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Tuesday, September 27th 2011

More On Work Hours

Currently non-intern physician residents are limited to working 320 hours in any four week period, 24 hours of patient care in any one continuous setting and most have 4 days off in any four week period amongst other rules.

The history of medicine’s self governing bodies limiting resident physician work hours in a patient protection bid has a long history, as do my complaints about such.

But I thought it worth reiterating one of the major problems with these work hours. They can only be policed by individuals who are largely negatively impacted by their violation.

Say you’re a obstetrics/gynecology resident at a program that has some rotations that regularly violate the 80 hours/week (averaged). Let’s say you, and all the other residents in your program, report those violations. That is the only way that programs (and thus medical schools and the ACGME) learn about violations…they ask their residents to report them. Mix in some other things and before you know it your program is on probation from the ACGME and then, a few years later as the work hour violations continue despite best efforts, your program is shut down.

All in the name of patient safety. Only there is evidence, despite our best intentions, that restricting resident work hours has done nothing for patient safety.

And so now you are an out of work ob/gyn resident who can only blame yourself for self reporting those duty hour violations. Now you have to go out interviewing across the country to find another residency program, costing you potentially tens of thousands of dollars. It’s true that your funding for your resident position (your salary) can travel with you as you look for a new residency program and that the ACGME will almost universally provide a waiver to any program that accepts you to increase the size of their residency program and so your odds of finding another residency program to accept you are high, even if you’re in a competitive specialty. However, that isn’t guaranteed and there’s a small chance you may not find another ob/gyn residency to accept you. Even if you do it means packing up your family and your belongings, leaving your friends and moving cross country.

There’s some evidence that the majority of residents continue to routinely violate duty hour rules, largely without complaint. For one, I’m not sure they see the adverse effects of doing such. For two, knowing the light at the end of the tunnel they swallow the long work hours. And, for three, reporting those violations most negatively impacts the resident physicians themselves.

This isn’t a call for some dramatic shift in how we track resident physician work hours or for mitigating the effects of program violations on residents. This is a call for some return to sensibility and some loosening of the work hour restrictions in the first place.

A pipe dream but I’ll dream it.