It’s widely known that life as a medical resident—the last required phase in a doctor’s training—is no picnic. Of the many factors contributing to the rigor of hands-on medical training, the grueling hours may be the most notable. Until recently, it was not unusual for residents to work well over 80 hours a week, sometimes in over 24-hour stretches. Some medical professionals support this trial-by-fire approach on the grounds that it fosters patient continuity of care while conditioning young residents to make tough medical decisions under taxing circumstances. As one doctor put it to NPR, “Training to become a practicing physician can be compared to training for a marathon. … You must learn how to pace yourself, take care of yourself and recognize your limits.”
But in the early 2000s, some medical professionals began to question this old school faith in the grind—wondering if limits should be imposed. Drawing on documented cases where overwork directly caused patient harm, or where doctors themselves were passing out on the job, they argued that, as in the aviation and transportation industries, fatigue in the medical field contributed to unsafe working conditions. Their arguments stuck, culminating in several regulations, the most important coming in 2003, when the Accreditation Council for Graduate Medical Education stipulated that there be no more than an 80-hour work week for all residency programs. In 2011, additional regulation required that first-year residents could not work more than 16 hours straight. Skeptics pushed back, arguing that these reforms would result in less effective medical care.
Now, a new study suggests that the trial-by-fire approach from the days before the 80-hour regulation might not have delivered the benefits its advocates claim. In the first national study to explore the impact of limiting training hours on physician performance to 80 hours a week, Anupam Jena, a doctor at Massachusetts General Hospital and a professor of public health at Harvard University, along with his colleagues at the Blavatnik Institute at Harvard Medical School, “found no evidence that the care provided by physicians who trained under the 80-hour-a-week model is suboptimal.”
Analyzing nearly a half million hospitalizations—cases in which patients were quite ill and therefore especially sensitive to negligence—Jena and his team used 30-day mortality rates, 30-day readmission rates, and inpatient spending as measures for comparison. Aware that a slew of hospital reforms over the last decade (better diagnostic methods, improved coordination of care, and advanced digital tools) could skew results in favor of physicians trained after the 80-hour regulation, the authors took efforts to study doctors’ performance post-80-hour-regulation and pre-80-hour regulation, in order to isolate the change due solely to the hour-limit regulation.
The authors were also careful to ensure that the categories of physicians in the study were dealing with the same range of diseases, chronic conditions, and patients of the same gender distribution and age. With these distorting factors controlled for, the authors could turn to comparing performance for those trained before the 80-hour limit and those trained after it.
The results for young (trained after the 80-hour limit) and old (trained before) doctors were barely distinguishable. The 30-day mortality rates among patients cared for by first-year attending internists were 10.6 percent before the other hospital reforms and 9.6 percent after. The 30-day mortality among patients cared for by 10th-year physicians before and after the other hospital reforms was 11.2 percent and 10.6 percent for the same years. The same held true for hospital readmission rates, with 20.4 percent of patients cared for by first-year physicians both before and after other hospital reforms experiencing readmission, compared to 20.1 percent and 20.5 percent, respectively, for those patients treated by 10th-year physicians.
The implications of these results could have an ongoing impact on the future of medical training—and probably one that encourages doctors to get more rest. Not only does it align closely with current research showing that sleep correlates favorably with academic learning and job performance in other realms of professional life, but it appeals to the basic common sense notion that, young or old, a well-rested physician is a better physician. As Michael Carome, director of Public Citizen’s Health Research Group, told NPR in 2016, “sleep deprived physicians are a danger to themselves, their patients, and the public.”
