At the end of June, 1981, the third author of this article finished residency training in adult psychiatry at the New York Presbyterian Hospital-Cornell Campus. In March, 1984, Libby Zion, an 18-year-old college student, died several hours after being admitted to this same hospital. Her father, the well-known journalist Sidney Zion, filed suit against the hospital, claiming that her death resulted from inadequate care she received at the hands of overworked, overtired, and undersupervised residents. Two and a half years later, a New York City grand jury decided not to issue criminal indictments related to Zion’s death but made recommendations to improve patient care, including a limit on consecutive working hours for residents. Thus was born the movement to limit work hours for graduate medical trainees, first in the state of New York, and ultimately throughout the rest of the United States.
The movement to limit work hours for house staff, which has gained momentum in the last several years, is part of a larger set of dramatic changes in residency training realized in the two decades since Libby Zion died and the first and second authors of this paper finished residency training (in 2003 and 2004, respectively). Here, we will present two points of view about the impact of work hours regulation on training in psychiatry. Drs. Lomonaco and Auchincloss from the residency program in general psychiatry at New York Presbyterian Hospital-Weill Cornell Campus will argue that regulation of work hours, at least in its present form, seriously interferes with the optimal training of psychiatrists. Dr. Rasminsky from Northwestern University Feinberg School of Medicine will argue that work hours regulations represent a long overdue and much needed set of protections for both resident psychiatrists and their patients.
In 1987, the New York State Commissioner of Health appointed the Ad Hoc Advisory Committee on Emergency Services to review the findings of the grand jury in the Zion case. This committee, chaired by Dr. Bertrand M. Bell of The Albert Einstein College of Medicine in New York City, recommended changes in graduate medical education which included limiting work hours for residents and improving supervision. In July 1989, the New York State Department of Health instituted regulations governing residents’ work hours and supervision as Section 405 of the New York State Health Code (1). These regulations provide for an 80 hour work week averaged over a 4-week period, 12-hour work limits in emergency departments, a maximum of 24 consecutive hours of scheduled work, a minimum of an 8-hour period between work assignments, and a minimum of a 24-hour period of nonworking time each week.
Since 1989, all residency programs in the State of New York (which train approximately 15% of the residents in the United States) have been subject to these regulations, commonly referred to as the Bell Commission regulations. Until recently, the extent to which these regulations were followed or enforced varied considerably from program to program (2), and elsewhere in the United States programs paid little attention to the issue of work hours. In 1987, the Accreditation Council for Graduate Medical Education (ACGME) authorized Residency Review Committees (RRC) for each specialty to incorporate requirements related to work hours into its standards, but did not act to set its own standards.
Beginning in the first half of 2001, the issue of work hours limitations began to heat up. In April, several groups and persons including the Public Citizen Health Research Group, the Committee of Interns and Residents, the American Medical Students Association, and Dr. Bell himself petitioned the Occupational Safety and Health Administration (OSHA) to establish and enforce a federal work hours standard for medical house staff (3). In September 2001, the ACGME established a Work Group on Resident Duty Hours and the Learning Environment and, in October, the Association of American Medical Colleges recommended that “After years of debate, we believe that prudence favors the establishment of a reasonable upper limit. We conclude, along with countless others, that 80 hours per week constitutes such a reasonable limit, albeit a generous one by any conventional standard” (4). In November, 2001, Representative John Conyers (D-Michigan) introduced federal legislation (The Patient and Physician Safety and Protection Act, H.R. 3236) that would limit resident work hours and provide federal enforcement of this limit. A little more than 6 months later, Senator Jon Corzine (D-New Jersey) introduced the same legislation in the Senate (S. 2614). Later that month, the House of Delegates of the American Medical Association weighed in on the issue by recommending work hours limitations, the State of New Jersey Assembly passed new work hours limitations, and the State of New York Department of Health announced the results of a new inspection that revealed well over half of its teaching hospitals to be in violation of work hours regulations.
