All in a day's work: The harried life of a medical resident

Residents at New York's Montefiore Medical Center balance furthering their education and providing patient care within the constraints of rules limiting their work hours.

By Jay Greene, amednews staff. Oct. 8, 2001.

On this day in late August, Stephen Cha, MD, arrives at Montefiore Medical Center at 8 a.m., fresh from seven hours sleep. For the next 20 hours, Dr. Cha, a second-year internal medicine resident, steadily works through morning rounds, chart reviews, patient care and ED admitting duties. Also mixed in are frequent consultations and meetings with fellow residents, attendings, medical students, support staff and patients.

"The hours I work are more than I expected, but the patients here require an immense amount of work, and it is sometimes hard to get it all done before your shift is up," said Dr. Cha, 28, a third-generation physician.

While the beginning of his day went smoothly, the afternoon and evening were frustrating because everything he wanted to do for his patients took longer than anticipated. Dr. Cha spent three hours getting a methadone prescription for a new patient. Another patient refused to take his medication, and it was well into the evening before he was able to get the four patients he admitted from the ED fully settled into their rooms. At 10:30 p.m., almost 11 hours after he ate lunch, he had time to eat dinner.

Dr. Cha does his best to cram as much education and patient care into his shifts at Montefiore as possible. That's because the number of hours he and the other residents at the Bronx, N.Y., hospital work are governed by the state of New York. It is the only state in the country that regulates resident work hours, supervision and ancillary support services. New York's laws were crafted in response to the 1984 death of 18-year-old Libby Zion -- an accident partly attributed to overtired residents. Dr. Cha said the state's regulations help encourage hospitals to develop schedules that keep him and dozens of other residents from working past the point of exhaustion.

New York residents are limited to 80 hours a week maximum over a four-week period, with shifts of less than 24 hours.

"There is a culture here where we back each other up," said Dr. Cha. "When you have a sick patient and have to leave, you check in with your buddy. We rely on each other for support. These are your friends. You share the bulk of your life with them. You lose patients together with these people and you save patients with these people."

New York's 12-year-old regulations require residents to limit their time to average 80 hours a week over a four-week period. The regulations also require one day off in seven, no more than three consecutive nights on call and shifts less than 24 hours long. Residents in emergency rotations are limited to 12-hour shifts. Surgery residents are allowed greater flexibility. Violation can cost $6,000 per incident and up to $50,000 for continued noncompliance.

"The regulations make this hospital a better place for residents and patients," Dr. Cha said. "I would not want to work in a state without regulations."

What should regulations be?

Hoping to extend New York-style regulations to other states, several physician advocacy groups filed a petition with the Occupational Safety and Health Administration asking it to limit resident work hours.

Montefiore's 70 residency and fellowship programs also fall under work-hour guidelines created by the Accreditation Council for Graduate Medical Education. ACGME's general institutional rules prohibit residents from working "excessive hours." Some experts, however, question whether ACGME's enforcement power is sufficient.

"Even with state regulations, I don't believe New York hospitals are any better in complying with ACGME standards on work hours than other hospitals [in the country]," said David Leach, MD, ACGME executive director. In 1998, surprise inspections by the New York state health department found all 12 hospitals it reviewed in violation.

While most medical organizations, including the AMA, oppose federal regulation and support greater ACGME oversight, Brian Currie, MD, Montefiore's medical director, said New York's rules serve the hospital, patients and residents well and could work elsewhere.

"Patient quality of care is improved by fewer work hours," said Dr. Currie. "The states could do it or the ACGME could do it. I am not concerned with who regulates hours, just that it is done intelligently and constructively."

Dr. Currie, who oversees 875 residents and fellows, doesn't believe the regulations have negative impacts. "Some of the rules are not that straightforward, and it takes time for some residents to understand them, but we have adjusted very well to the rules," he said.

Sharon Silbiger, MD, program director in internal medicine, believes the combination of state rules and ACGME standards is a good mix.

"The [ACGME's residency review committee's] focus is to ensure residents learn what they need to learn and provide them with reasonable quality of life," Dr. Silbiger said. "The health department is more interested in work-hour compliance. The two complement each other well."

Hospital adjusts to work-hour limits

Scheduling residents under New York's regulations is a challenge for Dr. Silbiger, who oversees Dr. Cha and 147 other internal medicine residents. "One of the main things you are concerned about is making sure the residents in program have a good experience," he said. "Some residents won't leave the hospital because they feel their patient is sick and they need to meet the needs of the patient."

The need to send a resident home only occurs about once a month when a resident has reached the maximum 320 hours, Dr. Silbiger said. "When this happens we try and switch the person's responsibilities [to another resident]," she said. "We have open communication, and everyone knows what the other is doing."

Like many hospitals seeking to reduce resident work hours, Montefiore's internal medicine program uses an on-call night-float system. Residents work 16 hours or less and leave early in the evening to get needed sleep. This can reduce work hours by 20% during the month.

"Night float answers some of the problems in continuity of care, and it relieves stress of residents in the system," Dr. Silbiger said.

In another effort to comply with the rules, Montefiore has hired more than 14 physician assistants and other ancillary support staff, Dr. Currie said.

"Even in these days of dwindling resources we have added specialty PAs at a cost of $3 million a year in salaries alone," he said. "Two years ago we added six surgical PAs to the rotation schedule in general surgery and two for orthopedic surgery."

Dr. Currie said PAs take care of patients before and after surgery during the day. "This alleviates work at night for the residents," he said. "PAs also compete for time with residents as assistants in the operating room. There is mild friction, but residents understand the hospital has to be creative to comply with the hour restrictions."

When he selected Montefiore, Dr. Cha felt he could work within the state-regulated work-hour rules. "Even with the regulations, I knew I would work very hard when I am on duty. You just try to be smart about your time."

ADDITIONAL INFORMATION:

Does limiting the length of a day's work limit care?

Paul Gitman, MD, is concerned that regulations limiting work hours could lead to continuity-of-care problems for patients and inferior educational experiences for residents.

"Are we training our housestaff to become shift medicine doctors?" said Dr. Gitman, an internist who teaches residents at Long Island Jewish Hospital in the New York City. This summer, Dr. Gitman sponsored a resolution approved by the Medical Society of the State of New York that recommends an evidence-based study on the effect of the regulations on patient care and house officer education.

"Some programs are so concerned with running afoul with the state regulations that they have scrubbed out some residents during surgeries because their hours were up," Dr. Gitman said. "I know of residents sneaking back into the hospital to see their patients or being escorted out of institutions to make sure they leave."

While he acknowledged that no hard evidence exists of poor patient care or inadequate education, Dr. Gitman said a study should be conducted to find out. "We need to look at this, especially with the possibility that other states or the federal government will adopt these rules," he said.