Originally published in Synapse on May 25, 1989.
The eyes of medical professionals and legislators throughout the nation will be trained on New York this summer as unprecedented regulations limiting resident working hours begin to take effect. Starting on July 1, New York medical residents will be allowed to work no more than 80 hours per week and no more than 24 hours in a single shift. They will be required to take one day off per week and will be supervised around the clock by attending physicians.
The New York regulations stem from the widely publicized Libby Zion case. In March 1984, 18-year-old Zion was admitted to a hospital in New York with relatively minor complaints. She died a day later as a result of what a New York grand jury called “woefully inadequate” care by unsupervised interns and residents. The grand jury recommended that the number of consecutive hours worked by residents be limited.
New York is the only state actually to mandate limitations on residency hours, although legislatures in Massachusetts, Pennsylvania, Connecticut, Hawaii and California have all considered similar proposals in recent years. The California Board of Medical Quality Assurance (BMQA) is currently studying the potential economic impact of reducing residents’ hours.
New York’s new law may already be affecting the popularity of its residency programs according to Dr. Bill Plautz, family practice resident and vice president of the California Association of Interns and Residents (CAIR). “One of the things we’ve seen in New York this year,” he said, “is that a higher percentage of residency programs were filled than in years past.”
Few people would disagree that interns and residents face difficult working conditions. A recent article in the Journal of the American Medical Association (JAMA) reviewed studies involving a number of the major stressors experienced by interns and residents.
Sleep deprivation headed the top of the list
Most studies of sleep deprivation suggest that it does indeed have a deleterious effect on physician performance. One study cited significant increases in errors reading electrocardiograms among sleep-deprived interns; another found decreased mathematical abilities among residents who had gone without sleep.
Many interns and residents feel that they are not performing at their best when deprived of sleep. A recent BMQA study found that 67 percent of residents surveyed had witnessed inadequate care and that over half had actually given inadequate care due to fatigue.
“There have been days while driving home when I asked myself if I should be on the road,” said a fourth-year UCSF medical student “I felt I was endangering my life and the lives of those around me because I was so tired. I always checked and double checked my orders, but it was scary for me to think that nurses were [following] my orders when I was barely capable of driving a car.”
Among the additional stressors cited in the JAMA article were an increase in high technology equipment, high patient volume, unstructured teaching and limited training in ethics. Residency stress has previously been linked to alcohol and drug abuse, divorce and depression. Fifteen percent of first-year residents stated that they would not repeat the experience if they had known what it would be like.
But many medical experts disagree with limiting residents’ hours. They say that long hours are a necessary part of the learning process, and that patient care is not compromised.
“There is no doubt that there are times when residents are overworked. You get beyond the point of learning after a certain amount of fatigue,” said Dr. William Hamilton, professor of anesthesiology and vice dean of the UCSF School of Medicine.
“Put my own belief from lots and lots of personal observation is that there are few, if any, instances of bad patient care as a result of fatigue that wouldn’t have occurred anyway.”
Dr. Orlo Clark, professor of surgery and director of resident programs at UCSF, agrees.
“For critical decisions, people snap up and start thinking pretty fast.”
Most physicians and residents agree that there is no substitute for first-hand experience, and that this can mean losing sleep.
“If you’ve seen [a problem], it’s easy. If you haven’ t seen it, you may never know how to treat it,” Clark says. “You’re in trouble, and your patient’s in trouble. You can’t get it from the books; you have to be there.”
The depth of professional opposition to changes in residency hours is apparent in the actions of the Hospital Association of New York State. The group has filed lawsuits, pending in federal and state courts, to halt implementation of the reforms.
Still, even in the medical establishment there are signs of change. Standards regulating internal medicine resident hours will take effect nationwide this October. The new standards were put together by the residency review committee for internal medicine, a panel under the direction of the Accreditation Council for Graduate Medical Education.
Under the new rules internal medicine residents will be limited to an 80-hour work week averaged over four weeks. They also “should on average spend at least one day in seven free of hospital duties.”
In addition, the number of patients which an internal medicine resident can admit on a given day will be limited, as will the number of patients for whom he or she is providing ongoing care. Unlike the New York reforms, the internal medicine standards do not put a 24-hour limit on consecutive hours on duty.
Failure to comply with the new rules could affect the program’s accreditation status, unless compelling reasons for disregarding the standards are given, according to ACGME spokesman James Weinlader.
Critics fear that enforcement of the rules will be lax and penalties for failure to comply unlikely. Others see the new standards as evidence that the medical profession is capable of addressing the problem of residency hours from within.
In California there are currently no regulations involving house staff conditions. In 1986 the Legislature passed a bill that requires the BMQA to examine the cost of implementing regulations. This economic impact study is scheduled to be completed next February.
In the BMQA study, residency program directors and chief residents are going to be asked to present work schedules of residents at all levels. CAIR’s Plautz criticized this aspect of the report.
“They are going to ask our supervisors how many hours we work. We’re saying ‘you really ought to ask residents themselves,’“ he said, “[program directors] want to say that there’s not a problem because they don’t want anyone to think their residents work too many hours.”
Most experts agree that the cost of limiting resident working hours will be great, and many are looking to New York as an example of what the actual financial impact will be.
Currently, attention has been focused on limiting the number of duties a resident must perform. For example, a May 9 demonstration at UCSF demanded 24-hour phlebotomy teams. Hamilton objects to this.
“While starting IVs and drawing blood samples do constitute a real workload phlebotomy teams take experience away from a person who is here to get that experience,” he said.
Many physicians are concerned that inappropriate legislation may be pushed through due to public pressure. It is difficult, they say, for outsiders to know what the demands of medicine are.
“It seems unwise to try to legislate something like this,” according to Hamilton. “I don’t believe that because somebody has won an election they necessarily have the wisdom that will allow them to solve a problem with which we’ve struggled very long and hard.”
Others feel that the medical profession has tried to avoid any significant change, and that the time has come for outside involvement.
“We can’t trust the medical establishment to solve their own problems. There really needs to be pressure from the outside to make significant changes,” Plautz said. “If the medical profession can’t regulate itself, someone is going to have to do it for them.”
