Efforts to limit work hours of residents spurred ongoing debate over whether patients are, in fact, safer as a result. Some ethical considerations include the following:
- The patient/physician relationship may be harmed if residents are forced to leave in the middle of an evolving clinical encounter.
- Residents may be hindered from following the progression of acute illnesses.
- Attendings are likely working more hours as resident work hours are curtailed.
Ethical concerns involving residency work hour limits persist, long after the Accreditation Council for Graduate Medical Education (ACGME) introduced restrictions in 2003 and again in 2011.
“The movement to restrict resident duty hours is most commonly attributed to the now-infamous Libby Zion case,” says Philip M. Rosoff, MD, MA, professor of pediatrics and medicine at Duke University Medical Center’s Trent Center for Bioethics, Humanities, and History of Medicine in Durham, NC.
In 1984, a young woman, Libby Zion, was admitted to the hospital with apparent dehydration and altered mental status. “There were no senior attending physicians directly involved in her care. The harried, and presumably exhausted, intern and resident on call were primarily responsible for her management,” says Rosoff.
After the patient’s death, her father launched a high-profile campaign to change the system of postgraduate medical education whereby residents worked long and grueling hours, sometimes over 100 hours a week.
“The underlying assumption for these efforts has always been that Ms. Zion’s death could have been prevented if the residents caring for her were not so tired, and if they had been properly supervised by an experienced doctor,” says Rosoff.
Over the years, improved supervision and limited duty hours for residents have been enacted, each further decreasing the number of consecutive hours residents can work.
“The assumption is that residents who are more rested and whose work is more closely overseen by attending physicians — even on the ‘graveyard’ shifts — would provide safer and better care,” says Rosoff. It is unclear if these expectations were realized, however, and whether there were any unintended consequences.
“Residents are certainly more rested. But in order to avoid the onerous penalties associated with duty hour violations, hospitals are rigorous in the enforcement of the rules,” says Rosoff.
This means residents are sometimes forced to leave patients in the middle of an evolving clinical encounter. “This could prove to be corrosive to the development and maintenance of a doctor-patient relationship,” says Rosoff.
Residents are sometimes unable to follow the progression and evolution of acute illnesses from hospital admission onward. “On the other hand, it could be argued that all of these negatives could be balanced, if not overridden, by any benefits that could accrue to patients, hospitals, and, of course, doctors themselves,” says Rosoff.
More “handoffs,” which put patients at risk for communication errors, are occurring. “We may have traded one kind of risk with another, which could possibly be even worse,” says Rosoff.
Rosoff sees potential harm in the way new doctors are educated. “Many would hold that there was inherent value in the intense, experiential involvement of physicians-in-training with their patients, despite the fatigue that was a necessary adjunct,” he says.
The more patients residents see under the guidance of senior physicians, the more expertise they presumably gain, adds Rosoff. “One wonders if this time-honored method of training may have been jeopardized by the zeal with which duty hours have been embraced and implemented,” he says.
Multiple ethical concerns
Aviva L. Katz, MD, MA, CIP, FACS, FAAP, core faculty at University of Pittsburgh’s Center for Bioethics & Health Law and director of the ethics consultation service at Children’s Hospital of Pittsburgh, sees several ethical concerns with residency work hour limits.
“It is important to recognize that the traditional workload of residents, particularly surgical residents, was not developed in a prospective, evidence-based fashion,” she says.
Excessive work hours were developed to meet the need of caring for patients, says Katz — not to meet specific educational needs. She argues that the real failing in the Libby Zion case was not work hours, but lack of supervision.
Another consideration is that attendings are likely working more hours as resident work hours are curtailed. “There is no oversight regarding attending work hours, and they are just as vulnerable to the effects of acute and chronic sleep deprivation,” says Katz.
Research clearly shows acute and chronic sleep deprivation have negative effects on physical and emotional health, and may have negative effects on cognitive abilities. “So there is a potential that we are exposing patients, and residents themselves, to harm when work hours are excessive,” says Katz. “This has been very hard to demonstrate with observational research, as patient care is a team sport.” Many people are involved in a patient’s care, including the resident who has worked for over 24 hours.
Katz rejects the argument that shielding patients from sleep-deprived residents did more harm than good because residents won’t become skilled attendings. “This is a false argument, and ignores the history of the development of residency,” she says. “We can do better than hoping that residents will learn what they need if we just keep them captive long enough.”
- Aviva L. Katz, MD, MA, CIP, FACS, FAAP, Core Faculty, Center for Bioethics & Health Law, University of Pittsburgh/Director, Ethics Consultation Service, Children’s Hospital of Pittsburgh. Phone: (412) 692-8778. Fax: (412) 692-8299. Email: email@example.com.
- Philip M. Rosoff, MD, MA, Professor of Pediatrics & Medicine, Trent Center for Bioethics, Humanities & History of Medicine, Duke University Medical Center, Durham, NC. Phone: (919) 668-9025. Fax: (919) 668-1789. Email: firstname.lastname@example.org.