Abstract
This paper will address the problem of the number of medical hours’ restrictions, allocated to medical residents in United States. Self-regulation by the graduate medical education community pushed excesses underground, as institutional resistance has led to underreporting of hours to meet the official limits. Considering the fact that sleepy and overworked medical residents pose risks to patients and themselves and therefore making the reform imperative. The paper will provide an overview of previous attempts at regulation addresses, the weakness of current proposals, suggestions and alternatives that respects professional autonomy and will not interfere with the educational purpose of residency programs. This is a proposal model on previous successful hospital regulation that rewards voluntary compliance instead of punishing violations.
Introduction
ACGME a corporate which is responsible of post medical degree training programs within the United States convened to work as a group to address medical residence work hours. The council faced rising pressure to address the long hours worked by medical residents and a rising public concern from the safety of the patient and this was followed by attempts by the residents to invite government intervention which completely failed compelling ACGME to respond. The measures contained in its report that were implemented in 2003, recommended that hospitals restrict the long hours worked by medical residents and it headed off the prospect of federal intervention and the legislation that was waiting to be implemented which expired without being enacted. The graduate medical education community waited to observe the new restrictions in practice but all was in vain, it even saw the; Patient and physician safety and protection act of 2002, S. 2614, 107th cong (2002), Patient and physical and protection Act of 2003, S. 952, 108th cong. (2003), Patient and physical safety and protection act of 2001, if R. 3236, 107th Cong. (2001) bills die in the committee (Accreditation Council for Graduate Medical Education 5).
Since then, the debate emerged due to the fallen standards of AGME to meet their goals bringing residents hours of duty down to sate level both for resident physicians and their patients. The self – regulation by ACGME only forestalled discussions that lasted for almost for ten years, namely; non – compliance, under reporting and other weaknesses of their approach have even renewed the controversy and these calls for an external regulation. Two years after the federal legislation was reintroduced after the AGCME regulations took effect other steps have been taken by several states to regulate resident hours. However, the task is not straight forward, as regulators must address both institutional residences for any cutbacks available and under staffing caused by restricting hours considering that current proposals do not meet this need.
This paper makes the case for a new alternative to AGCME’s regulations of residents’ duty hours arguing for incentives to over come stubborn internal controversy and the call for federal regulation (Lee 2006 9).
Background Information
It is not a secret that hospital residents routinely work long hours, inspire of popular television shows glamorize the lives of residents, their excessive schedules in reality cannot be glamorized. The lives of both patients and themselves are endangered by the chronic sleep deprivation. Nevertheless, the educational culture embraces its tradition of long hours, and stubbornly resists change.
Role of residents in medical education
The roles played by medical residencies are very important and vital and in graduate medical education. After completing their four-year medical degree programs, aspiring doctors complete a multi-year residency, choosing a specialty and learning the practice of medicine hands-on experience. These are the years which are the most formative and essential in a physician’s training and their professions. The modern residency program has developed over the last centaury to become an integral part of graduate medical education. John Hopkins University was the first to built and operate a hospital as part of its program in medical education in 1893. At first the term in-residence was used to describe advanced specialty training which follows internship. It is this program that became the American model as a graduate medical education shifted away from a system of an apprenticeship to a hospital centered learning process. (Draza & Epstein 7). The house – staff physicians or house officers, were referred to as residents because they actually lived in hospital and were always available. They lived, worked and slept in the hospital in order to follow evolution of the illnesses of patients who were hospitalized for external periods. This complete immersion is seen as the best ways for doctors to learn the craft (Chao 6). During the first year residency is often called an internship, though ACGME no longer recognizes this distinction ad considers all post graduate training programs to be residencies, but nevertheless the first year residents are still often are referred as interns.
National Resident Matching Program (NRMP)
Graduating medical degree students each spring, participates in the National Resident Matching Program, a private non-profit corporation; this program matches residents with teaching hospitals based on surveys of participants’ preferences
Approximately16, 000 U.S. medical school graduates compete with about 18,000 independent applicants for the approximately 24,000 residency positions throughout the states and on Match Day, the third Thursday in March, the results are announced publicly. The Match was created to replace a hodge-podge of conflicting deadlines and offers that “forced students to make rash decisions” before they heard back from all the programs they had applied to (WRP 6)
Applicants for a residency are informed on the Monday before Match Day whether or not they have been matched and if not, they must scramble to find an alternate program by the next day, forgoing the typical research and thought that would ordinarily accompany such a decision, and some applicants end up switching specialties. The March has come under criticism because some residents claim that participation prevents them from bargaining over wages or hours (Hadmever 5)
The tradition and culture of long hours
The traditional resident work schedule imposed extraordinary demands before the ACGME proposals to shorten hours took effect, they were supposed to complete all the tasks of a trainee routinely required 100 hours of work a week or more. A study shows that 25 percent of residents reported working more than 80 hours per week even when averaged over the entire year, the typical hours range from 60 to 136 hours per week. Residents must work long overnight shifts, known as being “on-call in order to attain those hours each week; most interns in a study carried out worked more than 30 consecutive hours and there were even 275 reports from interns who worked more than 40 continuous hours. Extrapolating nationwide suggests that physicians in training worked approximately 20,000 extended shifts and this exceeded 40 consecutive hours while caring for patients” in 2002–2003.
