Since its inception in 1981, the Accreditation Council for Graduate Medical Education has monitored and evaluated over 130 resident training programs in a variety of settings in the United States.  10 years ago, the ACGME instituted codified work-hour regulations that restricted the number of hours a resident or junior could work.  The ACGME implemented the changes because of increased resident work demands, public concern, and new information on the harmful side effects of sleep deprivation.  While the restrictions have brought about some needed changes, they have also led to new problems.

Benefits of Work-Hour Restrictions

• Residents are better rested – Current ACGME restrictions only allow a resident to continuously work 16- and 24-hour shifts, and 8-10 hours must be allotted for rest before returning to duty.  Also, work weeks are capped at 80 hours and 1 in 7 days must be devoid of any clinical duties.  These restrictions help make sure residents are better rested when they arrive for their shifts.
• “Burnout” rate decreased – Fewer medical students are dropping out of residency programs than before the work-hour regulations were implemented.
• Higher quality of life for residents – Residents who are working under the new work-hour regulations reported a higher quality of life than those residents who were surveyed before the restrictions were in place.

Drawbacks of Work-Hour Restrictions

• “Shift-Worker” mentality – Because of the regulations that prevent residents from working certain shifts, medical professionals fear they will begin to develop a “shift-worker” mentality, which can lead to complications when patients are passed from one resident to the next.
• Compromised training experience – A recent study found that only 17% of program directors believed resi­dents were adequately prepared for clinical practice as an attending ortho­pedic surgeon, while 20% believed that residents had sufficient outpatient clinic exposure.  Many medical professionals believe that residents will not receive adequate training if they are not subjected to the trials and tribulations of longer, unregulated shifts.
• Increased strain on senior residents – Because of the limitations of interns and junior residents, there has been an increase in workload up the chain in command.  Much of this is picked up by senior residents, which lowers their quality of life and can increase the likelihood of making a mistake.
• Unregulated shifts prepare junior residents for the worst – One intern recounted the story of his first weekend he filed in for a resident on emergency leave.  Although he had a chief resident available, the intern still handled 27 consuls, 6 hip fractures, 5 open femoral and tibial fractures, 3 crushed elbows, and a C5 spinal cord injury.  Although he was exhausted from his experience, the intern learned the importance of preparation, calmness under pressure, prioritization and decision-making.  He said he fears that future interns will not have the chance to develop these skills like he did.

Dr. Silverman Comments

Is it better to have a well-rested orthopedic surgeon, or a wise one?  There are two sides to this argument.

Doctors can’t possibly develop an instinct for making the right choice (‘saving lives’) without experience, and experience doesn’t come without continuous exposure. Injury and disease do not work their damage during only an 8-hour shift.

As to the development of the “shift-worker” mentality, continuity of care means that the next doctor who picks up the patient knows what is going on and knows what to expect going forward. If a patient does what they are supposed to (gets better), no one is troubled; it’s when something happens that is not expected that red flags get raised. Understanding the causes of a red flag gives the doctor a better likelihood of saving lives.

Ultimately, you can only understand what happened and learn from the errors if you were actually involved in the decision-making process.

Related source:  American Journal of Orthopedics