America’s resident physicians have strict limits on how many hours they can work in the hospital. Many break that limit and keep quiet about it. Others lie.
Resident physicians are the doctors-in-training that millions of Americans come into contact with at teaching hospitals across the country. We work for three to seven years (it depends on the medical specialty) under the supervision of attending physicians. From admission to discharge, we are the often-tired, ever-present doctors who likely take part in your hospital care.
We are supposed to follow rules that specify how many hours we are able to work in a single stretch and over the course of a week. As an intern (a first-year resident), I’m not supposed to work more than 16 hours a day and no more than 80 hours a week (averaged over a four-week period). More senior residents can work for 24 hours straight but still can’t work more than an average of 80 hours a week. These limits are dictated by the Accreditation Council for Graduate Medical Education (ACGME).
The rules were created for good reasons. Studies have shown that tired young doctors working long hours are more prone to make mistakes. Hoping to reduce these errors and increase safety for both physicians and patients, the ACGME first enacted work hour limits in 2003, and revised them in 2011. Now the organization proposes to change them once again.
In spite of these rules, many residents work longer than they should — but keep it to themselves. I see it happen all too often. And though I’ve felt the pressure to work past the limit, I have never done that — and I’m a critic of the practice of under-reporting hours.
Why not be truthful about working an extra hour (or 10) each week? When a resident works longer than allowed, his or her residency program gets a “work hour violation.” Too many violations can lead to a warning from the ACGME. In extreme situations, they can be grounds for a residency program losing its accreditation. That can mean losing out on education funds from the Center for Medicare and Medicaid Services; graduates from unaccredited programs can also face trouble getting their medical licenses. Many residents underreport extra hours to avoid these violations.
It’s important to ask why residents are working beyond their limits in the first place. Studies of resident work hours show that they exceed their limits to take care of you and your loved ones, to finish adding their notes and other information in patients’ charts, and to complete other tasks.
Several colleagues and I recently reported in the New England Journal of Medicine that a significant number of residents exceed the work hour limit because of external pressure from authority figures. Others blame it on internal pressures, such as guilt about leaving the hospital or feeling they are expected to work beyond their limits. These internal and external pressures are alarming given the high rates of burnout, depression, substance abuse, and suicide among resident physicians across the country.
We aren’t talking about a few residents underreporting here and a few there. Most do it. National surveys have found that around 60 percent of respondents falsify how long they actually work. Our study found that more than 70 percent worked longer than they should have at least once without reporting it. More worrisome, 60 percent of that group reported routinely exceeding their work hours on an average week.
Many in the medical community oppose the current work hour policies. Critics argue that the reforms harm the education of residents by making it difficult for them to follow the care of their patients. They also say that work hour limits increase transitions of care between providers. Many call for a relaxation of these policies, even though a report from the Institute of Medicine offered considerable evidence that long shift lengths place both physicians and their patients at risk.
The most recent research on resident work hours comes from a clinical trial of general surgery residents enrolled in the highly influential FIRST Trial. It showed that less-restrictive work hour policies, compared to the current more-restrictive ones, did not result in worse patient outcomes. A soon-to-be-published report in the Journal of the American College of Surgeons by the same authors of the FIRST Trial shows that many physicians at all stages of training violate their work hour limits and are working longer than they should.
The ACGME is now proposing multiple revisions to current work hour policies. Among them is replacing the current 16-hour maximum shift length for interns with shifts that could last up to 28-hours without sleep. The weekly limit will remain capped at 80 hours, at least for the moment.
Why should you care about what looks like an internal matter among medical educators? There is already significant evidence that working long hours puts patients — and providers — at risk for serious medical errors.
Instead of addressing underreporting or the culture of guilt and coercion within residency training that drives residents to lie about how long they work, the medical community simply seems to be saying: work longer. The ACGME proposal to boost shift lengths falls short and misses an opportunity to address why residents feel pressured to lie about their hours, an issue that has been ignored for far too long.
When we have evidence that residents make fewer mistakes when they work shorter shifts, evidence from the FIRST Trial that longer hours don’t have “worse” outcomes on patients, and evidence of widespread depression and burnout among residents, the default shouldn’t be to ask doctors to work longer. At least not when we also have evidence suggesting that doctors are already working longer than they are supposed to because of guilt and pressure in residency training. Instead, we need to first address the guilt and external pressures in residency programs that already drive residents to work longer hours than they should.
If for some reason you find yourself spending some time as a patient in a teaching hospital, ask the residents treating you how many hours straight they have been working. You may get the truth and you may not. If they fess up that they have worked longer than they should have, or if they’ve done that but aren’t telling you, are you OK with that? I know I’m not.
Christopher Lee Bennett, MD, is an emergency medicine resident at Massachusetts General Hospital and Brigham and Women’s Hospital, both in Boston.