July 7, 2000 (Washington) -- How tired would you be at the end of a 100-hour work week? Now is the time to contemplate that question, because the first week of July traditionally marks the start of many medical residency programs. As the young doctors dive into the excitement of frontline medicine, they know it will take up most of their waking life.
"It's about falling asleep at the wheel when you're driving home," says Chris Cogle, MD, chairman of the American Medical Association's resident and fellow section, recalling 100-hour weeks in his internal medicine residency.
But some organizations hope to temper this grueling schedule, for the benefit of both patients and medical residents."I am absolutely sure we'll devote more attention to this whole problem," says Robert Moyers, MD, chairman of the American Medical Association's Council on Medical Education.
As national concern over medical errors has grown, it "has highlighted the desirability and the necessity of looking into resident fatigue as possibly part of the problem," according to Moyers. "It's realistic that a resident who is totally fatigued can't be as attentive to details as somebody would like."
Just one state, New York, has work-hour rules that limit residents to 80 hours per week. A handful of specialties have hour limits for residents, but most don't go beyond allowing one day in seven away from patient care, and barring in-house on-call duty more than every third night.
Even so, many hospitals are facing budget and staffing shortages that are forcing residents to log more time, sometimes for nonmedical activities. "It happens in many, many locations," Cogle tells WebMD.
But things may be changing. Earlier this year, for the first time ever, the nation's governing body for residency programs published work-hour violation totals for the nation's residency programs. According to the Accreditation Council for Graduate Medical Education, 20% or more of the programs in 10 specialties violated work-hour requirements in 1999. The worst offender was the pediatric surgery specialty, with seven out of 13 programs cited for violations.
Why the new pressure on enforcement? In a landmark ruling last November, the National Labor Relations Board sparked greater attentiveness among medical schools to their residents' working conditions. The board ruled that residents, whom it said were employees more than students, had the right to collectively bargain with their programs under federal protections.
"People are listening. They're finally starting to look at work hours," says Cogle.
Too little, too late, says Mark Levy, executive director of the Committee of Interns and Residents (CIR), a labor union that represents about 11,000 residents. "It's good that they're starting to do it, but it's reactive. I don't see it as a solution," he says.
"Each state needs to pass regulations, and I think there needs to be federal regulations for a maximum of 80 hours per resident week," Levy adds.
But others say that the rigidity of time-clock limits doesn't serve care well. "The patient may be needing somebody who knows the problem, rather than the resident at the end of the shift turning it over to the next person," says Moyers.
"You really lose a lot of pride when you hand off your patient to another team," says Cogle, adding that academia abhors the concept of physician labor unions.
"A lot of residents do feel [their experience] is an indentured servitude, and that's a heartstring that the CIR can pull," Cogle says. But many residents, he notes, are willing to forgo sleep for the long-term goal of soaking up as much medical knowledge as possible.