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The Debate Behind Balancing Resident Work Hours

The 2015 Medscape survey results reflect the highest burnout rates among critical care (53%) and emergency medicine (52%), and with half of all family physicians, internists, and general surgeons reporting burnout.

As an undergraduate, I frequently shadowed physicians and remember vividly many moments and anecdotes from those experiences, many of which would go on to shape my future career aspirations. One of my close mentors, a veteran vascular surgeon at the end of his career, once reminisced about his surgical training at The Johns Hopkins Hospital in the early 1960s, telling me half-jokingly, “During my intern year, I walked into the hospital on the morning of the First of July and didn’t leave its doors for the next year.” He went on to say, “They called us House Staff for a reason. When you’re a resident, the hospital is home.”

Of course, a lot has changed since then. Resident work hours are now regulated by the Accreditation Council for Graduate Medical Education (ACGME), which first instituted work hour restrictions in 2003 after a series of lawsuits, research studies and reports revealed how sleep deprivation and long hours can lead to breaches in patient safety, preventable mistakes, and trainee depression.

Since 2003, these regulations have been critically examined and periodically modified, the subject of an interminable and fervent debate among medical trainees, doctors, politicians and the general public. In 2011, the ACGME revised duty restrictions, banning 30-hour shifts and placing a 16-hour cap on shifts worked by first-year residents. On March 10th, the ACGME Task Force released another revised set of work hour restrictions, which will go into effect on July 1. The new rules increase the maximum shift that interns can work from 16 to 24 hours, plus four hours to ensure safe patient handoffs and allow residents to participate in non-direct patient care educational activities, while maintaining the 80-hour work week limit. Importantly, second- and third-year residents can already work a maximum of 24 hours per shift under the previous rules.

In its announcement of the change, the ACGME noted that “the hypothesized benefits associated with the changes made to first-year resident scheduled hours in 2011 have not been realized … and the disruption of team-based care and supervisory systems has had a significant negative impact on the professional education of the first-year resident, and effectiveness of care delivery of the team as a whole.”

Learning Effective Leadership vs. Resident Burnout

Proponents of the change argue that the longer shifts reduce handoffs between physicians, a key source of medical errors); maintain continuity of care in critical situations, such as during a surgery or immediately following a new admission; and give residents and educators more flexibility to optimize their training. The change also gives interns more opportunity to observe and follow patients throughout the natural course of an illness, especially on the night of admission.

When asked about the goals of the revisions, Dr. Jessica Bienstock, Johns Hopkins Associate Dean for Graduate Medical Education and member of the ACGME Task Force, stated “The Common Program Requirements encourage training programs to teach new physicians how they can be effective participants and leaders of team-based patient care that is the standard of healthcare today … and allow residents to benefit from the personal and professional satisfaction and sense of accomplishment, indeed the meaning and joy, that comes with professional commitment to one’s patients when you care for them in a longitudinal manner.”

Opponents of the change, including Public Citizen consumer group and the American Medical Student Association, argue that sleep-deprived residents are at greater risk of car accidents, needle-stick injuries and depression, and that the vast majority of patients oppose loosening of duty hour restrictions. With increasing awareness of the high rate of burnout, depression and suicide in the medical profession, this rule change has some worried that wellness among medical trainees is still not a top priority.

There is no simple answer. Optimizing duty hour restrictions depends on many competing factors, and it is clearly hard to reach a consensus about what is best for patients and residents. The relationship between duty hours and burnout is a complicated one, as burnout is a multifaceted and complex problem. Research has not always demonstrated a clear correlation between duty hours and burnout. Despite the contentious nature and strong emotions that often overshadow work hour regulations, in the end. patients, residents and medical educators are all united by the same priorities: a desire for high quality and safe medical care, effective and efficient training, and happy, healthy medical trainees.

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