Originally published in Synapse - The UCSF student newspaper, Feb. 18, 1999.
Fourth-year medical student Todd Whitehurst has initiated a process that could affect the way medicine is taught and practiced throughout San Francisco. His recently drafted “Patient Safety Initiative” would limit the number of hours that interns, residents, and medical students work to 72 per week.
It would restrict their shifts to 24 hours or less, except in case of emergency, and require eight hours off between shifts. In addition, it would legislate at least one 24-hour period off per week, and regulate the maximum “on-call” frequency to not more than once every three nights.
The initiative has been reviewed by lawyers, and Whitehurst will soon begin the process of collecting the 10,500 signatures necessary to put it on the next San Francisco ballot, where it will be presented to the voters. Whitehurst based the initiative on the “Libby Zion Regulations” currently in place in New York State.
Those limit housestaff to 80 work hours per week. They were passed in 1989, after the unexpected death in 1984 of Libby Zion, an 18-year-old girl whose father was a prominent New York journalist.
Agrand jury investigation into her death found that it was due in part to mistakes caused by the exhaustion and inadequate supervision of residents caring for her. A similar law, Assembly Bill 1199, was passed in California in 1992, but vetoed by then-governor Pete Wilson.
Despite the existence of such regulations in New York, compliance by hospitals there has been poor. In May, 1998, the New York State Health Department found 37% of residents were working more than 85 hours per week, and 77% of surgical residents worked more than 95 hours per week.
Whitehurst hopes to increase compliance by including larger fines for training programs found in violation.
Hospitals would pay $10,000 per day for their first violation of the year, $50,000 per day for the second, and no less than $500,000 per day for their third violation of the year. The New York regulations include a fine of only $5,000 per violation.
The proposed 72-hour limit, while less than the New York maximum of 80 hours per week, is not unusual. In the United Kingdom, New Zealand, Australia, and Quebec 72-hour maximum work weeks are the law.
It is likely that the European Union will soon adopt a similar limit. Whitehurst believes the initiative is necessary for both patient and housestaff wellbeing.
“The purpose of this law is to protect patients from overworked, exhausted residents. Being awake for over 24 hours is equivalent to having a blood alcohol concentration of 0.1% [see Nature, July 1997, ‘Fatigue, alcohol, and performance impairment’]. The legal limit for driving is 0.08%.”
When asked if 72 hours per week is enough to effectively train residents, Whitehurst added, “Yes, definitely. Currently, housestaff spends a lot of time on noneducational, ancillary tasks, such as patient transport, retrieving medical records, drawing blood, starting IVs, etc. This law would require hospitals to rely on other staff members to do the majority of that work. If the University has to hire more nurses or physicians to meet staffing needs, then they should.”
Moffitt Hospital OR nurse Brandon Horvath didn't mind this idea.
“I think it'd be fantastic. The only problem is nurses get paid more than medical students or residents, so I can see the University fighting that. Our department was around $11 million overbudget last year, so there is a budget crisis.”
Increased hospital costs are the most common argument against cutting residents’ hours. Other arguments include the idea that long hours are a rite of passage, that patients suffer when their care is transferred to a new shift of physicians, and that residents benefit by seeing a disease process evolve over several days.
Additionally, because residents need to do a certain number of procedures for licensing purposes, some fear that the duration of residency programs might need to be lengthened to allow them to complete the required number of procedures.
Supporters of working-hour limits respond to these concerns by citing study results showing increased number of physician errors after sleep deprivation.
They claim work limits would create more jobs for nurses and ancillary staff, decrease motor vehicle accidents caused by sleep-deprived housestaff, improve learning by giving housestaff time to study, and improve the mental health of housestaff (as many as 30% of whom suffer from depression, according to some studies).
While tradition holds that most attending physicians would oppose this type of legislation, an unscientific survey of those eating lunch in the Moffitt hospital cafeteria found them relatively sympathetic.
“The patients in the hospital today are much sicker than when I was a house officer,” remarked Professor of Radiology Roy Filly. “It's more grueling than it used to be. The discharge criteria for patients today [are the same as] the admission criteria of yesterday.”
An oncology attending who preferred to remain anonymous commented, “Nobody ever worried about me when I was a medical student. I did get awfully sleepy. Most of us
weren't married, so we could be on all the time We lived at the hospital.”
Professor of Urology Jack McAninch felt that residents in his service worked less than 72 hours a week already.
“Seventy-two hours is a lot of hours, then you expect them to study, and read and learn also.”
An anonymous anesthesiology attending was sympathetic as well, but added, “Many old school people would say we are pampering”
Whitehurst remarks, “Some attendings believe it's a rile of passage, 'I did it, we all did it, you have to do it.' I can't even comment on that. Let the voters decide if they would rather have residents who are tough enough to slay up for 48 hours, or whether they would rather have a doctor who got a good night's sleep.”