In the face of possible new federal regulations and in an effort to regain control over the issue, the ACGME announced new work hours regulations for residents throughout the United States, effective July 1, 2003. The new regulations limited duty hours to 80 hours per week, averaged over a 4-week period, and in-house call to 24 consecutive hours, with an additional 6 hours for didactic activities, transfer of care, outpatient clinics, and continuity of medical and surgical care (5).
At the same time, the New York State Department of Health announced it was contracting with Island Peer Review Organization (IPRO) to conduct surprise audits of New York State teaching hospitals. In response to the New York State statement that anything less than 100% compliance is inadequate, New York Presbyterian Hospital instituted daily online monitoring of work hours by each resident as a condition for employment at the hospital.
Work Hours Regulations: Impact on Patient Safety
According to the Institute of Medicine, medical errors are currently the eighth leading cause of death in the United States (6), and a growing body of data suggests that sleep deprivation is a major contributing factor. In 2004, the Harvard Work Hours, Health, and Safety Study demonstrated that interns in the intensive care unit working a traditional schedule (up to 34 continuous work hours) made substantially more serious medical errors, medication errors, and diagnostic errors when compared with interns limited to 16 consecutive hours (7, 8). A study of pediatric residents found that impairment on tasks measuring sustained attention, vigilance, and simulated driving during a “heavy call” rotation (80 hours per week, with 34–36 hours of consecutive work every fourth or fifth night) was equivalent to impairment associated with a blood alcohol level of 0.04–0.05g% (9). A recent meta-analysis of the effects of sleep deprivation on cognitive performance, memory, and vigilance in physicians and nonphysicians found that even after 30 hours awake (the current upper limit), physicians’ overall performance declined by one SD and clinical performance degraded even further (10).
Those who oppose work hours reform argue—largely without data— that patient care will suffer as a result of the frequent handoffs that result from limiting residents’ time in the hospital. But unless we return to a system in which house officers are truly residents, living in the hospital, handoffs from one physician to another are a necessary part of practice. Clearly, it would be bad medicine for a doctor to get up and leave in the middle of a patient emergency, but both proposed and existing regulations make provisions for appropriate, thorough transfer of care. H.R. 3236, the proposed federal bill to limit resident work hours, explicitly states that “The Secretary shall promulgate such regulations as may be necessary to ensure quality of care is maintained during the transfer of direct patient care from one postgraduate trainee to another at the end of each 24 hour period … and shall take into account cases of individual patient emergencies” (11).
The real issue here seems to be what kind of new work, if any, is reasonable to expect of a resident after he or she has already worked for 24 consecutive hours. Barring a genuine clinical emergency, I would argue that the answer is none. Like other specialties, psychiatry requires its practitioners to make judgments that can affect life and death. In dealing with a suicidal patient, for example, a resident must often decide whether to let the patient leave the hospital. Such decisions, difficult to make under the best of circumstances, require nuanced judgment of a kind that comes with experience—and with alertness.
The nature of the work in psychiatry requires exceptional attentiveness and empathy. This is particularly true in the outpatient therapeutic setting, but is also true in the emergency room, on the inpatient service, and when doing consultation. Increasing evidence suggests that sleep deprivation interferes with empathy (12, 13). At best, this translates into indifference; at worst, into anger at the patient for being the cause of the resident’s misery. The psychiatrist’s primary tool is his or her ability to connect with a patient. A therapist who is irritable, falling asleep, or simply disengaged is doing no one any good—and may be doing actual harm.
No longer do we accept the old adage, “The problem with working every other night is that you miss half the good cases,” recognizing—among other things—that one’s ability to learn new information declines considerably after a long period awake (14). Sleep is not a luxury; it is a necessity that makes it possible to respond appropriately to the punishing new demands of contemporary medicine.
