SHIFT IN FOCUS
Hospitals, physicians debate impact on patient care
Dr. Lauren Hughes said she doesn’t regale first-year residents with war stories about how, back in the day during her first year in training, she used to literally work all day on 24-hour shifts—which is something they’ll never have to do.
If she wanted to, though, she could—even though, to Hughes, “back in the day” was less than a month ago.
Occupying somewhat the same space as tail-end baby boomers who were in the last round of kids to have black-and-white baby pictures, Hughes and her fellow second-year residents are the final class of doctors who, in their first year of training, slogged their way through marathon shifts running on fumes and fueled by caffeine and adrenaline. As of July 1, the law of the land—as written by the Accreditation Committee for Graduate Medical Education—dictates that first-year residents are limited to 16-hour shifts under a new rule aimed at improving patient safety as well as providing a better learning environment for new doctors in training.
Three weeks into the new era, physicians running resident programs at teaching hospitals say the restrictions have forced a variety of immediate changes, such as hiring hospitalists to fill gaps and packing more tasks into shorter shifts. They and their residents have mixed feelings about the clinical and financial effects of those adjustments, some of which are spurring talk that certain training programs may need to be extended by as many as seven years in surgical specialties. In addition to limiting the length of shifts, the rules call for increased supervision of residents, more time off between shifts and stricter limits on “moonlighting,” the practice of working beyond one’s normal schedule— either in house or at another institution—to pick up some extra money and experience. The ACGME, however, did keep in place the existing 80-hour weekly work limit (averaged over four weeks) with an exception made for neurosurgeon residents, who can extend their week to 88 hours.
Hughes is the former president of the American Medical Student Association, an organization that petitioned the U.S. Occupational Safety and Health Administration to usurp and take over ACGME’s resident regulatory authority.
A family-medicine resident in the University of Washington’s Harborview track, Hughes now holds an ambivalent view of the work-hour debate. In fact, Hughes said she came to appreciate working 30 straight hours that included 24 hours of clinical duty followed by six hours of administrative tasks. Hughes said that at Seattle Children’s Hospital, the administration decided that having different-year residents working different-length shifts was a logistical mess, so they assigned everyone to 12-hour shifts. She said she has learned to adjust.
“I grew quite fond of the long shifts—there
University of Illinois Medical Center neurology residents speak with a patient. Because new shift restrictions limit first-year residents to 16 workdays, some say hand-off errors may be more of an issue than fatigue-related errors.