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The origin of work-hour regulations for house officers

Interns and residents have always worked long hours in hospitals, and there has always been much to admire about this. Beyond the educational benefits that accrue from observing the natural history of disease and therapy, long hours help instill a sense of commitment to the patient. House officers learn that becoming a doctor means learning to meet the needs of others. This message has never been lost on them.

However, it has also long been recognized that house officers are routinely overworked. This point was emphasized in the first systematic study of graduate medical education, published in 1940. In the 1950s and 1960s, the hazards of sleep deprivation became known, including mood changes, depression, impaired cognition, diminished psychomotor functioning, difficulty with interpersonal relationships, and an increased risk of driving accidents. In the 1970s, the phenomenon of burnout was recognized. In the mid-1980s, after prospective payment of hospitals was introduced, the workload of house officers became greater still, as there were now many more patients to see, the patients were sicker, the level of care was more complex, and there was less time with which to care for patients. House officers understood they were in a dilemma where their high standards of professionalism were used by others to justify sometimes inhumane levels of work.

Despite their long hours, the public generally believed that house officers provided outstanding medical and surgical care. Through the 1980s, the traditional view that medical education enhanced patient care remained intact. So did the long-standing belief that teaching hospitals provided the best patient care — in large part because they were teaching hospitals.

In 1984, the traditional belief that medical education leads to better patient care received a sharp rebuke after 18-year old Libby Zion died at the New York Hospital. Ms. Zion, a college freshman, had presented to the hospital with several days of a fever and an earache. The next morning she was dead. The case quickly became the center of intense media interest and a cause célèbre for limiting house officer work hours.

Surgery by tpsdave. Public Domain via Pixabay.
Surgery by tpsdave. Public Domain via Pixabay.

The public’s fear about the safety of hospitals increased in the 1990s. In 1995, a seeming epidemic of errors, including wrong-site surgery and medication and medication mistakes, erupted at US hospitals. These high-profile tragedies received an enormous amount of media attention. The most highly publicized incident involved the death of 39 year-old Betsy Lehman, a health columnist at the Boston Globe, from a massive chemotherapy overdose while being treated for breast cancer at the renowned Dana-Farber Cancer Institute. Public concern for patient safety reached a crescendo in 1999, following the release of the Institute of Medicine’s highly publicized report To Err Is Human. The report concluded that 48,000 to 98,000 Americans died in US hospitals every year because of preventable medical errors.

The result was that in the early 2000s, a contentious debate concerning resident work hours erupted. Many within the medical profession felt that work-hour regulations need not be imposed. They correctly pointed out that little evidence existed that patients had actually suffered at the hands of overly tired residents, and they also claimed that resident education would suffer if held hostage to a time clock. Critics, particularly from outside the profession, pointed to valid physiological evidence that fatigue causes deterioration of high-level functioning; they also argued that high-quality education cannot occur when residents are too tired to absorb the lessons being taught. As the debate proceeded, the public’s voice could not be ignored, for the voices of consumer groups and unions were strong, and Congress threatened legislative action if the profession did not respond on its own

Ultimately, the medical profession acquiesced. In 2002, the Accreditation Council for Graduate Medical Education (ACGME), which oversees and regulates residency programs, established new work-hour standards for residency programs in all specialties. Effective 1 July 2003, residents were not to be scheduled for more than 80 hours of duty per week, averaged over a four-week period. Over-night call was limited to no more frequently than every third night, and residents were required to have one day off per week. House officers were permitted to remain in the hospital for no more than six hours after a night on-call to complete patient care, and a required 10-hour rest period between duty periods was established.

Ironically, as the ACGME passed its new rules, there was little evidence that resident fatigue posed a danger to patients. The Libby Zion case, which fueled the public’s concern with resident work hours, was widely misunderstood. The problems in Ms. Zion’s care resulted from inadequate supervision, not house officer fatigue. At the time the ACGME established its new rules, the pioneering safety expert David Gaba wrote, “Despite many anecdotes about errors that were attributed to fatigue, no study has proved that fatigue on the part of health care personnel causes errs that harm patients.”

On the other hand, the controversy over work hours illustrated a fundamental feature of America’s evolving health care system: Societal forces were more powerful than professional wishes. The bureaucracy in medical education responded slow to the public’s concerns that the long work hours of residents would endanger patient safety. Accordingly, the initiative for reform shifted to forces outside of medicine — consumers, the federal government, labor, and unions. It became clear that a profession that ignored the public’s demand for transparency and accountability did so at its own risk.

Recent Comments

  1. Phil Hyde

    At last, a balanced article from within the megalomaniacal sado-maso profession of self-styled supermen, outlining the shameful history of denial of workhour common sense by supposed healers in the USA. Laurels to Ludmerer for achieving the necessary extension of self-interest and focusing, albeit imperfectly, on the issue of worktime per person and the reduction thereof, which has become the key to general and sustainable human progress in the age of machines, automation, and now A.I. and robotics. By kneejerk-responding to technology with downsizing instead of workspreading ‘timesizing’ we are violating an economic system requirement and falling right into the “Ford-Reuther trap”: Henry Ford “Let’s see you unionize these robots!” Walter Reuther “Let’s see you sell them cars.”

  2. Aidan O'Donnell

    This is an interesting article. On the one hand, society expects medicine to be a vocation. We expect a career in medicine to be more than just a job; for doctors to do it for more than just the money. We set the bar high because we want the brightest and best to be doctors. There is an element of proving yourself against an ordeal, which means that not everyone makes it, but those who do are considered “tempered in fire”.
    On the other hand, we have consistently over-worked our junior doctors for a generation. I was one such junior doctor, and I have found myself weeping with exhaustion more than once. There may be little evidence that this is bad for patients (although I would need a lot of persuading that this is so), but I am certain it was bad for doctors. Working fewer hours, could I have achieved all the experience, all the training, all the expertise, in the same number of years? Probably not. But did it those long hours make me a better doctor? I am certain the answer is no. I don’t think that there was anything achieved, which couldn’t have been achieved with less stress and misery on my part.
    The introduction of the European Working Time Directive in the UK has put a mandatory legal cap on the hours which junior doctors work. This has led to some protests (from juniors themselves) that their training and experience has suffered, and some protests (from seniors) that junior doctors don’t feel enough of a sense of commitment to the profession; that they “clock off” at the end of their shifts, rather than sticking around for their sicker patients. (But I am willing to bet that they are, in general, happier and better balanced than their peers a decade previously were).
    Somewhere in the middle of all this there is probably a sweet spot. It seems that if we let senior doctors decide junior doctors’ hours, their hours are too long. If we let the courts decide, their hours are too short. Perhaps junior doctors themselves could have a say– now that they have the time to devote to answering the question.

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