PRO/CON DEBATE
Implementation of the 80-Hour Work-Week Limitation for Residents Has Improved
Patient Care and Education
Sairam Parthasarathy, M.D.
Section of Pulmonary and Critical Care Medicine, Southern Arizona Veterans, Administrative Health Care System, University of Arizona, Tucson, AZ
I
n order to better understand the implications of changes to the
residency system in the United States, or the answers to any
difficult question for that matter, one needs a historical perspective. Historically, the concept of internship was imported into the
United States from the French system of medical training. In 17th
century France, the medical student first became a Praktikant
(equivalent to the Anglo-American clerkship for undergraduate
students) and then became an internat, or intern (equivalent to
the Anglo-American house officer of 20th century medicine) after passing an arduous examination termed the concours.1 After a
year of training, the intern graduated into a practicing physician.
In the United States, by the year 1890, the experience of spending
a year or more in a hospital as a house officer after graduation
from medical school to acquire practical bedside training—so often lacking in medical school—had become quite common. Three
of 4 graduating medical students were enrolling into internships.
By 1923, all hospitals were offering internships, and “advanced”
internships that lasted 3 years were offered in 1950. Therefore, the
concept of residency was born and evolved from being nonexistent to the current 3 to 5 years. In contrast to the dramatic metamorphosis that has taken place over the past century, the recent
work-hour restrictions imposed by the Accreditation Council on
Graduate Medical Education (ACGME) are miniscule. Besides
providing us the vantage point of such perspective, history serves
yet another purpose. History prepares us to expect more change
in the near future.
Change is difficult. Change is disconcerting. Such circumstance prompts the question, where is the evidence that the 80hour work-week limitation helps improve patient care and medical education? This is a difficult question to conclusively answer
at this point in time. Improving patient care and medical education are large global objectives, some of which may not be evident
for years to come—such as the impact of medical education on
the quality of future physicians and the patient care that they will
provide. But, what is of prime importance here is intent.
The intent to acknowledge the defects in the current system
of training, and the willingness expressed by the medical community to address such issues and institute change—although not
widely popular—is an important first step. Our understanding of
the effect of sleep deprivation on the medical professional has
evolved tremendously over the recent years with the publication
of landmark papers from the Harvard Work Hours, Health, and
Safety Group.2-4 But, how do we capitalize on such advancements? Has the mere implementation of the 80-hour work week
helped or hurt? Should we further tighten work-hour limitations
to 65 hours per week, as has been advocated by the Harvard Work
Hours, Health, and Safety Group? These are important questions,
for the intent may be there, but inadequate implementation may
spell the death knell for success. Therein lies the fodder for the
“Con” position.
Prior to the publication of the Harvard studies, the effect of
resident work hours on patient safety was unclear.5 However, the
seminal studies from the Harvard group have provided convincing
evidence of the adverse impact of excessive resident work hours
on both patient and physician safety First, the work by Lockley
and colleagues was performed in a small number of interns during their rotation in the intensive care unit.2 The investigators
measured attentional failures—measured by means of continuous electrooculography and defined as intrusion of slow-rolling
eye movements into polysomnographically confirmed episodes
of wakefulness during work hours. The interns were subjected to
an intervention that consisted of restricting work hours to 16 or
fewer consecutive hours—a measure that is even more restrictive of work hours than are the current ACGME-mandated work
hours. The conventional arm consisted of interns who worked in
the traditional manner—85 work hours per week. The investigators demonstrated that the interns worked fewer hours per week
during the intervention: an average of 85 and 65 hours in the traditional and intervention groups, respectively. More importantly,
the interns in the intervention group slept 6 hours more per week,
slept more in the 24 hours preceding each working hour, and developed fewer episodes of electrooculographically documented
attentional failures.
In the accompanying study, Landrigan and colleagues demonstrated that interns committed more serious medical errors
when working in the traditional schedule, as compared with the
intervention schedule.3 The total rate of serious medical errors
was 22% more during the traditional schedule than during the
intervention schedule. Also, interns made 6 times as many seri-
Disclosure Statement
This was not an industry supported study. Dr. Parthasarathy has indicated
no financial conflict of interest.
Address correspondence to: Sairam Parthasarathy, M.D., Section of Pulmonary and Critical Care Medicine, Southern Arizona VA Health Care System,
3601, South 6th Avenue, Tucson, AZ 85723; Tel: (520) 629-4649; Fax: (520)
629-1861; E-mail: [email protected]
Journal of Clinical Sleep Medicine, Vol. 2, No. 1, 2006
14
Work-Week Limitation Improves Patient Care and Medical Education
There are some data regarding the impact of an 80-hour work
limit on surgery residents. Twenty-one percent of residents in an
academic surgery residency who were polled responded that the
ACGME rules had had a positive impact on teaching, whereas
35% thought that the rules had had a negative impact.12 In a crosssectional survey of 164 surgery residents, fatigue improved; however, few thought that caseload or progression of skills improved,
and the residents’ ability to read or study was unchanged or better.13 In the same study, the residents reported that free time at
home and being less tired at home improved, with many reporting
that happiness as a person improved. Also, in an annual survey of
193 radiology programs, chief residents reported improved call
experience and enhanced educational experience following the
ACGME regulation.14
In a multicenter questionnaire-based study, medicine residents
reported that subjective daytime sleepiness and perception of
propensity to commit medical mistakes were less following the
80-hour limit.15 In another single-center study, following the institution of the 80-hour limits, medicine residents’ quality of life
improved, sleepiness while driving decreased, and errors in order
entry decreased.16 These reports, however, were presented in abstract form and are undergoing peer review.
