Doctors fear work caps for residents may be bad medicine

The workload of medical residents has long stoked controversy, especially since 2003, when they were capped for the first time to an average of 80 work hours a week to reduce fatigue and errors. Now that cap could be tightened to 60 hours.
By Ian Shapira
Washington Post Staff Writer
Thursday, March 18, 2010

A few months ago, Glen Silas, 40, an obstetrics and gynecology doctor at George Washington University Hospital, wanted a young resident to observe a sophisticated procedure in which a renowned laparoscopic surgeon was operating on a uterine tumor. Silas was certain the resident would eagerly embrace the opportunity.

But as doctors gathered in the staging area, the resident declined, telling Silas, "I am at the end of my shift anyhow, so I will see it another time."

"Even those at the attending level still learn from this surgeon, so for a resident to say that . . . is a special thing," Silas said. "I just told the resident, 'Wow. That is disappointing that the restrictions on your hours keep you from participating.' I don't even think I got a response."

Since 2003, when an 80-hour-a-week cap was placed on the nation's medical residents, many older physicians have worried that the next generation of doctors won't have seen enough patients and done enough procedures, even as residents continue to complain that working so many hours without sleep diminishes their ability to absorb lessons and avoid errors.

Now, the group that governs residency programs is considering even tighter limits, possibly down to 60 hours a week, leading some older doctors to argue that constant baton-passing by shifts of residents can disrupt patient care.

The changing shape of medicine's boot camp has fostered a generational tension between baby boomers and Generation-Xers, who trained in an era of 36-hour shifts and 120-hour workweeks, and millennials, the young doctors who have come up in a time of heightened concern about the impact of marathon work shifts.

"We hear about it all the time from attending physicians," said Xiaomang Ba, 29, an OB-GYN resident at George Washington. "They just say, 'Ignore your family for the entire weekend.' It sounded like people didn't really have a life [under the old rules]. It's all joking, 'Oh, you guys have it so cush. . . . I can stay awake for 40 hours straight, can you?' But once you go past a certain number of hours, you stop learning."

Under the existing work limits, some residents say they feel as if they are sneaking around if they stay late to observe an interesting operation. Rachel Seay, 29, a George Washington first-year resident, said she usually works 70 to 75 hours a week but sometimes stays beyond her shift to take part in procedures involving fetal abnormalities.

Someone will ask, " 'Aren't you supposed to go home?' and you say, 'I am not here,' " Seay said.

The issue of work hours can be so sensitive for fourth-year medical students, who find out in Thursday's annual "Match Day" ritual where they will serve their residencies, that they can be reluctant to ask about it in job interviews. Not one of the 90 candidates for George Washington's OB-GYN residency this year dared to mention duty hour limits, said Nancy Gaba, the school's OB-GYN residency program director.

Gaba said young doctors seem hesitant about diving in to the intense life of a resident. "You used to work 120 hours a week," she said. "Now you get a different kind of person. They're somewhat protected; the lifestyle has changed. These poor residents are in the middle of two competing [realities]: If you're fatigued, you're not taking good care of patients, but you're also not learning anything."

Doctors and patients also worry that shorter hours mean that patients will see a longer procession of doctors and, thus, that there will be more opportunity for errors. On Friday morning inside GWU's labor and delivery unit, Elizabeth Gray walked the halls with her husband, nervously hoping that her baby would be delivered by Seay, the first-year OB-GYN whose shift was to end Saturday morning.

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