International Journal for Quality in Health Care 15:103-105 (2003)
© 2003 International Society for Quality in Health Care
Counterpoint |
Opening Pandora’s box: residents’ work hours
Hadassah Hebrew University Medical Center, Jerusalem, Israel
In March 1984, an 18-year-old woman named Libby Zion died at the New York Hospital a few hours after she had been admitted through the Emergency Room. Her death was unexpected and therefore prompted a series of investigations that have resulted in recommendations for profound changes in the medical profession, at first in the USA and later in many other countries [1,2]. The media coverage of the Libby Zion case prompted questions about the quality of care in teaching hospitals. Many questions focused on the long hours that interns and residents work. The grand jury that investigated the case recommended that ‘the State Department of Health should promulgate regulations to limit consecutive working hours for interns and junior residents in teaching hospitals’. At the same time a sociological study of residents suggested that long work hours and other intense pressures of clinical training, condition physicians to view patients as enemies, in contradiction of the implicit and desired principles of patient care [3].
An Ad Hoc Advisory Committee, appointed by the commissioner of the New York State Department of Health, recommended that the shifts worked by house staff and attending physicians in emergency services be limited to 12 hours, and that physicians caring for patients outside of the emergency services work in shifts limited to 16 hours with at least 8 hours off between shifts.
Potential problems of implementation included effects on graduate medical education, hospital staffing, malpractice litigation, and health care financing. Analysis of the proposed recommendation showed a need for an additional 2045 attending physicians and 974 ancillary personnel or their full-time equivalents in 50 New York City hospitals.
The political pressures to limit residents’ working hours stem from both a desire to improve patient care and the personal demands of residents and other physicians for predictable working hours and increased leisure time.
The long working hours of residency are a tradition in physicians’ training. Some believe the tradition is maintained by inertia, others claim that the long hours are essential to proper training and that an understanding of the evolution of many acute diseases and their processes can be gained only through the observation of affected patients over time. These arguments hold some truth but the real issue is the quality of care given to the ill patient. The cognitive abilities of residents have been shown to be impaired after a night on call. One study found the ability of residents to recognize electrocardiographic arrhythmias significantly reduced after being on call and another found their mathematical abilities decreased. Neither study measured the quality of patient care directly but it is a logical supposition that it too would be impaired [4]. Long working hours adversely affect the relationship between doctors and patients, since failure to spend enough time with patients damages the quality of medical care. Moreover, the bad habits learned during residency later fuel the malpractice crisis.
In Israel in the first half of the year 2000, there was a 3-month strike of physicians against the government and other employers. One of the most conspicuous of the physicians’ demands proposed that physicians assigned to the night shift in its various forms should end their duty at 0800 hours the following morning or at the very latest, 1000 hours. This would mean that the working day of resident doctors should be limited to 24 hours duration (and not more than 26 hours) and would include the night shift. An agreed contract between all the parties appointed a supervisory system of observation and disciplinary action of all departmental heads and hospital management personnel accountable for implementation of the agreement with no allowance for lapse of the agreement’s terms. Two years later, it was found that only 70–80% of the departments of all hospitals nationwide were conforming to the contract and acting according to the terms of the agreement. In some hospitals only one department had not conformed, whilst in others several departments failed to conform. It was evident that the noncompliant departments were mainly those of surgery and its specialities, such as thoracic, cardiac, orthopedic etc. The heads of these departments and the hospital management had not been taking the required steps for implementation of the terms of the agreement. The major reason for this failure was that the budget for employment of the additional 200 doctors, required to replace those residents who go off duty, was not granted by the government. In departments with a limited staff of doctors it is impossible to continue with the daily routine of the department without the doctors who have been on duty all night. In addition to these departmental difficulties there are other dilemmas for hospital management: there is a requirement that a senior physician must be present in the Emergency Room 24 hours a day, and not only for the morning shift [5]; the facts show that in certain conditions of illness there is an increase in the mortality rate at weekends [6]; and there is always a need for budgetary restraints, which mean a freeze on expenditure and a limitation on manpower. But nonetheless, concurrently there are projects in progress for efficiency promotion, expansion of activities in hospitals and clinics, and quality improvement in service programs. When we view the national hospital system in toto, it is apparent that the entire system of health care has not suffered a decrease in output in spite of the actual cut in manpower of hundreds of resident physicians—those who go off duty at 0800 hours after the night shift. On the contrary, activities in hospitals and out-patient systems have increased, the number of invasive and non-invasive procedures has risen, including the introduction of new techniques and innovative methods, without increase in morbidity or mortality.
