If you want us to exercise, then give us time to go to the gym! Many in the room began to clap and nod because the sentiment felt all too true. I was proud he had said something, yet disappointed that we work in a system that led to that point. How long should doctors be working? This question has been at the center of debate for many years in the United States.
This study was a much anticipated investigation into whether imposing a limit on the maximum number of hours a resident can work would have a positive or negative impact on numerous outcomes, including patient safety, educational experiences for trainees, and overall wellbeing for doctors, specifically among those in internal medicine residency programs.
The study compared hospitals that were assigned to use standard duty hour regulations with hospitals that had more lenient regulations. The standard duty hour regulations stipulated that first year residents could not be made to work more than 16 hour shifts at a time, and second years and beyond no more than 24 hours.
Both groups had a limit of working no more than hours per month, but in the liberal regulations group, there was no limit on how long a shift could be, and no minimum requirement on the number of hours off between shifts. Patients may also not appreciate having multiple different doctors taking care of them. The comparative issue with liberal duty hours is that allowing or requiring residents to work longer shifts will make them more tired and compromise their ability to function properly, increasing the risk of harm to patients and to residents themselves.
The iCOMPARE trial found no differences in the amount of time dedicated to direct patient care, and no difference in standardized test scores a proxy for physician knowledge base. However, interns in the group with longer working hours expressed significantly more dissatisfaction with their jobs, morale, personal lives, personal health, and their educational experiences. While outcomes for patient safety will likely not be available for another year, a similar study in examined strict versus liberal duty hours among surgical residents.
As with any study, there are biases and alternative possible explanations. As an intern now over halfway through my first year of training, I have found it immensely gratifying to work in a hospital where I know what time I will be going home, give or take an hour or so. Having a more fixed schedule means I can plan a Skype call or dinner with my loved ones, or make it out for drinks with friends on occasion.
I can say that having the time to have a life outside of the hospital makes me feel like a more enthusiastic, thoughtful, and caring doctor. Feeling like my residency program cares about my wellbeing is inherently empowering. It makes me want to come to work, and it allows me time to think critically about my patients without the constant stress of the hospital.
Other demands are less easily explicable. Residents in America are expected to spend up to 80 hours a week in the hospital and endure single shifts that routinely last up to 28 hours—with such workdays required about four times a month, on average. Some licensed physicians continue to work similar schedules even after residency but, importantly, only because they choose to do so.
The vast majority of doctors work fewer than 60 hours a week after they complete their training. Overall, residents typically work more than twice as many hours annually as their peers in other white-collar professions, such as attorneys in corporate law firms—a grueling schedule that potentially puts both caregivers and patients at risk.
In Europe, by contrast, residents are subject to a maximum workweek of 48 hours , without apparent harm to patient care or the educational component of residencies. Part of the reason medical training is so demanding in the United States is that hospitals control the labor market for residents by assigning spots based on a centralized matching system rather than an ordinary, competitive market.
Just as an enterprising entrepreneur cannot form an independent baseball team and challenge the Yankees for a spot in the A. Considered on its own terms, the match seems fair. Moreover, the original purpose of the system was to improve the bargaining power of medical students vis-a-vis residency programs. Signer therefore dismisses the notion that the match harms residents. But creating order out of the chaos of a free labor market also contributes to industry norms of punishing hours and low pay, by restricting competition among employers that could result in better wages and working conditions.
Legal niceties aside, it is hard to argue with this general characterization of the match. After a federal district court initially ruled that the match might be an illegal restraint on trade, Congress immediately enacted legislation immunizing medical training programs from antitrust liability. While residency-program administrators no doubt take their educational obligations seriously, residents are also a cheap source of skilled labor that can fill gaps in coverage.
They are paid a fixed, modest salary that, on an hourly basis, is on par with that paid to hospital cleaning staff —and even, on an absolute basis, about half of what nurse practitioners typically earn , while working more than twice as many hours.
In ranking programs, as Signer of the NRMP points out, most medical students are mainly concerned with prestige and the quality of training, not money.
One study showed , for example, that even without the match, residents would still earn far less than their true market value—which is estimated to be about double what they presently earn—because they, in effect, accept a pay cut for high-quality medical training and a prestigious residency placement. Similar preferences are observed in other labor markets for professional training—for example, law clerks working under judges—in which the long-term career benefits outweigh any temporary earnings hit.
Accordingly, it is not clear whether the free market would necessarily yield better resident pay. Working conditions, though, are another matter. Residents work exceptionally long hours and are subject to unrivaled physical and psychological demands. And it used to be worse. The ACGME established further restrictions in which, among other things, reduced the maximum shift lengths to 16 hours for first-year residents otherwise known as interns and 28 hours for more experienced residents.
These reforms appeared to substantially relax the extreme nature of medical training. Before, it was routine for residents to spend or even hours a week in the hospital and, yes, there are only hours in a week , with single shifts stretching to 48 hours and beyond.
Grumbling by the old guard aside, most in the profession agreed this system was abusive, outdated, and in need of replacement. Averaging hour workweeks and regularly putting in hour shifts is still brutal by any measure. In fact, the evidence is mixed as to whether duty-hour reform did much of anything to reduce the number of hours residents actually work.
However, other surveys found that the reforms led to no change in overall work or sleep hours, and that the reforms actually made residents less satisfied with their work schedules.
How could it be possible for limits on work hours to not lead to less work? Most fundamentally, duty-hour restrictions did nothing to reduce the overall workload of residents, meaning the reforms simply require residents to do the same amount of work in less time. For example, the number of patients admitted at teaching hospitals rose 46 percent from to , a period during which the number of residency spots increased only 13 percent.
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