Rookie Doctors' Work Hours Capped

New regulations went into effect Tuesday capping the number of hours medical residents can work in a week, a change celebrated by many at Harvard’s teaching hospitals but criticized by some as short-sighted.

Trainee doctors are now only allowed to work 80 hours per week, according to the new rule imposed by the Accreditation Council on Graduate Medical Education (ACGME).

Though the cap is not federal legislation—such legislative attempts to limit hours of medical residents have previously failed in Congress—ACGME has the power to take away the accreditation of those hospitals that allow their residents to exceed this limit.

The regulation also stipulates a 24-hour maximum length for resident shifts, a required one day off in seven and a mandated ten-hour period between certain shifts.

Backers of the new regulation support it as a means of enhancing the learning environments of the newest doctors and improving patient care.

Opponents have traditionally argued that dealing with long-hours and stress is a necessary skill for doctors, and that a limitation would compromise continuing patient care.

On Tuesday this debate began to play itself out on the hospital ward floors, as schedules had to be refigured and some residents may have gained a few hours of sleep.

According to Wilder Professor of Pediatrics R. Alan B. Ezekowitz, head of pediatrics at Massachusetts General Hospital (MGH), the change was planned well in advance in his department and thus went smoothly.

“This is something we knew would happen about six to nine months ago,” Ezekowitz said. “We’ve been planning for it like a military operation. The changeover has been extremely orderly, we started the transition a week ago.”

Some departments already had hour limitations in place, meaning the new rules were hardly noticed.

The regulations are hitting other departments harder, Ezekowitz and others said.

Several predicted that the surgery program—which requires that residents receive training in a multitude of procedures—would have to make more serious changes in adjusting to the cap.

“One of the downsides is that in order to get enough experience, [the change] may lead to extending the length of time residents have to train,” Ezekowitz said.

And according to Rotch Professor of Pediatrics and Children’s Hospital’s Physician-in-Chief Gary Fleisher, the new rule will cost his hospital about $1 million each year.

“Schedules have been rearranged, attending physicians have assumed duties formerly performed by the residents or ancillary providers have been added,” Fleisher said.

Supporters of the change say the adjustment costs are well worth it, and that the limitations are overdue.

Jodi Abbott, who directs the Beth Israel Deaconess Medical Center’s obstetrics and gynecology residency, has been an advocate for a cap since her residency—when she sat on a committee that studied the issue.

“Residents are supposed to be trainees who are learning, and I believe that although being tired is part of the job for a doctor who delivers babies, students need to be awake to learn,” she wrote in e-mail. “In a field where an error in judgement can lead to a lifelong disability for a child, that we have an obligation to our patients to be alert.”

As a resident in the late 1980s, Abbott said she worked 100 to 120 hours per week, a practice which she said continued for some up until recently.

“We became very proficient but did not have time to read, analyze literature or see our families,” she said.

“Our residents in the past worked up to 100 hours per week when they are covering someone else’s vacation or time off,” she said. “There is no question in my mind that [those working 100-plus hours] have been overworked, and perhaps made errors due to fatigue.”

According to Abbott, the push for this change has been long in the running. After a 1984 death of a New York teenager, where jurists found negligence on the behalf of unsupervised residents, New York became the first state to limit the hours residents’ could work.

And while Massachusetts formerly had no 80-hour medical resident regulation, some hospital departments took it upon themselves to limit the work-hours of their newest doctors.

A few years ago a committee at MGH not only capped obstetric residents’ work-week to 80 hours, but also outlawed work that exceeded more than 36 hours straight.

“We knew that [the national hour-cap] was going to happen at some point,” said Meigs Professor of Gynecology Isaac Schiff, who heads the department. “We began to respond to it and anticipate it. Our residents are excellent residents; we thought it would be better for our own well-being if they could be alert and not exhausted and provide the best care to all.”

But some questioned the wisdom of the change as implemented.

“I wish that I, personally, and the medical profession, in general, had more data on the issues,” Fleisher said. “[An appropriate cap] might be 60 [hours], 100, somewhere in between, or completely different for various individuals. We can only hope they made the right guess when they pulled 80 out of the air.”

—Staff writer Jasmine J. Mahmoud can be reached at mahmoud@fas.harvard.edu.