So how has the system adjusted to the change?
Two basic measures have been taken: the hiring of outside ‘temporary’ staff, and the loading of extra functions onto the senior physicians. The ‘temporary’ staff are doctors who are ‘moonlighting’ and who are not registered as members of the official departmental staff. They arrive for night duty at 1600 hours and go off duty at 0800 hours the following morning. They take on one to two night shifts per week. As they are not staff members they do not attend staff meetings, pathology conferences, etc. They have no involvement in research nor in teaching commitments. As far as is possible, these ‘temporaries’ are fitted into the daily departmental schedules during the weekdays (not weekends), so that the resident physicians can be freed from night duty and can participate in the morning routine of the department. There is a problem however, in that these ‘temporary’ doctors are not familiar with the patients’ conditions, particularly with those in serious condition; they are also unfamiliar with the departmental and hospital regulations. Their personal accountability to the patient is minimal, and their work standards are different. Their intention is to fulfil their shift duties sufficiently, without attempting to solve difficult and complicated problems, but just to keep the patients stable until the morning staff arrive.
The other basic impact of this change is a great increase in the work load of the senior physicians when the residents go off duty at 0800 hours. The senior physicians in the surgical departments are having to perform many more operations (because of the lack of residents) and are therefore prevented from taking a more active part in teaching of residents, in research, in the development of special projects and in the advancement of the department and of the hospital. They are involved, far more than previously, in departmental routine—ward rounds, operations, clinic attendance—and less in improvement including quality and progress. Changes have also been introduced into work routines, and not always to the advantage of the patient. For example, the operation lists, which are planned by the resident physician in charge of this duty, are organized so that the most interesting cases will be arranged on the days when the residents are scheduled to operate, and these operations will be for surgical procedures which they need to perform in order to achieve their specialization accreditation. All other operations are then moved to the days when the senior physicians operate. Another consequence of this change, which is already emerging today, is a reduction in the number of physicians entering the academic field, since the change forces them to invest more of themselves in the daily routines of the hospital and less in their own professional development. One of the main complaints advanced is that the quality of service to patients is deteriorating since the change. However, the health authorities are not making any of the necessary attempts to clarify and measure the validity of this complaint, perhaps for fear of uncovering its truth, which will give rise to complex and difficult problems in all the issues of health services—mortality, morbidity, economic considerations and so on, for which no feasible solutions may be found. But apart from these aspects, the decision to limit the working hours has also had wide repercussions on relationships between doctors, on the doctor–patient relationship, on the education of junior doctors and on the medical profession itself.
When a resident physician concludes his/her night shift at 0800 hours, he/she has no commitment to continue follow-through with the patient admitted during the night, or to monitor the progression of the patient’s illness, the results of the treatment and all other events in the patient’s care, whereas the physicians (continuing work) in the department must assume an extra load and further responsibilities. Procedural regulations in the surgical departments require the participation of a senior physician at every operation. This creates a curious situation where, should an operation become necessary during the night shift, the senior physician on-call is obliged to participate in the operation and to be responsible for care of the patient. In fact, the senior and junior physicians operate together, but while the resident physician goes home at 0800, the senior, who has not slept all night, remains to continue treating the patient, whilst carrying out all his/her other commitments. What are the thoughts and feelings of the senior specialist in this situation?