Drs. Lomonaco and Auchincloss:
A major goal of work hours restrictions has been to protect patients from error caused by fatigue. However, studies investigating the relationship between fatigue and various aspects of work performance are marked by inconsistencies and methodological flaws (15). In a review examining the relationship between fatigue and work performance, Howard et al. (16) state, “There is little consensus among studies on the effects of fatigue on the performance of health care personnel.” Gaba and Howard (17) acknowledge that “despite many anecdotes about errors that were attributed to fatigue, no study has proved that fatigue on the part of health care personnel causes errors that harm patients.” The Harvard Work Hours, Health, and Safety Group study of interns on traditional and limited schedules concludes that reducing interns’ work hours in an intensive care unit significantly decreased attentional failures (7, 8). However, the study could not control for increased supervision of interns on the limited schedule by worried residents and faculty who were not blind to the conditions of the study (18) and it did not look at delayed effects of a night-float system on patient care. Clinical errors may be caused by multiple factors other than resident fatigue, including the frequent handoff of patients between clinicians, delays in ordering tests, and lack of communication between providers (15, 19). There is some evidence to suggest harm to patient well-being as a result of discontinuities in care due to interventions designed to limit resident work hours (20). In psychiatry, we are particularly concerned about the effect of frequent handoff on the doctor-patient relationship.
Work Hours Regulations: Impact on Resident Well-Being and Professionalism
Drs. Lomonaco and Auchincloss:
The relationship between fatigue and housestaff health, including mental health, is often cited as a reason for more stringent work-hours monitoring. However, the actual effect of unregulated work hours on house-staff health is difficult to study, and there are many reasons to be concerned that rigid restrictions may actually interfere with the optimal training of psychiatrists. Citing increased program size, a decline in professionalism, decreased intimacy in training, and limited diversity of patient exposure, Bellevue NYU’s Director of Residency Training in Internal Medicine argues that work hours regulations are having a negative impact on residency training in internal medicine (21). We share all of these concerns (and more) as they pertain to residency training in psychiatry.
Restricted work hours leads to less overall training. In Cornell’s program, where a resident is on call approximately 30 days per year, a full month is lost per year as a result of postcall work restrictions. This work is lost for classroom work, for research, and above all, for patient care. Less exposure to patients is a serious threat to the training of clinicians. We are especially concerned that learning psychiatry in a setting where patients are frequently handed off to other residents will lead to less immersion in the lives of patients, less sense of responsibility for patients as individuals, and a deterioration of the resident-patient relationship, already weakened by reduced length of stay in inpatient units. Therapeutic alliance has been shown repeatedly to predict for positive outcome in all kinds of psychiatric treatments (22), and we are concerned that these threats to the alliance may have serious effects on patient outcomes.
In our opinion, residents are increasingly being encouraged to see patients not as people but as objects to be handed off from one to another, and to see themselves not as doctors but as shift workers with no real interest in either the daily life or the long term welfare of those in their care. Work hours regulations for residents as presently mandated contribute to this trend, effectively forbidding a postcall resident from staying involved with a patient who is desperately sick. The young physician’s tie to his or her patient is one that should not be rigidly regulated. The overall movement toward a shift-work mentality aggravated by rigid work hours regulation has disastrous consequences for the personal accountability so crucial to professional identity formation in young psychiatrists.
Time is neither an adequate nor an accurate measure of patient care. In psychiatry, we limit a therapy hour to 50 minutes, but that tells us nothing about the therapist’s commitment to the patient. Similarly, rescheduling a therapy session postcall, when the therapist might otherwise have fallen asleep in session, is far from a sign of indifference. The new system must teach residents both to be accountable to their patients and to be attentive to their own limitations and needs. Overwhelmingly, patients support limitations on resident work hours, and express serious reservations about being treated by sleep-deprived physicians (23).
In years past, residents were responsible for everything from psychotherapy to phlebotomy to patient transport, but times have changed. With shorter stays on inpatient units and increased productivity demands in the outpatient setting, it is simply not practical for physicians—either residents or attendings—to be performing nonphysician work. Far from representing a decrease in accountability, the movement on the part of residents to reallocate tasks that could be performed by others comes from a deep commitment to providing the best possible patient care. What residents fighting for reform recognize is that there is a difference between physical presence and emotional involvement with the patient.
