Jennifer & April Edwell // In 1938, congress passed the Fair Labor Standards Act, which limited the standard workweek to 44 hours. However, this regulation did not extend to medical training programs. In fact, there was no national duty hour limit for medical residents until 2003. Efforts to improve duty hour guidelines have been driven by concerns about patient care as well as resident well-being.
What do the medical humanities have to offer this discussion?
In this post, we reflect on the history of residency programs in the United States and the creation of duty hour restrictions. Then, we highlight several of the challenges that have resulted from these recently-implemented recommendations. Finally, we outline a few potential ways medical humanities scholars can collaborate with medical researchers and educators to improve training for the next generation of physicians.
A Brief History of Residency
The first modern American residency program was established at John Hopkins in 1889. In his history of American medicine, Kenneth M. Ludmerer explains that John Hopkins’ residents signed on to “live in the hospital for… years, learning a speciality and investigating clinical problems” (19). The John Hopkins program was a tiered institutional apprenticeship. “Interns,” or first-year trainees, served a 12-month term, where they were responsible “for the moment-by-moment management of patients” (Ludmerer 21). After completing the intern year, “assistant residents” were offered renewable 12-month appointments that entailed supervising the interns as well as research (Ludmerer 21). A select few went on to be “chief residents,” coordinating and supervising the other residents, teaching, and conducting research (Ludmerer 22). Graduate medical education in the United States is based on this this model.
When John Hopkins launched its medical residency program, there were no limits to the number of duty hours trainees were expected to work. Moreover, the term “resident” corresponded with the expectation that trainees lived at the hospital.
The first state-level regulation of duty hours followed the well-publicized death of Libby Zion in 1984. At that time, Libby was a freshman in college. She experienced cold-like symptoms (fever and ear ache) and, late in the evening, visited the Emergency Department (ED) at New York Hospital. There, Libby was seen by two residents (an intern and assistant resident), who thought she had a virus and “hysterical symptoms,” given her agitation and strange movements. They prescribed her meperidine, “an opiate drug, to stop the shaking movements” (Ludmerer 276). Over time, Libby became more agitated. The intern was telephoned and prescribed medical restraints and a sedative. Libby’s temperature then rose to 107 degrees, and she eventually suffered a cardiac arrest and died.
A grand jury was convened to investigate Libby’s death. In hindsight, physicians believe Libby likely suffered from serotonin syndrome, which resulted from the interaction of phenelzine (an antidepressant) and meperidine (given in the hospital for agitation/shaking). However, an exact cause of death was never declared. The grand jury indicted the residency program for allowing “inexperienced physicians” to staff the ED and leaving residents unsupervised (Ludmerer 277). They also noted that resident work hours were “counterproductive to medical care” (Ludmerer 277). A committee was established to follow up on Libby’s case and investigate medical training in New York. Based on the committee’s findings, in 1989, New York adopted new rules (known as the “Libby Zion Law”) limiting residents to an 80-hour workweek and a maximum of 24 consecutive hours per shift.
Libby’s untimely death sparked a broader debate about the impact of resident work hours on patient care. However, it was another 14 years before national guidelines were implemented by the Accreditation Council for Graduate Medical Education (ACGME). The 2003 guidelines limited residents to an 80-hour workweek and stipulated that “residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period.” In 2011, the ACGME released revised guidelines that mandated rest periods between duty periods, increased supervision for junior trainees, and stipulated a 16-hour limit on continuous duty hours for interns.
Residency Duty Hour Limits: Challenges to Implementation
Numerous studies have been conducted to evaluate the effectiveness of duty hour restrictions in relation to patient care and resident well-being (particularly sleep loss/fatigue). Overall, limits on duty hours have been found to correspond with increased sleep; however, more generally, studies have not consistently demonstrated improvements in patient care or resident well-being (see Desai et al. 2013).
In fact, restrictions on duty hours have produced a number of new challenges.
For example, shorter shifts necessitate more frequent handoffs of patient information. Instead of one resident caring for a patient for 30-36 consecutive hours, there are multiple doctors doing so across that same time period. As a trainee, it can feel like as soon as you finally understand your patient and what’s going on with them, it’s time to sign out to a different doctor. At times, the oncoming doctor (especially for the night shift) may not be able to examine the patient at the time of handoff (e.g., if the patient is sleeping). As a result, physicians may make decisions for patients that they have literally never met. Mistakes happen with handoffs: details get missed, medications are forgotten, checkboxes remain unchecked.