The subject of doctor–patient relations has today come to the forefront of medical deliberations, and changing physicians’ behavior has become an important focus of medicine over the last two decades [7]. There can be no doubt that residents going off night duty after a 24 hour shift has had its effect on this important issue. However, on the other hand, it is obvious that fatigued residents threaten the safety of the patient. What is more important? What is more critical?
Medicine is practiced differently today: the subjects of malpractice insurance and risk control direct and influence to no small degree the decisions made by physicians in the field. What is the significance of going off shift after night work on the physical and mental health of the residents themselves? On their families? These are all questions that must be given due consideration.
Until recent years, physicians were committed to their patients and to their work in a different way. Resident physicians used to stay on for long hours on their own initiative, in order to take part in an unusual operation, or to treat a patient in life-threatening condition. Today the approach has changed. The trend is for the physician to work for a specified number of regular hours. Residents want more time for themselves and their families and a growing number of physicians are not interested in research and academic careers. Therefore, there are those who hint that the whole discussion is not to seek solutions to the problems of the safety of the patients and quality of care, but rather for the problems of the doctors [8].
What then are the solutions? It is definitely clear that there is real need to shorten the working hours of the resident physician. Normally, this type of problem is solved through an increase in budget and manpower allocation. However, this is only a temporary or partial solution and does not get to the root of the matter, because meanwhile there have been significant changes in the whole system which need to be addressed. For example, what is more vital for the patient’s well-being—a doctor who works on a 24 hour limit, or a specialist on every shift? Or both? Perhaps the whole residency program and its duration should be reviewed [9]. It should be considered whether the duration of the residency should be calculated exclusive of the off-duty days which the resident spends after the night shifts, and only the actual on-duty working days should be taken into account along with the number of operations the resident must perform. Other suggestions proposed include decreasing the number of courses, creating non-teaching care services and reallocating resident time [10].
The issue of resident physicians’ working hours has many aspects which affect medicine in general as well as associated fields. Since the change in their working hours is now established and has been in place for the last few years, it is time to deal with the various problems involved. At present we seem to be ‘living on the edge’, and the health care system has no margins of safety whatsoever. Not all the questions raised above have constructive solutions, and additional investments of resources and manpower are not a sufficient answer. It therefore seems advisable to select two or three of the central issues with the greatest impact on care provision, to study and assess them, and to offer the most appropriate solutions. This process could well extend over several years, but it is the only effective way of dealing with the cultural, organizational, behavioral and economic changes that have been imposed upon us by the switch to an allocation of fixed working hours for the resident physicians only, without taking into account its implications for the total health care system, and in particular for our clients—the patients.
I wish to acknowledge the help I received from Helena Bornstein in preparation of this paper.
References
- Asch DA, Parker RM. The Libby Zion case. N Eng J Med 1988; 12: 771–775.
- Pickersgill T. The European working time directive for doctors in training. Br Med J 2001; 323: 1266.
- Mizrahi T. Getting rid of patients: contraindications in the socialization of physicians. New Brunswick: Rutgers University Press, 1986.
- McCall TB. The impact of long working hours on resident physicians. N Eng J Med 1988; 12: 775–778.
- Cooke MW, Kelly C, Khattab A, Lendrum K, Morrell R, Rubython EI. Accident and emergency 24 hours senior cover—a necessity or a luxury. J Accid Emerg Med 1998; 15: 181–184.
- Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Eng J Med 2001; 345: 663–668.
- Bauchner H. Changing physician’s behavior. Arch Dis Child 2001; 84: 459–462.
- Smith R. Hamster health care. Br Med J 2000; 321: 1541–1542.
- Moulton R. Duty, trust and the training of residents. J Trauma 2000; 49: 575–579.
- Stimmel B. The Libby Zion case revisited: what have we learned. Mt Sinai J Med 1998; 65: 302–303.
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