Medical Education Is Changing in a Bad Way and It Will Affect You!

As a former surgical residency program director for more than 23 years, I must comment on the proposed changes in the way physicians, particularly surgeons, are trained. Some history. In 1984, an unfortunate young woman died at a prestigious hospital in New York. The case was followed closely by the media. Several important issues relevant to her death were under-reported. She had taken illicit drugs on the night of her death and she withheld this fact from her doctors. Because of this, she had a reaction to sedation that was administer which led to her death.

There was a suggestion that the residents may not have been properly supervised. The residents who treated her had been on duty for UNDER 24 HOURS. Her father, a reporter for the New York Times, started a crusade against what was perceived to be the main cause of her death, doctors-in-training working long hours.

This case resulted in the creation of the Bell Commission which formulated regulations limiting doctors-in-training in New York State to a maximum of 24 hours of work per shift and 80 hours per week. [Note to any non-physicians reading this: being on-call for 24 hours straight does not mean that one is necessarily always awake for all 24 hours.]

Several years later, the national organization that governs medical resident training, the Accreditation Council for Graduate Medical Education (ACGME), adopted similar rules. The ACGME has now decided to ratchet down the hours for first year trainees to a maximum of 16 hours per day with a mandatory 10 hour rest period thereafter.

It is amazing to realize that in the so-called era of evidence-based medicine, none of the current or proposed work hours rules are based on any solid evidence that tired doctors are harming patients or that limiting hours worked will lead to better patient outcomes. In fact, Bertrand Bell, head of the commission that first limited resident work hours, admitted that the limit of 80 hours was based on no data, but rather just seemed like a good number.

Here is what Dr. Bell said in a letter to the Journal of the American Medical Association in 2007, “The specific “80-hour week” was actually determined by a colleague ON MY PORCH [my emphasis added] and was based on the following informal reasoning: (1) there are 168 hours in a week; (2) it is reasonable for residents to work a 10-hour day for 5 days a week; (3) it is humane for people to work every fourth night; (4) subtracting the 50-hour week (10 hours per day × 5 days) from 168 hours leaves 118 hours; (5) divide 118 by 4 (every fourth night) and add to the 50 hours and, eureka, that equals an 80-hour week.” How’s that for evidence? I particularly like “… eureka, that equals an 80-hour week.”

There is good evidence that limiting work hours can be detrimental to surgical resident education and possibly to patient care due to a lack of continuity and frequent “handoffs” of patient care. Certainly, there are no studies proving that patient outcomes are better since the initial work hours changes went into effect and there are several that show it has made no difference. Don Nakayama, a surgical program director in Georgia, pointed out an unintended consequence of the rules that has occurred as supervision was increased as well.

He said, “The unanticipated problem is one of excessive supervision of residents at all levels where residents never have the experience with practicing independently.” This has led to a feeling among graduating residents that they must take further fellowship training because as Nakayama put it, they “…feel unsure and avoid going into independent surgical practice right out of training. The effects (of excessive supervision) aren't going to be seen until the pre-duty hour, pre-malpractice crisis, pre-health care crisis generation retires.”

A program director who wanted to remain anonymous said, “Where is the response from organized medicine on this (the work hours rules)?” Another program director asked, “How can a first year resident advance to the second year and supervise next year’s first year residents if he/she has never even worked a 24 hour shift?”

What about the projected shortage of general surgeons within the next few years? A decline in the number of general surgeons per capita already exists. If restricting work hours leads to a lengthening of surgical residency training, how will the future need for surgeons be met? How can surgery training be lengthened from what is now 5 years in the face of massive debt for college and medical school tuition incurred by most residents? Absent the first year residents in the wee hours, who is going to pay for physician extenders to help care for patients? Well, I can only think of these questions, not answer them. Maybe someone else has an idea.