The 2003 ACGME proposal limits residents to 80 duty hours per week, averaged over a four week. Residents must have one free day per week and cannot be on-call more often than every third night; these limits are also averaged over a four week period. The proposals also restrict shifts to 24 hours, with up to 6 hours allowed to transfer and debriefing. Residents must be given 10 hours off between shifts. Finally, if a resident is called from home any time spent in the hospital this counts forward their limit (AGCME 13).
Long hours pose a public health danger
Their long work schedules push residents’ bodies to their functional limits. The dangers of excessive and long-term sleep deprivation have long been known and in the context of patient care, the potential for harm is extreme. This therefore means that patients are at risk when treated by sleep-deprived residents who are more prone to make medical errors. In addition, the residents themselves are at a much higher risk of hospital and automobile accidents from chronic sleep loss. These dangers raise the issue of resident work hours to the level of a public health risk. In other industries regulations are common where sleep-loss brings public risk. The levels of continuous duty and work hours for health care personnel are much greater than those allowed in industries like transportation and nuclear-power industries, the long hours required of residents harm the national health care system (Gaba & Howard 4) The. This therefore means that we have house officers working enormous hours. We would never do that if we were designing a good system in terms of quality of care considering that the problem is widespread, as 70 percent of residents report having seen colleagues work while impaired, and most often due to lack of sleep, this is more than a simple labor dispute, excessive resident hours demand public attention (Dawson & Reid 9).
Residents sleep deprivation is dangerous for their patients
Residents’ sleep deprivation is dangerous for their patients, as a result of their work schedules; hospital residents are frequently sleep-deprived, especially during overnight call shifts and the effects of being awake for extended periods of time impairs their ability to be effective. A study has found that psychomotor performance was equivalent to performance with a blood alcohol concentration of 0.10 percent after being awake for 24 hours, higher than the legal limit for driving a vehicle, if alcohol were a problem in hospitals, the public surely would not tolerate drunk doctoring and therefore sleep deprivation deserves the same level of scrutiny Higher rates of error are unavoidable under those circumstances, A study by the Harvard Work Hours, Health and Safety Group published in 2004 compared the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an “every third night” call schedule) and while they were working according to an intervention schedule that eliminated extra work shifts and reduced the number of hours worked per week.” It was found that the traditional schedule led to 35.9 percent more serious medical errors, including 56.6 percent more no intercepted serious errors. These problems can be effectively addressed by reducing the number of hours worked. In a similar parallel study, the Harvard group also found that residents on an intervention schedule of less than 80 hours per week slept more and “had less than half the rate of attention failures while working during on-call nights,” (Lockley & Steven, et al. 6).
Sleep deprivation on dangers the residents themselves
Sleepy residents are not just more likely to commit medical errors that harm their patients; they are also more likely to harm themselves due to their impairment. Sleep-deprived residents were at a significantly higher risk for motor vehicle crashes when their schedule included extended work shifts and they were more than twice as likely to report a crash and nearly six times more likely to report a near-miss after working an extended shift than after working a shift of less than 24 hours. In addition, every extended work shift that was scheduled in a month increased the monthly risk of a motor vehicle crash by 9.1 percent and increased the monthly risk of a crash during the commute from work by 16.2 percent. Tired residents are also more likely to injure themselves in the hospital. A study of interns examined how extended shifts affect the odds of accidental needle sticks and laceration injuries, finding that most common contributing factors were loss of concentration and fatigue, and injuries of this type were 1.61 times more frequent during extended shifts. In addition, the stress of long hours can take an emotional toll. Overwork and exhaustions did perverse things to caring individuals who entered medicine to serve, but not surprisingly, stress-related depression, emotional impairment, and alcohol and substance abuse were well-documented phenomena among house officers.
