New policy for medical interns: More rest, less work

NORFOLK

Coffee fueled the 24-hour shifts that were typical for Dr. Shilpa Babbar during her first year of residency at Eastern Virginia Medical School two years ago.

However, first-year residents who started work this month won't have such a brutal introduction to the field of medicine.

New guidelines established July 1 by the Accreditation Council for Graduate Medical Education restrict first-year residents to working no more than 16-hour shifts. Second- and third-year residents will be permitted to work 24 hours at a time.

It's the latest step in a national drive to address concerns of fatigue-induced errors, which can be an issue with everyone from air traffic controllers to bus drivers to doctors.

The change in the medical field is an attempt to improve patient safety, but it does not come without controversy. Some academics worry the restrictions will water down instruction and result in less-prepared doctors.

"You need to have some training under duress," said Dr. L.D. Britt, chairman of the Department of Surgery at EVMS, and president of the American College of Surgeons. "No one wants to exhaust a trainee. But we also can't dumb down our profession. We can't continue to take hours away. We have more to teach in 2011 than we did in 1970."

Linda Archer, associate dean for graduate medical education at EVMS, said the school has been retooling schedules for 10 months so they would be in place by the July deadline. Medical schools across the country are complying with the new guidelines to maintain their accreditation.

Another new policy requires more supervision of residents. Before, "you could be a medical student one day and see a patient alone the next," Archer said.

Now first-year residents, also called interns, must be supervised by another physician. Residents must also be educated about sleep deprivation and have access to "call rooms" in hospitals that are "safe, quiet and private" to catch some shut-eye. First- and second-year residents also must have eight hours off between scheduled duty periods.

Archer said work schedules have been adjusted to cover patient care, an electronic monitoring system has been set up to track resident hours and instruction on the signs of fatigue has been bolstered. About 300 residents at EVMS fall under the new guidelines.

"To the public and health care system, it's going to be seamless because we've been running the scenarios for a while now," Archer said.

But for medical educators, it's a sea change to the culture. After all, the term "resident" is derived from the idea that doctors in training spend so much time at the hospital they practically reside there. Britt remembers working 120 hours a week when he was a resident, which he concedes is too much. He remembers once taking a medical history when he was so tired he not only fell asleep, but fell out of his chair. "The patient had to wake me up."

Britt said residency hours have been reduced since then, but he's worried the accreditation agency is going too far, particularly in high-pressure specialities like surgery. "There are times, as a surgeon, you are called at 2 in the morning and you have to be ready for that."

A critical step toward hour restrictions came in 1989, when the state of New York passed what is known as the Libby Zion law, restricting resident hours in hospitals to 80 hours a week. Libby Zion was an 18-year-old college freshman who died under the care of overworked medical residents. The accreditation agency adopted similar 80-hour work week restrictions in 2003.

The latest batch of policies was first released last year for comment.

At that time, a survey of residency program directors found that more than half thought it would erode competence in core areas of study and 87 percent said it would harm the continuous care of patients.

Patient safety advocates, on the other hand, have questioned why the 16-hour restrictions don't apply to second- and third-year residents as well.

Dr. Kedar Lavingia, a first-year resident in surgery at EVMS, said he and many of his colleagues worry the restrictions will limit the number of learning experiences they'll have during their training.

"If we want to be here, why not? We enjoy doing what we do, so if we could, we'd stay longer," Lavingia said.

Babbar, a third-year resident in an EVMS obstetric-gynecological residency, said she remembers well the difficulty of working the long hours during her intern year.

But she said she learned a lot working long hours and also appreciated having a little more autonomy than interns will have now with the new restrictions.

"It was a good learning experience," Babbar said. "It makes you feel like you can endure when put to the test."

But she also understands the thinking behind improving patient safety.

"Ultimately it comes down to patient care, and that comes before anything."

Elizabeth Simpson, (757) 446-2635, elizabeth.simpson@pilotonline.com