One of my best friends in medical school returned from an interview for a surgical residency program. He told me how some of the surgeons there bragged that they were worked so hard that the divorce rate among their trainees was greater than 100 percent, ‘cause some of them burned through two marriages.

They were proud of this. I was horrified.

I doubt the statistic was true, even twenty years ago. And I’m even sure it’s not true now. But it points to an important truth: some physicians equate suffering with commitment, and believe that a residency should be grueling and difficult.
The limits on how we train residents and what new studies say about it is the topic of this week’s Healthcare Triage.

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A resident is a physician undergoing further on-the-job training after completing medical school. When I was one, I regularly worked 80+ hours a week. When I was in the infant Intensive Care Unit, I was on Q3, meaning that in addition to working 12-hour days, I worked every third night between them as well. In a bad week, I could easily clock more than 90 hours. And I was a pediatrician. Many specialties, like surgery, have it far worse!

Personally, I couldn’t believe that this was good for patient care. Others agreed. In 2003, the Accreditation Council for Graduate Medical Education passed new regulations that capped resident hours at 80 hours per week, and also limited shift lengths and required time off between shifts. In 2011, these were strengthened to limit further the time that interns, or first-year residents, could work.

There are other people in the healthcare industry who believe that such changes are bad for patient care. Reducing hours and shortening shifts mean that doctors have to hand-off patients to one another more regularly. Things could be missed; doctors who are coming on shift might not understand the patients as well as those coming off. Maybe reducing hours is bad for patients.

Most evidence does not support this claim though. A systematic review found that patient health didn’t improve after duty hours were restricted, but few studies found that it worsened.

Beyond patient health, there have been concerns that reduced hours might result in worse education: residents with reduced hours would miss lectures, surgical residents might be forced to leave procedures. These concerns make sense, but most evidence doesn’t support that claim that education is being harmed either.

A recent study published in the New English Journal of Medicine brings us new answers. It was a national study of 117 general surgery residency programs in 2014 and 2015. Programs were randomized to one of two work-hour policies.

The first was traditional – interns couldn’t work more than 16 hours straight, and other residents couldn’t work more than 28 hours straight, 24 for work and 4 for transition. All residents had to have at least 8 (but preferably 10) hours off between shifts, 14 hours if they’d just worked their 28-hour shift. Residents couldn’t work, on average, more than 80 hours a week over four weeks. They had to have 1 full day off every 7 days over 4 weeks, and they couldn’t be on call more than every third night.

The other group was assigned the new flexible policy. In that one interns could work more than 16 hours straight, and residents could work more than the 24/28 hours straight. They weren’t required to have the 8-10 hours off between shifts, or the 14 hours off after a long shift. They still couldn’t work more than 80 hours a week, averaged over four weeks, however. And they still had to have at least one day off for every seven, and still couldn’t be on call more than every third night.

In other words, residents in the flexible policy still had maximum hours capped and days off required, but they could work longer hours per shift to avoid missing procedures or having to hand off patients if they didn’t want to.

Data were analyzed on almost 139,000 patients.  The rates of death and/or serious complications were 9.1% in the flexible policy group and 9% in the standard policy group.  The flexible policy group was therefore not inferior.  The concerns we might have about patients being hurt if doctors work longer shifts do not appear to be well supported by data, at least using these criteria for hurt.  What about satisfaction?  Of the 4,330 residents studied, 11% of the flexible policy group and 10.7% of those in the standard policy group reported dissatisfaction with the overall education, which is essentially no difference.

With respect to well-being, almost 15% of those in the flexible policy group and 12% of those in the standard policy group reported dissatisfaction.  Again, hardly a difference.  Moreover, residents in the flexible policy group were less likely to report negative effects of duty hour policies on patient safety, continuity of care, professionalism, and resident education.  They were also less likely to leave in the middle of a procedure, 7% versus 13.2% or to report having to hand off patients in the middle of continuing problems, 32% versus 46.3%.  The flexible policy doctors were, however, more likely to report negative effects on personal activities.  

The author's conclusions gave me the impression that since giving residents more flexibility, like working longer shifts, didn't increase complication rates and seemed acceptable to residents.  The complaints of those who demand that residents be protected are overblown.  We should let them work more and not interfere.  It's safe and feasible.  I'm not sure I agree.  

Another way to look at this is that holding residents relatively shorter shifts didn't result in higher rates of death or complications in patients either.  Given that there don't appear to be patient harms, the only reason to switch is because you believe it's better for residents, and it's hard to imagine that's true.

Further, asking the residents what they think may not be the best way to determine if that's the case.  Residency programs have a way of indoctrinating new recruits into believing that misery is somehow noble.  A better metric, and one that we should all care about, is whether resident surgeons are less well-trained and skilled when they come out of residency now than they used to be before.  

I've heard plenty of anecdotes from colleagues to support this notion, but I've seen no good evidence to prove it, and without good data, it feels more like the usually griping each generation seems to have about being the last great one.  

The concerns of those training physicians are valid and they shouldn't be ignored.  However, if patients aren't harmed and education doesn't suffer, we should probably err on the side of treating our doctors-in-training as benignly as possible.  As I've discussed before, depression and other mental health problems are already too common among doctors during training.  We want to be sure that as we create doctors, we aren't sacrificing human beings. 

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation.  Your support makes this show bigger and better.  We'd especially like to thank our research associate Joe Sevits and thank our surgeon admiral, Sam.  More information can be found at patreon.com/healthcaretriage.  

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