Healthcare is a round-the-clock industry — hospitals must be staffed and prepared to handle medical emergencies and provide high-quality care for patients at all times. But the question about which physicians should be at the hospital and for how long has been long debated.
In 2003, the Accreditation Council for Graduate Medical Education required that residents not exceed 80 hours per week in the hospital, according to an article by Dhruv Khullar, MD, a resident physician at Boston-based Massachusetts General Hospital and Harvard Medical School, in The New York Times. In 2011, the ACGME restricted individual shifts for first-year residents to 16 hours. Since then, findings on the impact of the number and length of shifts per week on resident health, medical education and patient outcomes have been mixed.
Here are seven key thoughts on residents' schedules and their impacts from Dr. Khullar.
1. A recent experiment that aimed to compare the effects on residents who worked 16-hour shifts with those who worked 28-hour shifts or more was deemed unethical by advocacy groups, who argued the trial exposed patients to dangerously sleep-deprived physicians while exposing the residents to increased risk of car accidents, needlestick injuries and depression, according to Dr. Khullar.
2. These concerns were not unfounded, as a recent study found that nearly a third of residents show symptoms of depression, while other studies reveal that almost 10 percent of fourth-year medical students and 5 percent of first-year residents have experienced suicidal thoughts in the previous two weeks, with minorities experiencing even higher rates.
3. However, more restrictive work hours wouldn't necessarily strictly yield improvements for residents and patients. With shorter shifts, there are more patient handoffs, increasing the likelihood that important pieces of information regarding each patient's case are overlooked and diminishing the quality of the patient's relationships with his or her primary caretakers.
4. According to Dr. Khullar, the metrics used to assess the impact of work hour restrictions — such as mortality, procedural complications, adverse events and readmission rates — are "crude." "They might make sense for hospitals and health systems designed to increase efficiency and insulate patients from human fallibility," he wrote. "But they fail to capture the nuances of care delivered at the doctor-patient level. Good patient care is about more than surgical infection rates and medication errors. At the end of a long shift, am I the kind of doctor — and person — I want to be? Do I make time to sit with a suffering patient? Do I snap at a well-meaning colleague?"
5. Dr. Khullar points out people's judgment of happiness and overall life satisfaction is surprisingly fickle, suggesting if he were to describe a particularly bad 16-hour shift, he would likely rate it worse than an exceptionally good 30-hour shift.
6. Additionally, tighter hour restrictions reduce the number of patients residents can see per shift, thereby potentially limiting important educational experiences, according to Dr. Khullar. At the same time, residents spend a significant amount of time on nonclinical, administrative tasks. Better delegation of such tasks to other healthcare professionals and focusing residents' time on clinical educational opportunities can maximize the benefits of a shorter shift.
7. In the end, Dr. Khullar suggests, "The right answer on how many hours residents should work may be more nuanced than we've been willing to accept. It isn't the same today as it was 20 years ago, as the complexity of caring for patients and medical technology continue to evolve. It varies by subspecialty — discontinuity may have graver consequences for neurosurgery, say, than for radiology. And it hinges more on the character of work than the length of it — I'd spend twice as long at a patient's bedside if I could spend half as long at a computer."