Critics of the 80-hour limitation have justifiably raised concerns regarding the effect of work-hour restrictions on physician
learning. In a single-center study, with a before-and-after study
design, Malangoni and colleagues evaluated the effect of the ACGME-mandated work-hour limitations on resident physicians in
a trauma center.17 The exposure of the residents to trauma patients
and the number of operative procedures did not change, but there
was a shift in the operations being performed by more-senior
residents. This would mean that junior residents are likely to be
exposed to emergency trauma surgery later during the course of
their training. The authors concluded that there was no significant
change in caseload. In a similar study, Spencer and colleagues
evaluated the experiences of residents in pediatric surgery and
found that there was no change in the number of surgical procedures, but the residents’ participation in outpatient clinics decreased by 49%.18 In a questionnaire-based study, Zuckerman and
colleagues found that residents and attending physicians in a surgery program reported a negative impact of the work-hour limitations on the operative experience, whereas the residents reported
improved quality of life and more time for reading.19 Long-term
studies are needed to address the issue of learning; however, such
studies may be extremely difficult, if not impossible, to perform.
When weighing physician learning against patient safety, the
temporary solution in favor of patient safety is obvious. However, long-term proposals for lengthening residency training and
fatigue prevention through mood-alerting medications20 need
careful consideration.
More importantly, the 80-hour limitation is neither a standalone program nor a panacea. There are simultaneous criticisms
that the 80-hour work limitation does too much21 and does too
little.4 There is nothing magical about the number 80. It is work in
progress. The success of such a program requires more than mere
regulations. It requires an action plan for the future and involvement from all participants. The training programs should monitor
endpoints other than mere work hours. They should measure the
quality of life of their residents, educate residents regarding the
importance of sleep,22 recognize that significant interindividual
variability in sleepiness exists,23 be proactive in providing cab
ous diagnostic errors during the traditional schedule as during the
intervention schedule. In this elaborate and well-designed study,
qualified observers constantly shadowed the research participants
for the purposes of data collection, data verification, and interception of medical errors. The authors concluded that eliminating
extended work-hour shifts, and reducing them to 16 hours, would
reduce serious medical errors in the intensive care unit. However,
the investigators had compared the system that existed prior to the
ACGME 80-hour work-rule system to a novel 65-hour-per-week
intervention system.
The third landmark study from the same investigators reported
the effect of the extended-duration work hours on driving safety in
interns.4 In the 2737 participants who completed 17,003 monthly
reports, the odds of encountering a traffic accident or a near-miss
incident after an extended work shift were 2- and 6-fold greater
than the odds following a regular work shift. The investigators
demonstrated a dose-effect relationship between the number of
extended work-hour rotations in a month and the risk for having
a motor vehicle crash during the same month. The authors concluded by stating that the current ACGME regulations allow residents to work 30 consecutive hours during a shift and that further
restriction of work hours are sorely needed.
Collectively, these studies would favor restricting the work
hours of resident physicians down to 65 hours per week! Imposing a 16-hour limit for continuous work-hour duration and decreasing work hours down to 65 hours per week may be an attractive means for improving physician and patient safety, but such
recommendations are mitigated by excess cost, availability of
manpower, and concerns regarding continuity of care and excess
hand-offs.6,7 Nevertheless, the extra cost in hiring more resident
physicians would probably be offset by the savings that would
ostensibly be incurred in preventing adverse patient events attributable to sleepy physicians.7 But, indeed, most institutions have
not recruited additional physician trainees for unclear reasons.
Besides upfront costs, ACGME caps for residency slots, lack of
Medicare compensation for additional resident training, and the
higher cost of recruiting physician replacements such as hospitalists or nurse practitioners may mitigate some systems from recruiting extra manpower. Other solutions to improving resident
safety have included a night-float system, free cab rides for postcall resident physicians, scheduling postcall “power naps,” educating residents of the adverse effects of sleep loss, and encouraging good sleep hygiene. The night-float system, in a single-center
study, has been shown to improve compliance with the ACGME
work-hour limitations and, at the same time, improve resident fatigue, sleep duration, and patient-satisfaction surveys.8
Despite accumulating evidence regarding sleep-related fatigue
and consequent medical errors, currently there is insufficient information regarding the effect of the 80-hour workweek per se on
patient care and resident education. Indeed, a recent systematic
review of work-hour reduction on residents’ lives included studies that were primarily performed before the ACGME restrictions
went into effect.9 Prior to 2003, studies performed by the ACGME
revealed that many residents were averaging more than 100 hours
of work per week.10,11 A decrease in work hours from more than
100 to less than 65 hours all at once could overburden the healthcare system with regard to a shortage of manpower alone. The
present reduction of work hours to 80 hours per week, although
seemingly insufficient, may be considered a staged approach in
the right direction.
Journal of Clinical Sleep Medicine, Vol. 2, No. 1, 2006
15
S Parthasarathy
ACKNOWLEDGEMENTS
This manuscript was prepared during the period that the author was funded by SAVAHCS/University of Arizona Research
Award. The author thanks Drs. Quan and Habib for their careful
review of the manuscript.
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Figure 1—“An individual’s view of the individual” by artist Piero
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8.
vouchers for sleepy residents who need to drive home after call,
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The physician in training, on his or her part, should observe
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The ACGME needs to campaign for increased funding for academic institutions that operate residency training programs, be
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16.
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