$1.6 billion to let physicians sleep more
Image by bitzcelt via Flickr
At this moment, there is a heated healthcare debate going on that many people don’t know about. It’s not about the uninsured or the high cost of health care. It’s about how much doctors sleep.
I run an internal medicine residency program, which is held to a set of rules forged by the Accreditation Council for Graduate Medical Education (hereafter ACGME). Spurred by the Libby Zion case, in which a young woman died while under the care of overtired resident physicians, the ACGME has adopted strict rules aimed at ensuring that residents’ work schedules allow time for adequate rest. Under the current rules, residents can work no more than eighty hours per week, must have one day off in seven, and must have at least ten hours between shifts.
The ACGME is meeting today to consider tightening those rules even further, based on the recommendations that were handed down in recent months by the highly influential group known as the Institute of Medicine, or IOM. Some of their recommendations include (among other things) more time off between some shifts, more days off per month, and an uninterrupted five-hour period of time for sleeping during shifts scheduled to last more than 16 hours. In other words, mandatory napping.
To say these recommendations have program directors across the country taking up torches and pitchforks may be something of an understatement. The reasons are many, among them the fact that implementing these recommendations would be a logistical nightmare. Moreover, some clever folks at UCLA crunched the numbers and found that implementing these changes could be spendy, to the tune of about $1.6 billion dollars, according to an article published in the May 21 edition of The New England Journal of Medicine. Even better, we have no proof that these changes would even achieve their intended goal: better-rested residents and, by extension, decreased errors and improved patient care. Can we really say that fewer patient care-related errors will occur because a resident had five days off last month instead of four? And is it worth spending over a billion dollars to find out?
In the midst of our current healthcare financial hemorrhage, shelling out an additional $1.6 billion dollars on the unfounded assumption that the changes recommended by the IOM will produce better-rested residents and improved patient care is questionable at best. I hope today’s discussions at the ACGME come to the same conclusion.
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Question for you Turi, I have a cousin who I’m pretty close with, she’s an OBGYN here in NYC. We’ve discussed the issue of resident’s work schedule in the past. Frankly I think it’s appalling, she feels it makes for better doctors. I really think her attitude is based on “I did it, why shouldn’t they?” Don’t you think there is a lot of this at play on this issue?
Great question, Brian. I’d agree that there’s an element of that at play. Before the duty hour restrictions, resident hours truly were appalling. Some of us who went through residency at that time do, I think, get a little miffed at the whole duty hours thing. But I’m actually not opposed to the duty hours as they stand. What I take issue with is the huge outlay of dollars for changes that may not make any difference, and may in fact erode the physician’s sense of responsibility to his or her patients.
In response to another comment. See in context »A few questions:
- Given that you are a residency program director opposing a reduction in the amount of hours worked, to what extent to you think residency programs encourage their employees to under-report their hours, so as to comply with the 80-hour-a-week restrictions?
- What is different about the field of medicine that requires a 80 hour workweek making life-altering decisions, when the vast majority of other employees around the country make far less important decisions for only 33-40 hours, given the medical research into the effect of even mild sleep deprivation on decision making abilities?
- How is “continuity of care” and “the physician’s sense of responsibility to his or her patients” related to the number of hours that a physician works, in contrast to nurses, who work fixed shifts while also having to maintain these features?
- What percentage of residents at your program currently a) use medication to treat depression b) abuse alcohol or c) have sought therapy? Given that national rates of these characteristics for residents are much higher than the norm, to what extent do you believe these traits are caused by overwork?
Pardon the difficult-to-conceal “slant” to these questions.
No problem, that’s what this website is all about. To answer your questions:
In response to another comment. See in context »1. The new recommendations don’t reduce the work hours. They’re still at eighty. Although I have heard rumors that some programs encourage under-reporting, it would mean almost guaranteed loss of accreditation if they were found out. Personally, I know of no program director who does this.
2. One difference is that residents are more students than employees, and we have to teach them a hell of a lot in a short period of time. If there were funding, materials, time, staff, and interest available to produce a well-trained physician in forty hours per week, it might be worth looking into. As it stands, however, we’re still faced with the challenge of ensuring that we produce well-trained physicians within a certain number of years.
3. These issues are a little bit more complex. During residency we have to make sure the residents understand the burden of responsibility that they bear. Unlike nurses, physicians have a lot more responsibility in determining the overall course of a patient’s care. If they’re constantly handing patients off to one another, they may not develop the skills necessary to see a patient through from admission to discharge.
4. HIPAA, HIPAA, HIPAA. I couldn’t possibly know for sure. Residents are at high risk for all of these things, and I do think that overwork may play a role. I also think staggering rates of student loan debt, starting new families, and relocation (in many cases) play significant roles.