Reduced hours proposed for medical residents - East Valley Tribune: Health

Reduced hours proposed for medical residents

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Posted: Monday, September 20, 2010 7:00 pm

VENTURA, Calif. - Dr. Galen Holmes occasionally works 80-hour weeks with on-call shifts that can keep her in the hospital from 6 a.m. one day to noon the next.

As a family practice resident at the Ventura County Medical Center in Ventura, she sees the long hours -- with responsibilities from performing cesarean sections to caring for stroke victims -- as a way to maximize learning and make her a better doctor.

The possibility of government regulations chopping those 30-hour hospital stays nearly in half is, in her eyes, a threat.

"Getting hands-on experience is the best way for a physician to learn the trade," said Holmes, one of the hospital's two chief residents. "Less time in the hospital may be less experience."

Federal officials of the Occupational Safety and Health Administration announced this month they will consider proposals from advocacy, labor and student groups that contend work-hour rules proposed by an accreditation council's task force don't go far enough. They're pushing for new caps including:

-- No more than 80 hours in any week, compared to current standards that allow for an average of 80 hours.

-- A limit of 16 hours in a single shift, which now can be as much as 24 hours, plus another six to transfer care to another resident.

-- One day off every week and at least two consecutive days every month, compared to an average of one day off a week over four weeks.

Studies show that residents who work marathon overnight shifts make more medical errors. They also suggest that heavy workloads are linked to depression and a higher rate of pre-term deliveries for female residents and that they contribute to injuries.

"You accidentally stick yourself after a patient," said Dr. Charlie Preston, a medical resident from Washington, D.C., and co-author of the petition to OSHA. "I know a resident in my program who was exposed to hepatitis."

Critics of the proposals talk about lost education, continuity of care and problems inherent with government regulation. But the issue boils down to safety, said Preston, who works with the watchdog group Public Citizen.

The medical center operates a three-year family residency program for 42 people, attracting candidates from medical schools across the country.

Dr. David Araujo, program director, said residents work an average of 62 hours a week, about four hours less than the national average.

In elective rotations, residents may work typical eight-hour days, but workloads during month-long stints in surgery and general patient care can average nearly 80 hours a week. On-call shifts can last 30 hours, with the last six hours dedicated to transferring care to the next shift.

Safeguards are built into the system. Residents can't see new patients after 24 consecutive hours on duty. Educational conferences are held on sleep management and fatigue. Schedules are closely monitored -- and changed if hours pile too high. There are always other residents on overnight shifts, and attending physicians double- and triple-check decisions to avoid mistakes.

The goal is balance, Araujo said. Residency programs can't compromise safety, but they need to put doctors in the same kind of situations they'll face after their residencies.

"You need to be able to learn how to provide care ... under a certain amount of stress," Araujo said.

Preston wants balance, too. But he thinks an accreditation council task force's proposed standards -- including limiting first-year residents from working more than 20 consecutive hours -- don't go far enough. He remembers on-call shifts of up to 30 hours at a Phoenix hospital.

"I did it every fourth day or every fifth day," he said. "I was falling asleep when I was talking to my patients. ... How can you do your job when you're that tired?"

Craig Finney, a professor at California State University, Northridge, researches the effect of stress on employees and their work. A controlled amount of stress improves work performance, but at a certain point the ability to function falls off, he said.

Stress limits vary for each person, but "if you're asking people to work 24 hours, that's just not consistent with the biological clock," Finney said. "... It gets to the point where their bodies can't handle it."

Limiting shifts to 16 hours could strain schedules at some residency programs, forcing them to hire more residents and attending physicians to pick up the workload. There are predictions that dramatic limits on workloads could lengthen residency programs by another year, causing deep funding issues and exacerbating an already severe shortage of primary care doctors.

One of the most persistent arguments involves handing off patients from one shift of residents to another. The more transfers, the greater the risk that something won't be communicated and that patient care will suffer.

"I worry about those risks," Holmes said. "I think the intensity with which we choose to train makes us the doctors we want to be," she said.

Preston says the standards being pushed by Public Citizen and others still would yield a marathon schedule.

"We're acknowledging that ... you have to cram a lot of training in, but we're saying let's minimize the dangerous safety effects," he said.

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