How Many Hours?

Abstract

In July 1989 the New York State Department of Health enacted regulations that limited hours worked by residents, increased supervision by attending staff, and augmented ancillary services. The plan, proposed by the Bell Commission, has radically transformed postgraduate medical education by paring down the work week to eighty hours and by restricting shifts to twenty-four hours. The state believed that improved supervision and shortened hours would improve patient care, foster medical education, and reduce resident fatigue and stress. Prompted by developments in New York, state legislators and policy-makers across the country are reexamining the grueling schedules traditionally worked by physicians in training. Although New York is still the only state with mandated restrictions, Iowa, Massachusetts, Michigan, and Pennsylvania have similar bills pending. Proposed legislation in Connecticut, Hawaii, Illinois, and Missouri that sought comparable reforms has been unsuccessful. Legislators in California and New Jersey are studying the issue in more detail. Although these reforms represent a long overdue correction of residency training first introduced nearly a century ago, the commission's recommendations may have hidden liabilities that could threaten fruitful post-graduate medical education and compromise patient care. Forcing house officers to leave after twenty-four hours on call may deprive them of an educational process that continues into the day after admission. A resident's preliminary clinical impressions are often refined by instruction from senior staff bolstered by laboratory results available only the morning after admission. This critical period of instruction could be jeopardized by state relations. Continuity of care is often compromised by shortened shifts which require that more physicians participate in an individual patient's management. Under the Bell regulations, patients admitted overnight to the hospital might expect their care to be provided by three different physicians over the first twenty-four hours of hospitalization. When a group of physicians replace an individual practitioner, the risk of miscommunication is heightened. Sign-out procedures between physicians are unfortunately unable to replace first-hand knowledge of a patient. The intricate "cross coverage" system needed to comply with the Bell reforms also requires residents to cover for patients they have never met. When residents do meet their colleagues' patients it is generally because of an acute problem that requires them to distinguish the unimportant complaint from the critical symptom. Deprived of any previous exposure to the patient, save for the sign-out sheet, inexperienced physicians will often order additional medical tests "to play it safe. …