Petition to Reduce Medical Resident Work Hours

September 2, 2010

• Full Report (pdf)
• Introduction
• Part 1: Resident Physicians Work Excessive Hours
• Part 2: Evidence of Harm to Resident Physicians
• Part 3: Existing Hours Limitations for Resident Physicians and Non-Resident Physicians
• Part 4: The Same Rules to Protect Resident Physicians and Subspecialty Resident Physicians Will Also Protect Patients
• Part 5: Arguments Against Reducing Work Hours
• Part 6: OSHA Has Jurisdiction Over Limiting Resident Physician Work Hours
• Part 7: Requests

PART 1: RESIDENT PHYSICIANS WORK EXCESSIVE HOURS

A. The Resident Physician Work Schedule

Depending on the type of residency, physicians-in-training can work anywhere from 60 to 100 or more hours a week, sometimes without a day off for two weeks or more. Specifics come from a nationwide prospective cohort study of US first-year resident physicians (interns) conducted by Landrigan et al., which evaluated hours worked in 2002-2003 and 2003-2004. [1] Four thousand and fifteen interns participated in the study, providing 29,477 monthly reports of their work and sleep hours. Even after implementation of the ACGME’s Common Duty Hour Standards in 2003,

• The average work week was 66.6 hours (95% confidence interval [CI] 66.3-66.9);
• The mean length of an extended shift was 29.9 hours (95% CI, 29.8-30);
• 29% of all work weeks were more than 80 hours in duration, 12.1% were 90 or more, and 3.9% were 100 hours or more;
• 83.6% of all interns reported hours of work in violation of the professional self-regulations that were established and are being monitored by the ACGME. This number far exceeds the rates of violations reported by resident physicians and residency programs to the ACGME, indicating both that widespread under-reporting exists, and that the ACGME’s enforcement has been ineffective.

B. Resident Physician Stress and Dissatisfaction with Excessive Work Hours

Resident physicians must deal with multiple stresses of patient care, patient death, the need for constant learning, the task of teaching medical students, the requirements of attending physicians and senior resident physicians, and the necessities of family and personal life ? all while being subjected to the chronic sleep-deprivation and exhaustion caused by their excessive work schedules. In a study conducted by Schwartz et al., 377 resident physicians answered a survey in which they were asked to rate the most stressful factors in their residency. Among choices such as “high mortality among patients” and “large patient load,” resident physicians rated “lack of sufficient sleep” and “frequent overnight call” as the top two most negative factors of residency.[2] Small has written of a “house officer stress syndrome” caused in large part by sleep-deprivation and excessive work load, in which physicians-in-training may suffer from (1) episodic cognitive impairment, (2) chronic low-grade anger with outbursts, (3) pervasive cynicism, (4) family discord, (5) depression, (6) suicidal ideation and suicide, and (7) substance abuse.[3]

A number of studies have sought to identify resident physicians’ own perceptions of their training. Although they are not objective measures, resident physician opinions offer some insight into the problem. Daugherty et al. found that resident physicians had only a moderate level of satisfaction with their learning and work experience.[4] When satisfaction with specific aspects of the internship year was reported on a scale from 1 to 7 (least to most), it was found that resident physicians were most satisfied with what they learned (4.8) and their relationships within the hospital (4.8). They were least satisfied with friend and family relationships outside the hospital (3.9), and with personnel support services (3.6). Nearly 20% of respondents rated their internship experience as less than satisfactory.

In a Letter to the Editor of the Journal of the American Medical Association (JAMA), Dr. Murad Alam of the College of Physicians and Surgeons at Columbia University wrote:

While many types of work require precision (e.g., computer programming) or concentration (e.g., air traffic control), medical internship is unique in requiring both from workers in a chronic state of fatigue. Living in the hospital for protracted durations prevents residents from obtaining respite from their job-related frustrations. The intrusiveness of being on-call barely allows for even a few minutes of privacy. For days at a time all personal activities are continually subordinated to the mantra of patient care. On-call responsibilities make residents exhausted, lonely, and unable to meet their own needs … [5]

In a survey completed by 108 male and female resident physicians, more than 40% of those who defined themselves as being in a committed relationship believed that they had “major problems” with their spouse or partner. Seventy-two percent of them believed that these problems were due to residency, and 61% of them reported that their spouse or partner agreed with this assessment.[6] Multiple regression analysis revealed that 50% of the variance in relationship stress could be accounted for by the following ten variables: high number of hours spent in the hospital, year of training, lack of moderate athletic activity, sleep deprivation, lack of family and social contact, inability to do daily errands, indebtedness, large amount of time spent doing housework, high number of spouse’s working hours, and fewer awake hours at home (model F = 3.05; df = 14; 42; p < 0.002). A paper describing a support group for the wives of resident physicians found that they had prevailing feelings of anger, depression, frustration, and impotence in coping with their husbands’ residency period.[7]