Medical resident work hours refers to the (often lengthy) shifts worked by medical interns and residents during their medical residency.
As per the rules of the Accreditation Council for Graduate Medical Education in the United States of America, residents are allowed to work a maximum of 80 hours a week averaged over a 4-week period. Residents work 40–80 hours a week depending on specialty and rotation within the specialty, with residents occasionally logging 136 (out of 168) hours in a week. Some studies show that about 40% of this work is not direct patient care, but ancillary care, such as paperwork. Trainee doctors are often not paid on an hourly basis, but on a fixed salary; in some locations, they are paid for booked overtime. Limits on working hours have led to misreporting, where the resident works more hours than they record.
Medical resident work hours have become a hot topic of discussion due to the potential negative results of sleep deprivation on both residents and their patients. According to a study of 4,510 obstetric-gynecologic residents, 71.3% reported sleeping less than 3 hours while on night call.
In a survey of 3,604 first- and second-year residents, 20% reported sleeping an average of 5 hours or less per night, and 66% averaged 6 hours or less per night.
In a recent landmark study published in May 2021, the World Health Organization and the International Labour Organization estimated that globally in 2016, more than 745,000 persons died as a result of having a heart disease event or a stroke attributable to having worked long hours (here defined as 55 or more hours per week), making exposure to long working hours the occupational risk factor with the largest disease burden.
Causes of high workloads Medical residencies usually require lengthy hours of trainees. Trainees are traditionally required to be present for set shifts, with the ending time of the shift dependent on momentary circumstances. The flexibility of this system makes it easy to abuse.
Junior doctors often lack bargaining power and have difficulty changing employers. This leaves them with little say over their working conditions. Critics of long residency hours note that resident physicians in the US have no alternatives to the position that they are matched to, meaning residents must accept all conditions of employment, including very long work hours, and that they must also, in many cases, contend with poor supervision. This process, they contend, reduces the competitive pressures on hospitals, resulting in low salaries and long, unsafe work hours. The National Resident Matching Program has also been accused of deliberately limiting the available residency posts, thus decreasing the demand for residents, despite work for many more residents being available.
In emergencies and in chronically understaffed health systems, all staff, including junior doctors, may be overworked. In some cases, excess work may be disproportionately assigned to junior doctors.
There are financial incentives for overworking junior doctors. Since the least-experienced staff are usually paid less, it is cheaper to assign paid overtime to them. Deliberate understaffing and paid or unpaid overtime for junior doctors is thus used to reduce costs for medical facilities, although this may also reduce quality of care, which can be expensive.
The medical culture has also been blamed. "Generation-bashing", where senior doctors look down on junior doctors who work fewer residency hours than they did, can push junior doctors to overwork. A desire for formal recognition, such as promotion, may also be important. A higher "entry barrier", with work conditions poor enough to burn out some residents, may be actively desired.
There is also a belief that long hours do, or can, improve training. The ability to follow a patient from admission through the next 30 or 40 hours may be valued more than observing several patients for shorter periods.
The desire to continue caring for a patient frequently leads doctors to work for longer than is permitted.
Effects on health
Effects of sleep deprivation on residents The evidence for harm to people who are deprived of sleep, or work irregular hours, is robust.
Research from Europe and the United States on nonstandard work hours and sleep deprivation found that late-hour workers are subject to higher risks of gastrointestinal disorders, cardiovascular disease, breast cancer, miscarriage, preterm birth, and low birth weight of their newborns. It has also been shown that slow-wave sleep assists in clearing out toxins that build up during the day. Consequently, the disruption of slow-wave sleep increases the level of amyloid-beta, a protein aggregate commonly found in Alzheimer's, present in cerebrospinal fluid the following morning. Chronic sleep deprivation and the resulting fatigue and stress can affect job productivity and the incidence of workplace accidents. There are also social effects. Married fathers in the United States who work fixed night shifts are 6 times more likely than their counterparts who work days to face divorce; for married mothers, fixed nights increase the odds by a factor of 3.
Effects of resident sleep deprivation on patients The public and the medical education establishment recognize that long hours can be counter-productive, since sleep deprivation increases rates of medical errors and affects attention and working memory. Chronically sleep-deprived people also tend to strongly underestimate their degree of impairment. A study found that after 24 hours of sustained wakefulness, hand-eye coordination decreased to a level equal to the performance observed at a blood alcohol concentration of roughly 0.10%. In a meta-analysis of 959 physicians, staying awake for a continuous 24 to 30 hours decreased physicians' overall performance by nearly 1 standard deviation and clinical performance by more than 1.5 standard deviations.
