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OB/GYN Editorial February 2003
Residents and
Decreased Duty Hours
Ronald T. Burkman, MD
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For those who follow trends in resident education, the two “hot
topics” for this year and the coming months are duty hours,
and competency-based learning and evaluation. This editorial will
focus on duty hours. For those unfamiliar with the changes, duty
hours are limited to 80 hours per week; on-call cannot be more
fre-quent than one night in three; and res-idents cannot, with
few exceptions, provide patient care continuously for more than
24 hours. Most of the older generation can certainly recall the
long hours both related to continuous duty in the hospital and
to on-call frequency. To many, the long hours were in many ways
a rite of passage. However, except for the most recalcitrant of
us, most would recognize that being on duty for up to 36 hours
without sleep is not conducive to learning, and just is not safe
for patients, especially during the last few hours of the day.
Although one might suggest that doing routine, noncognitive activities
might be all right in such situations, the truth is that adherence
to protocols or guidelines and recognizing variations are critical
for error prevention such that one needs to have some degree of
alertness even when performing mundane tasks. Further, there are
probably more technical and cognitive tasks facing house officers
today compared to former years that cannot be accurately completed
when in a sleep-deprived state. It is also important to recognize
that the personalities and expectations of today’s younger
physicians are different. For earlier generations, the duty to
one’s patients took precedence, and family and personal pursuits
were sacrificed due to the requirements of work. In contrast, today’s
generation feels their professional life has an important, but
finite, place that should not totally drive one’s lifestyle.
Thus, there is less willingness to accept a profession in which
long duty hours leave little time for other activities. As an aside,
it will also be of interest to track applicants for residency programs
who have this change in attitude in mind. A significant concern
for many program directors of obstetrics and gynecology residencies
is whether the number of applicants will begin to drop due to these
concerns as well as other concerns such as the current liability
crisis.
There is, however, a flip side to the debate. Reducing duty hours
and on-call schedules means there will be less continuity for some
patients and more “handoffs” among residents, leading
to an increased chance for error. In addition, within a specialty
such as obstetrics and gynecology where there are a substantial
number of technical skills one must learn, less duty means less
exposure to some clinical situations. In my own residency of five
house officers per year, one could anticipate that as much as 20%
of experience may be lost by each graduating resident unless one
can craft a revamped approach to coverage and on-call. Unfortunately,
nestled among those normal deliveries will be the unpredictable
occurrences of shoulder dystocia and postpartum hemorrhage that
residents need to experience to become competent obstetricians.
One can cite other examples where exposure to complicated cases
will likely be reduced under these new guidelines. There is also
some concern that these requirements do not reflect the demands
on time that some graduating residents will face once they enter
practice. Although working reduced hours or even part-time is possible
today, it is important to recognize that income will accordingly
be reduced. For house officers with large debts accrued in medical
school, today’s reimbursement rates and practice costs may
not allow those physicians with sizable debt to work such limited
hours. A final thought: if long duty hours are deemed unsafe for
young physicians in training, what about older physicians already
in practice? Although I for one feel that on-call duty limitations
for all physicians are now inevitable, I guess only time will tell.
Ronald T. Burkman, MD
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