The controversial decision ends the latest phase in a decades-old discussion over how to balance physician training with the safety and needs of patients whose care is sometimes handled by young, sleep-deprived doctors — a practice that a consumer group and a medical students' organization oppose as dangerous. The council said Friday that under the amended standards, the physicians’ mental and physical health actually will be bolstered by requiring their supervisors to more closely monitor their well-being.
Those standards will allow four hours to transition patients from one doctor to the next, so first-year residents could work as long as 28 straight hours, the same as more senior medical residents. The 125,000 doctors in training, known as “residents” and “fellows” depending on how many years they’ve completed, are the backbone of staffs at about 800 hospitals across the country, from large medical centers to smaller community facilities.
“What we want is to be able to say at the end of residency that we have a physician who is highly trained and is ready to go out into practice,” said Rowen K. Zetterman, co-chairman of a task force that spent two years looking into the issue. Zetterman noted that many doctors work 65 to 70 hours a week for much of their careers.
Following a study of patient safety and work rules by the Institute of Medicine, the accreditation council imposed the cap on first-year residents’ hours in 2011 and banned 30-hour shifts that some residents had been working. A later study of surgical trainees showed that many young physicians are willing to work longer shifts to hone their knowledge and skills and that the extra hours do not affect patient outcomes. Supervisors who set up hospital staffing have complained that more frequent handoffs harm patient care.
But one consumer group, which has opposed lifting the cap every step of the way, rejected the rationale for Friday’s announcement. Michael Carome, a doctor who heads Public Citizen’s health research group, called the move “a dangerous step backwards.”
“We know from extensive research, multiple studies, that sleep-deprived residents are a danger to themselves, their patients and the public,” Carome said. Sleep-deprived residents are at greater risk of car accidents, needle-stick injuries and depression, the organization contends. In recent years, the medical profession has acknowledged the high rate of burnout and depression among physicians overall.
A nationwide poll commissioned by Public Citizen last July found that 86 percent of respondents opposed the longer hours for first-year residents. Eighty percent wanted their more senior colleagues to work shorter shifts as well.
Yet Anai Kothari, a third-year surgical resident who served on the council’s task force, said the current arrangement forced him to miss critical moments with his patients during his first year of training, when he was forced to go home.
The 16-hour limit created “this artificial divide between upper-level and the new residents that are coming in,” said Kothari, who works at Loyola University Medical Center in Chicago. “It really does fracture the team. That impacts patient safety certainly, but it also really affects how you’re educated.”
Other work rules were retained in the council’s latest review. Residents are not allowed to work more than an average of 80 hours weekly, must have one day off every seven days and cannot work overnight in the hospital more than one night in three.
The new standards require hospitals and residency programs to give residents time off for their own physical and mental health appointments. The institutions also must provide ways to foster young doctors’ well-being, fight burnout and mitigate fatigue. Previously, doctors were forced to find some way to steal a few hours of rest on their own.
Zetterman said that when he was training, “I don’t know that anyone ever thought about whether we were physically well or mentally well.”
For patients, the policies emphasize a team approach to care that helps ease the burden on the first-year physicians.