Thus, for trainees and patients, there are some advantages to the extended continuity of long shifts. In regards to learning the art of medicine, physicians are able to gain deeper insight into the unique circumstances and needs of the patient by being continually present. Further, patient care tends to be bifurcated: new plans are made in the daytime, but the effect of those plans is witnessed/assessed during the night. There are benefits, then, to being present for both “phases.”
Of course, anyone awake for more than 24 hours will find that their mind is a bit slower and details are a bit fuzzier. Accidents can happen as a result, in the hospital and in residents’ lives (e.g., car accidents (Landrigan et al. 2008)). However, the complexity of implementing duty hour restrictions prompt a number of questions. What exactly is the problem are we trying to fix (physician fatigue, clinical mistakes, or something else)? How do changes in the structure of residency programs address the problem? How do changes to the residency program affect other hospital processes? What kind of culture are we promoting within residency programs?
Insights from the Medical Humanities
To our knowledge, medical humanities scholars have not contributed to discussions about duty hours or evolving institutional practices related to residency programs. However, we believe this is a topic ripe for such collaboration. To conclude, we offer a few tentative ideas for ways medical humanities scholars might partner with medical education leaders.
Institutional Lessons: Humanities scholars can offer insights on the power dynamics that permeate medical training programs. Cohen et al. (2013) have demonstrated that top-down pressure to meet duty hour limits can lead to dishonest reporting. Because the consequences for violating limits impact current residents, residents are incentivized to misrepresent the number of hours they work. Cohen et al. suggest that rather than penalizing the residents, who are already in a vulnerable position, a better solution would be to create a system that incentivizes honest reporting from residents. Along these lines, humanities scholars might draw on historical or contemporary examples to help contextualize these challenges, adding historical and philosophical depth to these conversations and helping to develop professional practices that are informed by humanistic values.
Cultural Critique: Humanities scholars can offer insights on cultural perceptions and pressures (both within and beyond medicine) that influence residents. There is a sense in medical culture that medical education is meant to be incredibly, unforgivingly rigorous. New residents may worry about being judged by the more senior faculty, who regularly worked 36-hour shifts during their residency. In addition to this intergenerational pressure, there is a popular myth that physicians are resistant to the effects of sleep deprivation. It is not uncommon for April (the MD co-author of this piece) to have conversations with friends about her work schedule in which someone will say, “I could never go that long without sleep,” as though April possesses a superpower. Medical humanities scholars could participate in studying perceptions of medical training and the impact of these perceptions on trainees.
Institution Rhetoric: In response to concerns about the new restrictions, the ACGME shifted its nomenclature. The phrase “clinical experience and education” was adopted in place of “duty hours.” According to ACGME, “This change was made to emphasize that residents’ responsibility to the safe care of their patients supersedes any duty to the clock or schedule.” Along these lines, humanities scholars have much to offer medical leaders in thinking about how their language shapes the practice of healthcare.
Interpersonal Communication: Medical leaders have recognized the challenges produced by increasing the number of handoffs, and this has spurred new lines of research. Medical educators have created acronyms and mnemonics to help doctors be better at these exchanges. Humanities scholars might collaborate with researchers and educators to help residents communicate effectively during handoffs. Also, since shortened shifts mean residents spend less face-to-face time with patients, humanities scholars might brainstorm ways to help ensure that patients feel seen and heard.
Cohen, G., et al. “Making residency work hour rules work.” Journal of Law, Medicine & Ethics, vol. 41, 2013, pp. 310-314.
Czeisler, C. “Medical and genetic differences in the adverse impact of sleep loss on performance: Ethical considerations for the medical profession.” Trans Am Clin Climatol Assoc, vol. 120, 2009, pp. 249-285
Desai, S. V., et al. “Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models on Sleep Duration, Trainee Education, and Continuity of Patient Care Among Internal Medicine House Staff: A Randomized Trial.” JAMA Internal Medicine, vol. 173, no. 8, 2013, pp. 649–655. doi:10.1001/jamainternmed.2013.2973
Landrigan, Christopher P., et al.. “Effects of the Accreditation Council for Graduate Medical Education Duty Hour Limits on Sleep, Work Hours, and Safety.” Pediatrics, vol. 122, no. 2, Aug 2008, pp. 250-258. DOI: 10.1542/peds.2007-2306
Ludmerer, Kenneth M. Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. New York, Oxford University Press, 2015.