As residency training moves into the 21st century, we need a new kind of professionalism. Freshly minted doctors are no longer mostly young, single white men whose sole responsibility is to their work. Increasingly, medicine is composed of women with young children, slightly older people for whom medicine is a second career, men and women whose partners also work full-time, and people who are simply unwilling to accept that becoming a doctor means giving up an outside life. Over the last several years, medical students have been choosing their specialty based less on income and prestige, and more on life style concerns (24). One of the major new tasks of training, then, has become to teach residents how to be good doctors without neglecting themselves, their families, and their friends. Navigating one’s absences and limitations with a patient is not an easy task, but the psychiatrist who learns this early will ultimately be providing a service to his or her patients.
Excessive work hours have an impact not only on patient care, but also on resident well-being. Recent studies from the Harvard Work Hours, Health, and Safety Group have demonstrated an increase in motor vehicle accidents (25) and needle stick injuries (26) in sleep deprived residents, and as the OSHA petition documented in 2001, sleep deprivation increases the risk of obstetric complications and depression (3). As psychiatrists, we must take seriously the possibility that we are causing or precipitating in our house staff one of the illnesses that we work so hard to eradicate in our patients. Available data suggest that rates of depressive symptoms and depression are higher in medical residents than in the general population (27), and that the prevalence appears to increase as rotations become more intense (e.g., in the ICU), and decrease by year of training (28). Sleep deprivation caused by long working hours, coupled with the tremendous stress of beginning training and caring for the very sick, may well be responsible for this increased prevalence.
In psychiatry, studies have repeatedly shown that both during and after residency, rates of depression and suicide are higher than in other specialties (29–31). The combination of fatigue and the emotional stress of sitting with psychiatrically ill patients is a recipe for depression. We tell our patients to make sleep a priority because fatigue contributes to their sense of dysphoria, but residents who make the same choice are faced with the (often internalized) message that their behavior is unprofessional. How can we condone a practice that makes it impossible for our residents to tend to their own mental health?
Work Hours Regulations: Impact on Academic Medicine
Drs. Lomonaco and Auchincloss:
As residents spend less time engaged in patient care, faculty spends more. Because work hours regulations are an unfunded mandate and programs are expected to comply without additional resources, the regulations often have the net effect of increasing work for attendings. A bizarre situation has ensued where after an overnight shift in the emergency department, residents go home to rest, and attendings, unprotected by regulations, continue to work.
This change in the balance of clinical care responsibility further undermines the development of professional identity in psychiatry residents. At the risk of sounding old-fashioned, we think there is something to be said for the development of “personal toughness” in young physicians. “Toughness” is not arrogance or a lack of empathy; it is a physician’s ability to focus on the patient regardless of competing demands, and it is acquired only from being on the front line often and over time. We worry that as faculty are increasingly responsible for “on the line” aspects of patient care, the development of our residents’ capacity for complete devotion to the patient’s well-being will be compromised.
We must also consider the fact that much of the clinical work required to keep academic medicine alive has been done by trainees who, relative to faculty, work long hours seeing patients for vastly lower wages. This long-standing distribution of labor has freed faculty time for teaching, supervision, research, and other academic pursuits. Now, however, the balance of clinical work is shifting. The increased clinical time demanded from attendings jeopardizes the whole structure of academic medicine, and bodes poorly for our trainees’ future as academicians. The original Bell Commission recommendations emphasized improved supervision for residents in addition to limiting work hours (32), but a paradoxical situation has developed wherein work hours regulations (as currently mandated) have the effect of decreasing faculty time available for supervision, and, as recent graduates of our program have discovered, jobs for faculty often come with little time for academic pursuit (33). Are we mortgaging the future of academic medicine for the short term goal of regulating resident work hours?
