It was 6 a.m. in the emergency room when the patient came in with labored breathing. His respiratory rate was so low that medical resident Dr. Maura Madou wanted to give him her full attention. That might have been easier if she hadn’t already worked 22 hours.
“He was pretty sick, and needed someone with high acuity,” she said. “I honestly couldn’t wait for the next shift to come in.”
First-year residents like Madou won’t be forced to summon full focus from their sleep-deprived brains and bodies come July. New national regulations will reduce the number of consecutive hours they can work from 30 to just 16. The regulations, issued by the Accreditation Council for Graduate Medical Education, also restructure the supervision residents receive.
Although the regulations only affect first-year residents, they will not be cheap.
San Francisco General Hospital, where Madou and more than 300 other residents work, expects to spend about $5 million hiring at least nine new doctors and could hire more than twice that many, said Dr. Sue Carlisle, associate dean for UC San Francisco. The money will come from The City’s’ general fund, insurance payments or federal funds.
The Veterans Administration Medical Center in the Richmond district could hire about as many new physicians, and UCSF’s Parnassus Campus may hire some new faculty as well, said Associate Dean Dr. Bobby Baron.
The changes come in response to public concern that fatigued residents may provide poor care. Although Baron said research has not yet concluded whether the change will improve patient care, California Nurses Association President DeAnn McEwen said all signs point to yes.
She said physicians are more likely to make errors when they are dog-tired and that she has had to repeatedly explain to an exhausted doctor the details of a patient’s medical history.
“The patients begin to run together, the diagnoses and the treatments run together,” she said. “It’s not acceptable to put patients in harm’s way to save hospitals money.”
But Carlisle said there are drawbacks. Following the progression of a patient’s disease throughout a full day is a valuable learning experience. And the more times doctors hand off a patient, the higher the chance some important information won’t be relayed.
“We’re human beings,” she said. “Things fall through the cracks.”
On the other hand, she recalled her own shifts in personality and emotions working a residency with no time limits. “I have to resist the thought that yeah, they’re losing a great part of the training by not being forced to do what we did,” she said. “But it’s not really a reasonable way to learn.”
Madou said she doesn’t believe she’s ever witnessed a patient getting bad care due to resident exhaustion. And since she’ll be entering her second year of residency, she will still have to pull some long shifts anyway. And she’s OK with that.
“There’s this adrenaline thing, where you just kind of do it,” she said. “You’re exhausted, but you do what needs to be done.”
How the rules are changing
New work limits for medical residents and what they could cost:
|Current regulations||New standards, starting July|
|- An 80-hour weekly limit, averaged over four weeks.||- A 16-hour limit on continuous duty for first-year residents.|
|-An adequate rest period, which should consist of 10 hours of rest between duty periods.||- A 24-hour limit for intermediate residents, with “strategic napping” when working more than 16 hours “strongly suggested.”|
|- A 24-hour limit on continuous duty, and up to six added hours for continuity of care and education.||- Intermediate residents must have at least 14 hours of free duty after 24 hours of in-house duty.|
|- One day in seven free from patient care and educational obligations, averaged over four weeks.||- First-year residents should either be directly supervised or direct supervision should be immediately available.|
|- In-house call no more than once every three nights, averaged over four weeks.||- Residents in their final years of education must be prepared for unsupervised practice of medicine over irregular and extended periods.|
- Direct costs nationwide for the changes (in 2008 dollars): $380 million
- Cost to the residency program at San Francisco General Hospital (in 2011 dollars): $5 million
Source: Accreditation Council for Graduate Medical Education