As European countries approach a 2009 deadline for fully implementing a 48-hour workweek for doctors, critics have renewed their arguments. In November, a study published jointly by the Royal College of Anaesthetists and the Royal College of Surgeons suggested that medical education in the United Kingdom would need an overhaul in order to maintain certain training standards while complying with reduced-hour rules. Testifying before the U.S. Institute of Medicine's committee on residents' work hours, Dr. Bernard Ribeiro, former president of the Royal College of Surgeons of England and an outspoken critic of shorter work hours, urged members to consider the implications of reducing residents' hours: British residents today perform 25 percent fewer procedures than they did before the regulations began to take effect, he said.
Despite such a warning, lessons gleaned from other countries played a modest role in the committee's deliberations. An appendix, "International Experiences Limiting Resident Duty Hours," took up 19 pages in the IOM's 480-page report, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. "Each system is different—it's hard to generalize," said one committee member, Dr. Kenneth Ludmerer, a professor of medicine and history at Washington University in St. Louis. "Ultimately, we're concerned about our own country."
But here, too, shorter working hours for residents have a spotty record.
In 2003, when the Accreditation Council for Graduate Medical Education ruled that residents could work no more than 80 hours a week, hospitals were forced to hire additional nurses, technicians, and senior doctors to pick up the residents' slack. Last week, the IOM committee said its recommendations could cost $1.7 billion a year. The committee justified the expense by saying medication errors and the cost of treating drug-related injuries in hospitals add up to more than $3.5 billion a year.
But if the mistakes of drowsy doctors are merely replaced by the mistakes of ill-trained doctors, there won't be as much benefit as the IOM predicts. Dr. Elias Traboulsi, chairman of graduate education at the Cleveland Clinic, points out that a quality medical education often hinges on how much time is spent treating patients and working in the hospital. Time restrictions also limit residents' exposure to the longitudinal nature of illness, said Dr. Joseph Loscalzo, chairman of the Department of Medicine at Brigham and Women's Hospital in Boston. "It really fragments the learning experience we wish our residents could have," said Dr. Loscalzo. The Accreditation Council for Graduate Medical Education allows hospitals to apply for small extensions of up to eight hours a week for some residents on the grounds that certain medical specialties, like surgery, benefit from more training, but those extra few hours might not be enough.
We all want our doctors to be well-rested, but the IOM's effort to ease the burden on overworked residents saddles some doctors with recommendations that could hinder their education. Across-the-board guidelines lump together doctors with vastly different skills, sleep needs, and career goals. More flexibility would keep the United States from facing the doctor shortages and training deficiencies seen by other countries. By allowing individual programs to tailor work hours to meet the needs of their residents, the rules could accommodate aspiring physicians for whom shorter shifts are sufficient as well as those surgery residents who may benefit from logging extra hours in the operating room. Then surgeons won't have to worry about fitting in nap time.
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