Finally, rigid regulation of resident work hours as currently mandated affects the administrative structure of residency training in ways that are harmful for the education of young psychiatrists. For example, residency training directors are forced to spend ever more time concerned with regulation compliance rather than with education. New York State now demands 100% compliance with work hours regulations with the threat of heavy fines for violations. New York Presbyterian Hospital has instituted daily online logging of work hours requiring constant monitoring by the Program Director and her staff. Fines up to $200,000 are proposed by Congress with further threats of nonaccreditation if compliance is not achieved. Some proposals also include whistle-blower protection and whistle-blower compensation if wrongdoing is uncovered. All of these developments threaten to turn program directors and residents into adversaries. Graduate Medical Education Committee meetings of New York Presbyterian Hospital have, on many occasions, deteriorated into discussions of what legal measures are available to force residents to not work. If we find residents taking care of patients, meeting with families, studying in the library, or attending class when they should be at home, they must be reprimanded and even punished in order to avoid dire consequences for the program.
Many of the problems facing residency training in psychiatry have little to do with resident work hours reform. A crisis in funding, the escalating power of managed care, increasing requirements for supervision, and lack of support for teaching all contribute to an environment in which attendings must work longer hours seeing patients and do not have the time to teach and write. But no matter how much or how little residents work, it will not solve the problem. Attendings, like residents, need to demand better working conditions that make possible the kind of teaching and mentoring from which earlier generations of psychiatrists benefited. The emerging data on sleep suggests that limits on work hours should be more rather than less stringent, and these rules should apply to attendings as well as residents. We should perhaps take a cue from the United Kingdom, where physicians’ work is now limited to 13 consecutive hours and 58 hours per week.
Although the ACGME reports that programs are largely conforming to the new regulations, with only 2.2% of residents working more than 80 hours per week and only 7.6% of residents working more than 30 consecutive hours (34), a recent large prospective study of interns’ compliance revealed that more than 80% of interns nationwide across specialties reported some violation of the regulation (35). Even in New York State, where strict monitoring is in place, violations were commonplace. In psychiatry, 86% of programs had work hours violations, with interns in 69% of programs working more than 30 consecutive hours and interns in 50% of programs working more than 80 hours per week. These statistics suggest that programs are vastly underreporting violations to the ACGME, either out of ignorance or fear of losing accreditation. Given the disparity between violations and reporting, whistle-blower protections are essential to real reform. Strict monitoring may be cumbersome, but without it, little has changed.
Two Sides of the Issue: Points of Disagreement and Consensus
Although we may disagree about the details of implementation and the number of hours that are reasonable for residents to work, we agree that there should be some limitations on resident work hours. Drs. Lomonaco and Auchincloss believe that work hours restrictions, as currently mandated and enforced in New York state, may well have unintended consequences for the health of patients. They argue that work hours restrictions have untoward impact on the professional development of residents and the overall structure of academic medicine. Dr. Rasminsky believes that work hours restrictions do not go far enough in protecting residents and patients from the harmful effects of fatigue. She argues that our definition of professionalism needs to be reexamined in light of emerging scientific literature.
We Recommend the Following:
1) There should be some limitations on resident work hours, with the exact numbers determined by growing scientific knowledge about the effects of prolonged wakefulness. Some provisions should be made for patient emergencies and transfer of care, but this extension should be used judiciously and not extended to new work (e.g., seeing outpatients).
2) Funding should be provided for increased ancillary staff, in order to allow residents to focus on patient care and complete their work in the most efficient manner possible.
3) We must develop a system for thorough transfer of care particular to psychiatry. Such systems have been developed in internal medicine programs (36).
4) Residents should be involved in determining best practices for creating schedules that allow them to complete their work efficiently. True change requires a commitment to thinking beyond existing structures, and the programs that will be successful in this process are those that are thinking creatively about all aspects of training.
5) Above all, we recognize that more study is needed, especially in psychiatry. We applaud the decision of the AMA Council on Medical Education to assess the effects of the ACGME work hours requirements on the educational and work environment of both learners and teachers (37, 38). We urge APA and AADPRT to follow its lead.
Further areas of study in psychiatry include: 1) evaluating the impact on work hours restrictions on learning, both in the classroom and in clinical settings; 2) evaluating the impact of work hours restrictions on mental health; and 3) what are psychiatry programs around the country doing to address the ACGME’s new regulations? What gets in the way of compliance? For those who are successfully restricting hours, how are they doing it?