The 80 hour work week

I've been working in the Pediatric Intensive Care Unit (PICU) for the past week, which is my excuse for not posting anything since May 9th.  While it was a relatively calm week in the PICU (at least on my team), I decided to take a short break from writing.  I'm looking forward to getting back into my normal cadence soon.

I am currently working on a talk that I will be delivering at the 2024 meeting of the World Federation of Pediatric Intensive & Critical Care Societies (WFPICCS 2024).  The title of my talk was supposed to be, "Next PICU Generations: Is the quality of personal life more important than the quality of training & education?"  I was told I could change the title as a condition of my agreement to participate, particularly after I expressed concern about the topic.  I think I said something like, "I wouldn't touch this question with a ten foot pole!"  I think I settled on a compromise that hits some of the program committee's request, and I will be certain to provide a follow-up report!

Sparing the details of my presentation (since I haven't quite finished it yet), I felt that I should at least touch upon the different generations that are working in the hospital today, with a specific focus on the fact that there are a lot of misconceptions (as I mentioned in my post, "Talkin' 'bout my generation!").  One of the most common misconceptions about Millennials is that they are too focused on work-life balance and don't want to work hard.  Given the fact that Millennials will soon comprise the greatest percentage of our workforce (if they haven't actually already done so), I thought that this would be an important discussion.  Next, I wanted to talk about some of the changes that have occurred in graduate medical education and whether this has had an impact on the quality of care that is delivered in the PICU.  I've certainly had some fun putting this talk together, so I hope that it will be an interesting discussion!

Medical education and training typically consists of four years of medical school after completion of an undergraduate degree (also typically four years), followed by three to six years of residency training (depending upon the specialty) and an additional one to three years of subspecialty fellowship training (again, depending upon the subspecialty).  For example, PICU physicians complete four years of medical school, three years of pediatric residency training, and three years of pediatric ICU fellowship training.  Prior to 2003, physicians in most residency and fellowship programs worked more than 80 hours per week, with shifts often lasting 30 hours or more in the hospital.  No one seemed to be too concerned about the high number of hours spent in the hospital until some high profile deaths (the most famous was the case of Libby Zion, whose death in 1984 at age 18 years was blamed on overworked residents in the hospital) that occurred in teaching hospitals due to medical errors committed by overworked residents.  In respone to these growing concerns, the Accreditation Council for Graduate Medical Education released a set of reforms in 2003 that restricted resident physicians to a maximum of 80 hours of work per week, as well as limiting single shifts to 24 hours.  Subsequent reforms were enacted again in 2011 (capping shift lengths at 16 hours for first-year residents) and 2017 (which allowed longer shifts for first-year residents, but imposed other limits).

While these restrictions have generally resulted in better resident and fellow wellbeing, better work-life balance, and reduced burn-out, they have not had a dramatic effect on hospital outcomes.  Several studies have shown that hospital mortality, length of stay, cost of care, and incidence of complications haven't really changed much since these restrictions were put in place.  On the other hand, these restrictions have led to concerns about the quality of education and training that residents receive, particularly in surgical fields where studies have shown a decrease in the number of surgeries that residents have performed upon completion of their training.  Even if the critical threshold is not specifically known, most experts in graduate medical education agree that building sufficient expertise requires physicians to see a minimum number of similar cases or perform a minimum number of procedures (think of Malcom Gladwell's 10,000 hour rule - see also my post, "Practice makes better, but does practice make perfect?").  The question becomes whether physicians have taken care of the minimum number of similar cases or performedd the minimum number of surgical procedures by the time that they complete residency or fellowship training and become independently practicing physicians!

My background research led me to a Harvard Business Review article by the economist Anupam Jena, "Is an 80-hour work week enough to train a doctor?"  The article is based upon two research studies that Jena and his team published in Health Affairs and British Medical Journal, respectively.  Using a difference-in-differences analysis of two cohorts (one from the state of Florida and the other from a national database), Jena and his colleagues found that 30-day hospital mortality, length of stay, and cost of care did not change after the 80 hour work week was imposed in 2003.  Specifically, hospital outcomes for patients cared for by internal medicine physicians during their first year out of residency training did not change after the work hour restrictions were imposed.  In other words, these newly independent physicians apparently received enough training during their residency, even with the 80 hour work week restriction, to provide excellent care for their patients.  Jena also found that "spending fewer hours in the hospital during training had, on average, no effect on internists' hospital readmission rates or costs of care when they subsequently entered independent practice."  He further wrote, "At a minimum, the data suggest that the incremental experience gained from working more than 80 hours per week as a resident doctor doesn't generally translate into improved patient outcomes later."

Jena and his colleagues were careful not to generalize their findings to surgical patients, arguing that the decrease in the number of surgeries performed during residency due to the 80 hour work week could have an adverse impact on outcomes after graduation.  However, Rachel Kelz and her colleagues published a similar study in the journal, Annals of Surgery ("Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons") that addresses this question.  Dr. Kelz found that the 80 hour work week restrictions did not have a significant effect on 30-day mortality following surgery using a Medicare database of close to 1.5 million patient encounters, though she did find some impact on length of stay, duration of the procedure, and costs of care.

These three studies are incredibly important, but they are not sufficient to make any definitive conclusions.  It's tempting to argue that physicians are less experienced when they graduate from residency and fellowship, but these three studies suggest that may not necessarily impact the care that they provide.  It could be that those of us who completed residency training prior to the 80 hour work week saw more patients and performed more procedures than what was necessary to become competent physicians.  I think more studies are necessary, and I suspect that this will be an important discussion for many years to come.