006 and 2010, found that doctors routinely lie when reporting the number of hours they worked to get around the shift restrictions.

In a commentary in this week’s JAMA, the Journal of the American Medical Association, Arora argues that flouting of the rules can be dangerous.

Working too long without a break and without sleep can lead to more errors, she says. Another study published in this week’s JAMA found that interns who weren’t given a break between shifts of at least five hours slept an average of less than two hours a night. Interns who slept longer were significantly more alert the next day.

Beyond patient safety, Arora says working extra hours on the sly raises ethical issues. “If you lie about your hours, are you more likely to lie about other things?” she tells Shots. “You’ve already engaged in misdocumentation.”

Arora says the reasons why this happens lie deep in hospitals’ work culture. She says some doctors who did their residencies before the new shift rules went into effect look down on new residents — something Arora calls “generation bashing.”

Residents can pick up on this and, as a result, feel the need to work longer hours and fudge their time sheets to impress their more senior colleagues.

“In our program, we let our residents know that we don’t want them to stay,” Arora says. The rules on shift length “are not going away. Engaging in generation bashing is counterproductive.”

Dr. Joanne Conroy, the chief health care officer at the Association of American Medical Colleges, says the new rules on work hours are not at odds with the longstanding principle of medical professionalism. “Nobody would actually want residents to not feel accountable and responsible for their patients,” she says. But “that requires that they be rested and that they be ready.”

 

 

 

Some vocabulary: 

-Bunch: Group, team

-Cap: Cover, plug

-Spur: Stimulate, encourage

-Budge: Move, assign

-Flouting: Disobeying

-On the sly: Secretly

-Bashing: beating, whipping, thrashing

-Fudge: Avoid

 

I consider this article could be interesting for us because in a few years we’ll be residents in a hospital. We know that when we’ll be residents we’ll do too many hours and many shifts, and more or less we accept that because it has been done for ages. But nowadays there have been some changes to improve the quality of life of the residents while they are doing the residence. I think that these changes are necessary because it could provide more efficiency and fewer mistakes. If a resident didn’t sleep a required number of hours or was awake too many hours, there would be more probabilities that the resident could cause some mistakes which could have been avoided.

However, there are some doctors who don’t agree with that because they say that the residence is a period of time where residents learn a lot, and if they do less hours, they will learn less. On the other hand, some doctors say that residents should work in suitable conditions to prescribe the right things, because it is known that many mistakes have been done by residents who were working many hours without any break.

So as you see, there are too many opinions about this item and I’d like to know what you think about that; and also I’d like to know if you think that the system of our country is a good one, and if not, what you would do to improve it.

 

SANDRA SORIANO SÁNCHEZ

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7 respuestas a Medical residents work long hours despite rules

  1. Belén Leal Mora dijo:

    I consider this article Sandra has found to be very interesting just because this is an extremely important issue to deal although people do not pay so much attention to it. As Sandra has already said, we are going to start our residency in the near future and therefore we are becoming the next to be affected by these broken rules; this is the reason that the information Dr. Vineet Arora provides us in this text is completely useful for us.
    Firstly, it is certain that, as some doctors state, the period of time doing the residency is when this team of future doctors learn the most. Nevertheless, it is well-known that a person who does not rest nor sleep for many hours, and he or she is also completely tired from working all day, cannot learn as well as a person who is rested and bright.
    In addition to this, there are some studies which declare that during the years of clinical or surgical specialty, a resident suffers from higher levels of stress than the rest of the population, and we are well aware that a person under high levels of pressure at least can’t think and act in the same way as others who are calm and are not constantly working under stressful situations. This is the reason why doctors in training, althoug they must acquire a deep knowledge and work experience, they must have enough time to disconnect from the hospital. Therefore, I think wether there is a list of rules based on an appropriate schedule for residents, it must be accomplished for both of them: medical residents and medical educators.
    Secondly, in response to Sandra’s question, I feel the existing system in our country is similar to United States of America’s system, based on much more hours of work than it is established. Nonetheless, a group of spanish residents started complaining about this issue in 2007, trying to come to an agreement with health autorities, just saying they were not able to operate nor make a correct diagnosis after working for more than twenty-four hours with non-stop. I obviously consider this first initiative to be the main step to change it for the better.

  2. MARTA SOJO ELIAS dijo:

    In my opinion this new law, which doesn’t allow to work for more than 16 hours for first-year residents, is great, specially with new interns, which aren’t used to sleep so few hours and because of that they could make important mistakes and ruin their careers.

