Why are we as a system so slow to accept that young doctors are being worked beyond necessity, and even beyond benefit?
I’ll admit it was hard to stay awake. Our lecturer was one of the world’s foremost experts on sleep disorders, but as he delved deeper into the physiologic effects of poor sleep, my eyelids only felt heavier. We, the audience, were interns (first year doctors) from across all specialties training at two of Boston’s top academic medical centers. We were gathered on an early morning for our annual “Wellness Retreat,” a well intentioned half-day program during which we would be taught (in theory) how to live more balanced lives during residency. At one point, the lecturer acknowledged the irony of it all—lecturing to sleepy interns about how to sleep better, and expecting them to be awake to learn how to do so.
As the professor wrapped up his final slide, turning to the room for any questions, one person’s hand shot up almost reflexively. He stood up, tall and confident, with the demeanor of a fearless and straight-shooting surgeon (which it turned out he was), and loudly asked, “Why do we get these lectures?! If you want us to sleep better, then give us more time to sleep! If you want us to exercise, then give us time to go to the gym!” The previously drowsy crowd had now awakened, taken aback by the unusual audacity from a fellow intern (we are, after all, at the bottom of the physician totem pole). Many in the room began to clap and nod because the sentiment felt all too true. I was proud he had said something, yet disappointed that we work in a system that led to that point.
How long should doctors be working? This question has been at the center of debate for many years in the United States. Last month some of the results of the iCOMPARE trial were published in the New England Journal of Medicine, and they were both surprising in ways, and expected in others.
This study was a much anticipated investigation into whether imposing a limit on the maximum number of hours a resident can work would have a positive or negative impact on numerous outcomes, including patient safety, educational experiences for trainees, and overall wellbeing for doctors, specifically among those in internal medicine residency programs. The study compared hospitals that were assigned to use standard duty hour regulations with hospitals that had more lenient regulations. The standard duty hour regulations stipulated that first year residents could not be made to work more than 16 hour shifts at a time, and second years and beyond no more than 24 hours. Both groups had a limit of working no more than 320 hours per month, but in the liberal regulations group, there was no limit on how long a shift could be, and no minimum requirement on the number of hours off between shifts. More broadly, the study aimed to help inform the duty hour requirements the ACGME sets.
The worry with strict duty hours is that critical tasks may remain unfinished, or handed off to the next resident who isn’t as familiar with the patient, potentially increasing the risk of error. Patients may also not appreciate having multiple different doctors taking care of them. The comparative issue with liberal duty hours is that allowing (or requiring) residents to work longer shifts will make them more tired and compromise their ability to function properly, increasing the risk of harm to patients and to residents themselves.
The iCOMPARE trial found no differences in the amount of time dedicated to direct patient care, and no difference in standardized test scores (a proxy for physician knowledge base). However, interns in the group with longer working hours expressed significantly more dissatisfaction with their jobs, morale, personal lives, personal health, and their educational experiences. Program directors, on the other hand, were more satisfied with their perception of the learning environment (interns’ ownership of patient care, intern morale, time for reflection and feedback, continuity of patient care, and other educational opportunities) in the group that had unregulated duty hours.
While outcomes for patient safety will likely not be available for another year, a similar study in 2016 examined strict versus liberal duty hours among surgical residents. That study found no significant differences in either group with regard to patient safety, but also found more dissatisfaction in terms of residents’ perception of their personal lives in the group that was allowed to work longer shifts with fewer regulations. As with any study, there are biases and alternative possible explanations. For instance, only 45% of participants in the iCOMPARE trial completed end of year surveys, so it is possible that the interns who were dissatisfied with their experience were more likely to respond.
As an intern now over halfway through my first year of training, I have found it immensely gratifying to work in a hospital where I know what time I will be going home, give or take an hour or so. Having a more fixed schedule means I can plan a Skype call or dinner with my loved ones, or make it out for drinks with friends on occasion. I can say that having the time to have a life outside of the hospital makes me feel like a more enthusiastic, thoughtful, and caring doctor. Feeling like my residency program cares about my wellbeing is inherently empowering. It makes me want to come to work, and it allows me time to think critically about my patients without the constant stress of the hospital. I often find myself reading medical cases and new research articles in my spare time, and rethinking my patients’ cases with new eyes.
The big question remains: are patients less safe because of doctors having better schedules? While the safety data is pending for internal medicine residents, we already have the numbers to prove that safety is not compromised among surgical residents. I am not shy to admit that handing off a patient to another doctor is a tough thing to do—but that means we should get better at doing it, not shy away from the changing nature of the medical workplace. As an example, the I-PASS study showed that standardizing handoffs between shifts significantly reduced medical errors.
Furthermore, we have studies showing that sleep deprivation beyond 19 hours of straight work begins to mirror the cognitive effects of having a blood alcohol content of 0.1.%—beyond the legal driving limit in the US. If anything, the iCOMPARE safety results may show the opposite—that longer shifts make errors more common.
We know that unregulated duty hours that allow young doctors to work for more than 24 hours at a time, sometimes for weeks straight without a day off, are not good for us. They offer no educational advantages, and at least among surgical residents, they are no better in terms of the safety of patients. With this in mind, why are we as a system so slow to accept that young doctors are being worked beyond necessity, and even beyond benefit? I can’t help but wonder how much of the stance from program directors is related to a “we had it worse than you” mentality; I know I have certainly heard those sentiments voiced before.
It is time our residency leaders take notice and introspect on why they continue to feel strongly about longer shifts with shorter breaks, because we as young doctors are the revving engines of most academic hospitals, and we are tiring out.
Abraar Karan is an internal medicine resident at the Brigham and Women’s Hospital/ Harvard Medical School. Twitter:@AbraarKaran.
Competing interests: None declared.