Resistance to change in resident duty hours
Despite the risks of long working hours’ reformers confront serious and nontrivial resistance from within the graduate medical education community. Many doctors believe in the virtues of long hours that continuity of care provides benefits to residents and their patients other doctors point to the costs of reducing hours in a system where all available employees are already working at their limits long hours are seen as essential to the educational purpose of residency. Teaching hospital consider their residents as students first and employees second and this is reflected in their salaries. On average the starting pay rate for residents is $43, 266 per year, for those residents working over 89 hours per week this totals only about $10 per hour, meager compensation for a position requiring so much work and responsibility in addition, in total the average medical graduate carried a debt of $ 110, 000 in 2003 a lone. But since the primary purpose of residency is education, many doctors feel that the long hours are justified by the ability to watch patients’ progress through the course of a shift; residents also reap benefits resulting from assuming total responsibility for one’s patients according to old doctors. The residency is a unique time in a physician’s career, fundamental in shaping the way a physician thinks, works, and acts in the sense that doctors see themselves as being in service to their patients above all else, so they cannot control what hours they must work. They, therefore view the residency as a time to learn under particular grueling conditions. In the same line it is argued that doctors should train at a level harder than what they’re expected to do in private practice as it prepares them to work under adverse conditions.
But perhaps of outmost most importance to many critics of regulation; residents who work fewer hours have less first-hand experience when their education is complete in that that long hours bring educational benefits that cannot be replaced: The long hours on duty have come at a cost, but they have allowed trainees to learn how the disease process modifies patients’ lives because taught a central professional lesson about personal responsibility to one’s patients, above and beyond work schedules and personal plans, saying even the residents themselves can feel that they are missing out on educational opportunities when they work shorter hours(Whang, et al.,3). Doctors feel that medical professionalism can be forged only in the flames of experience and therefore limits on hours on call will disrupt one of the ways they have taught young physicians the critical value of personal responsibility to patients and without this understanding, many fear that the soul of the profession could be lost, at the expense of exchanging out sleep-deprived healers for a cadre of wide-awake technicians. The idea of low pay, the older doctors say, is to impress from the beginning that doctor’s his duty is to patients, and not just to make money.
The attitude towards long hours, many doctors in addition to its educational benefits look on the residency as a sort of hazing ritual for young physicians for the belief that residents put up with the long hours to meet expectations, and their supervisors demand long hours almost as a rite of passage
In the sense that nearly all current doctors have passed through the residency program with its traditional demands for long hours (Lee, 2006, p 9).
Conclusion
The problem of medical resident hours is serious, and despite considerable time and effort spent on regulation, the result seems to be that excessive work has been pushed underground, through institutional resistance coupled with underreporting of hours to meet the official limits. But sleepy and overworked residents pose a risk to themselves and patients, and the problem cannot and should not be swept under a rug.
The proposals presented here by the AGCME are just one of potential ways of addressing the issue. The critical point to note, though, is that institutional resistance will always undermine reforms that do not reinforce educational goals. Any further attempts at regulation must recognize that restrictions cannot simply be imposed on this industry but the regulations must respect the profession, and regulators must find a way to dovetail their interests with the educational purpose of residency programs. Only then can they overcome stiff resistance that has met previous attempts, and only then will America’s resident physicians be able to openly and honestly meet the demands of their profession with only time left for a good night’s sleep.
Work cited
Accreditation Council for Graduate Medical Education, Web.
Clark J. Lee. Federal Regulation of Hospital Resident Work Hours: Enforcement With Real Teeth, 162 (2006)
Dr. Kenneth M. Hadmever. A Job or more School? Young Doctors on the Marten 19 (2004).
Drew Dawson and Kathryn Reid, Fatigue, alcohol and performance impairment, 388 Nature 235, 235 (1997).
David M. Gaba and Steven K. Howard, Patient Safety: Fatigue among Clinicians and the Safety of Patients, 347 (2002).
Edward E. Whang, et al., Implementing Resident Work Hour Limitations: Lessons from the New York State Experience, 237 (2003)
Jeffrey M. Draza and Arnold M. Epstein. Re-thinking medical training; the critical work Ahead, 7 (2002)
Lynn Chao, Resident work hours; the evolution of 136 archives of surgery 142 (2001).
Laura K. Barger, et al., Extended Work Shifts and the Risk of Motor Vehicle Crashes among Interns, 352 (2005).
National Resident Matening Program how the WRMP process works (2007) Web.
Steven W. Lockley, et al., Effect of Reducing Interns’ Work Hours on Sleep and Attention 182 (2004).