Since the implementation of the 80-hour physician residency training work week in 2003 by the Accreditation Council on Graduate Medical Education (ACGME), the medical community has debated whether or not this was going to impact patient care and mortality.
A new observational study in the British Medical Journal, demonstrated no difference in patient mortality, admission, readmissions or costs for internal medicine physicians who trained under these new regulations.
As two doctors who began training before these regulations came to be, we are both reassured by these findings but also hopeful that they motivate continued attention to patient safety, professionalism and the humanism of health care professionals.
During the time when the ACGME revealed these new rules for physicians in training, one of us was in the middle of a rigorous OB/GYN residency in the New England area. The cold winters, life and death scenarios for babies and mothers and tense situations with young cancer patients who were dying made residency feel malignant.
Half of residency was spent working over 100 hours a week watching in slow motion the implementation of the new regulations, acutely aware of all the older, bitter attendings and nay-sayers who believed our training would result in a lack of ability to handle these life and death scenarios for mom and baby or complicated surgeries.
Results of this study suggest that, despite fewer hours of trainee time, both trainees and patients will do fine. Students and residents do not have to be exposed to and endure malignant training environments to learn what they need to know to care for patients.
Hostile working conditions that have been the standard culture in medical training along with long work hours contribute to poor sleep and physician burn out. Insufficient sleep has serious social and adverse health outcomes as poor sleep is associated with seven of 15 leading causes of death.
Research shows physicians and trainees have higher rates of burn-out, undiagnosed mental health problems such as depression and suicide. Twenty-eight percent of physicians in training experience a major depressive episode during residency, compared to 7-8 percent of similarly aged individuals in the United States. Perpetuating hostile working environments impacts the humanity of our health workforce.
By reducing the number of hours, it is our hope that the training will not be as rigorous and will permit better self-care for physicians in training. However, the culture of medical training still has to change.
While hierarchy is an important part of medical student and resident training, malicious and insulting commentary as well as sexual harassment that has been a common part of training across most specialties needs to end.
Thankfully, physician mentors, the Times-Up health-care movement to end sexual assault, harassment and inequality in the health-care space, and ACGME work restrictions have been put into place to aid the training process. While this study supports that fewer hours do not harm patients, it’s not just about time.
To be sure, less time is great as long as trainees learn what they need and patient outcomes are not impacted. But, trainees also deserve high quality education in an environment that promotes their optimal learning, not only of the technical knowledge and skill to care for patients, but the empathy and compassion that are part of the hopeful vision so many carry into their medical training and are at risk of losing in what can be a grueling training experience.
Creating supportive working environments can help restore seemingly fleeting optimism in medicine. And, it only better prepares and motivates trainees who become attendings where work restrictions no longer apply and hours can be equally long.
The other one of us — an intensive care attending whose overnight call this week marked more than 80 total hours working for the week and more than 24 consecutive hours awake — can attest that eager trainees were working alongside her, motivated to learn, and staying late to review their care of critically ill children. This was not because they had to, but because they wanted to know if they could have done better.
While we may have both begun our training in the pre-regulated era, we are hopeful that the restrictions — and the knowledge that they will not impact patient care — reflect a needed and welcome shift in the culture of medicine.
Sameena Rahman M.D., is an obstetrician-gynecologist, clinical assistant professor at Northwestern University's Feinberg School of Medicine and a Public Voices Fellow with the OpEd Project. Erin Paquette M.D., J.D., MBe is a pediatric critical care doctor, lawyer and ethicist, assistant professor of Pediatrics at Northwestern University’s Feinberg School of Medicine, Adjunct Professor at NU’s Pritzker School of Law, and Pediatric Critical Care Scientist Development Scholar. She is a Public Voices Fellow through The OpEd Project.