5.26.2009

Medical Residents Should Not Have to Work 80 Hours Per Week

When I’m flying, I don’t want the pilot of my plane to be sleepy – a point I made recently when writing about processes of small commuter airlines that set up pilots for fatigue and may have contributed to a recent crash.

Similarly, when I’m sick, I don’t want to be treated at a hospital by a sleepy doctor.

I mention that because of recent reports of a controversy over whether to revise guidelines that let hospitals make medical residents work 80 hours per week.

Believe it or not, the rules used to allow residents in some specialties to work 100 hours per week. The current guidelines resulted from a revision in 2003 (which came about after the death of a patient).

A government-funded report released last year suggested further restrictions, including a maximum 16-hour shift without sleep, or time for naps during longer shifts.

But as a recent article in The Wall Street Journal notes, the New England Journal of Medicine just published an editorial challenging the new recommendations.


Ever since the 2003 guidelines were implemented, however, no conclusive evidence has emerged that the shorter workweek leads to a reduction in patient harm, according to an editorial in this week's New England Journal of Medicine.

"Published studies on this question focusing on mortality rates or a propensity for medical errors have not reached consensus," says the editorial, co-written by Melvin Blanchard of the Washington University School of Medicine in St. Louis

A follow-up study to the 2008 report on the proposed reductions says the recommendations need to weighed against the costs. The study, also published in the New England Journal, estimates shorter shifts and naps would cost about $1.6 billion a year, because teaching hospitals would have to hire more residents or other personnel. Implementing the recommendations "would be costly, and their effectiveness is unknown," says the study…

Another study has indicated that shorter shifts might actually increase patient harm because a departing resident hands over the patient to a fresh resident unfamiliar with the case. "Reducing the work hours of residents leads to an increase in the number of handoffs in care, and this increase outweighs the potential benefits of reducing residents' fatigue," argues the NEJM editorial, whose three authors "strongly disagree" with the Institute of Medicine's recommendations for shorter shifts.


While I don’t dispute the risks of increasing the number of handoffs, proper procedures for handoffs can go a long way toward reducing those risks.

And while hospitals may very well face increased costs, I can’t see that as a justification for overworking residents. There may not be consensus about the benefits of reducing work hours, but you can’t convince me that having doctors who are sleepy is a good thing.

I write about this because I see lean principles at issue here. One is respect for people, meaning residents should be respected by not being forced to work under conditions that lead to fatigue.

More importantly, patients are entitled to medical care that does not put them at risk, which can happen when a doctor is fatigued. This is not only a safety issue, though that may be the most important aspect. It is also about delivering value for patients (customers), which is what lean is all about.

Somehow, I suspect that patients find value in having a doctor who is rested and alert.

I know I do.

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