    On the other hand, I think the system of our country is a good one, but of course it can be improved. It depends on the attached doctor you have, because some of them leave you working and while they rest you have to do his/her work, they only supervise expecting you would do a brilliant work and if not they scold you. Other doctors try to explain and teach everything to you and make sure you understand and memorize the important ideas, so that you can not make big mistakes.

    The only ideas I can think of to improve our sanitary system are to propose something similiar to the law of the article about limited work hours, and offering a course about the most common mistakes residents have, because I think we can learn of our errors.

  3. Ana Narbona dijo:

    I have like to read this information very much. It is a comfort to know that some improvements are being done. As futures residents any changes are important but reading that those changes are positive is just great.
    I have always been aware and worried about how many hours a doctor may work without resting. For me it is something scary, I know myself and how I need to rest well at night or I will be doing silly mistakes all day long as well as I get this annoying dizziness and slowness of brain when I’m exhausted. My major worry about the future residence is not been able of proper work due to being too tired. Because of all that I’m extremely glad to read that some changes are being done in United States and I hope that soon there will be similar changes in Spain.
    ANA NARBONA DIEZ

  4. Carolina Pérez Benito dijo:

    This article, from my point of view, is the most interesting article than we have commented. Not only important for us but also for the patient. In a few years, we will all be residents.
    Working in a hospital is tiring and require being fully attentive. A full shift respecting the hours to be worked is no more stressful as a shift of more than 16 hours or even 24, 36 hour.

    Nowadays is true that health personnel have been cut out, that means that fewer physicians for more number of patients. But we’re talking 36horas work shifts, stressful, which can threaten the patient’s life. The job of any health requires concentration, knowing what you are doing.
    It is important and necessary to get the sleep you need to stay awake. Not the first or last time we hear a new on TV about a person who works in a hospital make a mistake due to fatigue.

    Years ago shifts were long and only you finished the work when no patients. It is not working last longer, but do the job well done, concentrate, knowing what you are doing and dedicating the time necessary for each patient.

    I think that is a very interesting article, important for all of us because in a few years this information could we help when we treated patients. It is important to know our limits, human limits, to avoid mistakes on the lives of our patients.

  5. IRIS LUENGO ARROYO dijo:

    It is obvious the importance of enough hours of sleeping and resting. But what about the work that has to be done? Some times doctors have duties that they cannot put in second place. You can’t go home although your shift is already finished, if you still have patients requiring your attention. Therefore, I understand the necessity of a break but it can be difficult to get that free time for doctors, specially young doctors who maybe have to work longer hours to make them respectable.

    Another important point is the fact of competitiveness. If your colleagues are doing more hours than you, the chief may be happier with them. So sleeping more than the others can be detrimental to you in order to get a job in the future.

    In Spain, after being on duty (a shift of 24 hours), doctors go home and don’t have to work the day after. That is, in my opinion, essential for an optimum medical assitance. In fact, that may be one of the points that make our National Health System so effective and remarkable.

  6. BELÉN ZAPATA dijo:

    My comment is focused on this question: should residents be forced to do a specific amount of work? Should they work more or less? In my opinion, patients go first. If there are studies which prove that residents who work many hours aren’t as productive as others, and may put their patients in danger, it’s reasonable to establish some limits. A neurologist explained to us in class that sleeping just a few hours affects your cognitive function. But I understand the people who complain about not having enough time of training as well. A possible solution would be to extend the residence a year more, as long as we get paid!

    As Dr. Lucian Leape says, “There’s very little evidence that more hours are better, and there’s a lot of evidence that it’s harmful to patients and residents”.

    BELÉN ZAPATA QUINTELA

  7. CRISTINA dijo:

    I think that this article is very interesting for us because in a few years we will be residents. I think that the measure proposed in the article is a good initiative, because logically if you are working 48 hours straight, without a rest, you won´t be able to work properly and it´s more probable that you can commit an error.
    On the one hand, it´s true that when you are a resident you have to learn and spend a lot of time in the hospital, doing a lot of job and too many shifts On the other hand, a lot of studies demonstrates that when a person spend a lot of time working, it becomes counterproductive. So, I think that it should be a balance between the time you spend in the hospital and the time you are productive.
    When you are resident you have to learn and you can be a help for the doctors, but you don´t have to do their work, and this is very common. In my opinion, all the hospitals must have the same number of hours for the residents and it has to be regulated .

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