Competence is affected by the number of work hours, number of continuous work hours, regularity of sleep, and frequency and speed of handovers to the next shift. "Night float" seems to have particularly bad effects, due to the circadian misalignment cause by abrupt switches between day and night shifts, but is the most commonly used method of adapting to duty hour restrictions.
Many studies have found performance impairment in medical residents due to sleep deprivation. The average sleep time was less for the same emergency department residents working night shifts than when working day shifts, and they took longer to intubate a mannequin and made more errors in a triage simulation when working on the night shift than the day shift. First year medical residents given an EKG arrhythmia-detection task performed significantly worse while sleep-deprived than when well-rested. Medical residents were also found to take more time and make more errors on laparoscopic procedures after one night on call.
A 2004 landmark study found reducing sleep deprivation substantially reduced errors in intensive care units. The study redesigned first-year junior doctors' schedules to minimize the effects of sleep deprivation, circadian disruption, and handover problems, assigning four shifts where there had been three and allowing an hour's overlap for handovers at the ends of shifts. Each junior doctor was closely observed under both schedules. Errors were recorded (and corrected); they were then rated for severity by other doctors blinded to which treatment the errors had occurred under. Doctors and observers inevitably knew that they were part of a study.
In 2015 two controlled studies of the effect of the ACGME-mandated maximum shift began, involving nearly 190 hospitals and residency training programs. The studies randomly assigned medical residents to shifts longer than specified by the ACGME regulations. A study led by the University of Pennsylvania, which will end in 2019, assigned residents in 32 medical training programs to shifts as long as 30 hours. It used 31 other programs as a control group. Despite the longer shifts, the other overall rules were still adhered to. The other study, led by Northwestern University and ending in 2015, was similar in design. Both were conducted with the approval of the ACGME. In neither study were residents and patients necessarily told they were part of a human subjects experiment and informed consent was not required, which caused some controversy.
Duty hour restrictions Effects of duty hour restrictions Regulatory duty hour restrictions, in theory, should reduce the number of duty hours worked. In practice, they may not because the restrictions are not always followed. Studies to evaluate the effects of duty hour restrictions on patient outcomes have been somewhat mixed.
Many of the studies rely on self-reported hours, self-reported errors, and self-reported sleep deprivation, with large opportunities for bias. More objective measures, such as tracking, perceptual tests, and blood hormone levels, are generally not used. Measurements of patient deaths and harm are often used as response variables. Many of the studies that have been done on this topic are specialty specific and so cannot be generalized to all medical residency programs.
Observations on the ACGME restrictions in US The 2003 working-hour restrictions imposed in the US by the ACGME allowed many studies comparing patient outcomes before and after the reforms. They generally show little effect. This corresponds to the impressions of medical staff.
One 2014 systematic review of 135 studies spanning 1980 to 2013 showed no overall improvement in patient safety but still indicated that duty hour restrictions have increased morbidity in some cases.
Another systematic review of 27 studies conducted in 2015 found similar results, and a 2007 study of over 8 million hospital admissions of Medicare beneficiaries that compared mortality rate before and after implementation of the ACGME standards showed no difference in mortality.
2003 reform One study of 318,636 patients done in a Veterans Administration setting showed that work hour restrictions reduced mortality substantially for a similar set of diagnoses.
Another study found that the 2003 ACGME reform restrictions were associated with a small reduction in the relative risk for death in 1,268,738 non-surgical patients drawn from a national survey of hospitals.
2011 reform When surveyed about duty hour restrictions, both medical and surgical residents, as well as residency faculty perceive that patient safety hasn't changed or has suffered as a result. Additionally, many residents note an increase in self-reported errors.
Problems with duty hour restrictions It is largely felt that actual duty hours (opposed to reported duty hours) have not changed substantially: prior to the implementation of work hour regulations, residents were already working an average of 82 hours per week. Many studies rely on self-reported hours, but significant bias to under-report duty hours exists for a few important reasons: One is that statutes do not provide whistleblower protections to residents who report work hour violations. Second, the penalty for work hour violation is loss of accreditation, which would adversely affect medical residents and prevent them from becoming board certified. Finally, some residents may be pressured by their residency programs to underreport hours or even punished if they do not.
Moreover, these studies – particularly the ones that find favorable results - may fail to account for confounders that positively impact outcomes, including the wide adoption of electronic medical records, a shift toward team-based care, and implementation of best practices.