Recommendations for rest periods for residents meets with skepticism

For decades, doctors in training have endured long hours and sleepless nights during residency. Due to concerns that their resultant fatigue might harm patients, in 2003 an 80-hour limit on weekly duty hours, along with a 30-hour limit on work periods, became mandatory for hospitals approved by the Accreditation Council for Graduate Medical Education. But a recent report by the Institute of Medicine (IOM) recommends stricter duty-hours rules that would allow residents more rest, while calling for stronger enforcement of existing rules.

Issued in December, the IOM report is the work of a committee of physicians and sleep experts that examined studies on the relationships among duty hours, sleep physiology and patient safety, including some research done since the 2003 changes. The committee concluded that the evidence was “nascent … but sufficient to recommend action now.” It proposed, among other changes, that residents working 30-hour periods pause on or before the 16th hour for five hours’ rest, and that they be granted an uninterrupted 48 hours each month to catch up on sleep. The 80-hour weekly maximum would remain in effect, as would such other 2003 rules as 10 hours off after a work day.

Yale educators, however, have reservations about the report. Peter N. Herbert, M.D. ’67, HS ’69, senior vice president of medical affairs at Yale-New Haven Hospital, called it “disappointing,” citing the scarcity of evidence that scheduling of duty hours affects patient safety. “It reflected, to many of us, a confusion about what their purpose was,” Herbert said. “It would probably be much more worthwhile to look at what work hours and schedules do to resident education.”

“We’re certainly philosophically on board with believing that rested, clear-thinking people provide better care,” said Stephen J. Huot, Ph.D. ’81, M.D. ’85, HS ’87, chair of the primary care internal medicine residency. But, he said, these well-intended changes might actually jeopardize patients, since they would require more frequent handoffs of patient care and might diminish access to care at some medical centers.

Academic neurosurgeons greeted the report with dismay. Neurosurgical operations last longer than other types of surgery, said Dennis D. Spencer, M.D., HS ’77, chair of the department, requiring longer and more flexible duty hours. “The 16-hour shift with the 10-hour-at-home rule means that our chief residents will never be able to come back to the hospital and see patients they may have operated on, or they will be unable to come to the hospital the next day,” Spencer said. “They will never learn responsibility for their patients and they will erode the mentor/student bond with attending faculty who are attempting to give them more responsibility. This destroys one of the main competencies we are supposed to be teaching—professionalism.”

Though the IOM committee estimated that the cost of adopting its recommendations could reach $1.7 billion annually, it recommended that these changes be adopted within two years.

Whether or not the new rules are adopted, the culture change alone implied by a 16-hour work period—a move toward shift work—has some physicians worried. Continuity of care and teaching a physician to “own” a patient, said Dean Robert J. Alpern, M.D., Ensign Professor of Medicine, are valuable lessons. “This focus on work hours has removed that culture from medicine,” he said. “Nobody seems to be concerned about where we’re headed with this loss in continuity of care.”

“We need to figure out how to continue to instill a sense of complete responsibility for the care of your patient—putting the patient’s needs above your own needs and do so in an educational system that allows you to still function as a person,” said Huot.