The Institute of Medicine Resident Work Hours Recommendations: A Program Director's Viewpoint

Abstract

Over the past several decades, the practice of medicine has changed dramatically. Hospitalized patients are sicker. The number of medication choices is larger. The pressure to discharge patients quickly is more intense. Despite these changes, the way in which we train residents has remained largely the same. The number of residents and the length of residency training have not changed significantly. Until recently, the hours remained quite long. In recent years, we have discovered that quantity and quality of sleep have a significant impact on the health and well-being of our patients. Driving while sleep-deprived is equivalent to driving under the influence of alcohol. We would never allow our residents to practice medicine while under the influence, and it makes sense to examine the impact of sleep deprivation on our residents' ability to learn and to practice medicine safely. If it is shown that medical mistakes increase with sleep deprivation, we should do what we can to minimize the risk to our patients. This is much more complicated, however, than mandating fewer work hours and protected sleep time for our trainees. With the last reduction in resident work hours, there was no concomitant increase in the number of residents accepted to training programs, nor to the number of supervising physicians. We essentially told our trainees to provide good quality medical care to larger numbers of patients with increased medical complexity. .. faster. Many residency programs have struggled with it, and further limitations in work hours cannot be made in a vacuum. If resident work hours are further limited, hospitals will have to find a way to provide adequate coverage for their patients. A seemingly innocuous solution would be the addition of more residency training positions. This might also be used to train more primary care physicians and other types of doctors for whom a shortage is anticipated. This is easier suggested than done, however. The way in which hospitals are reimbursed for their training of residents is already antiquated and inadequate. The training of more physicians would also require that more supervising physicians be hired. Alternatively, hospitals could forego the hiring of more trainees, and simply shift the burden of patient care to more senior physicians. After all, such physicians have no work hour restrictions. If interns and residents are more prone to mistakes as a result of sleep deprivation, it would follow that sleep-deprived supervising physicians would be less likely to notice and correct the errors of their trainees. Another potential solution would be to increase the duration of residency training programs. Difficulties abound here as well. Residents would require additional years of wages. The wages that they currently receive during their period of training are quite low, given their prior education and the number of hours they are asked to work. This would potentially deter a significant number of prospective physicians from entering the profession. There are innumerable other ways in which the challenges of further limiting work hours can be addressed. All of them are quite costly, as the Institute of Medicine (IOM) freely admits. I wonder where this extra funding will come from? I hope that as President-Elect Obama's incoming administration examines potential changes to our healthcare system, they remember to take a fresh look at how we train physicians.