Overworked, Underslept, and the Politics of Resident Shift Hours

Bret S. Stetka, MD; John Watson


November 30, 2016

In This Article

New Proposals Reignite an Old Dispute

The benefits of adequate sleep are myriad and undeniable.

Our nightly neural shift into quiescence is thought to not only lower the risk for chronic illnesses—including cardiovascular disease,[1] infection,[2] and possibly even certain cancers[3]—but also have profound positive effects on cognition.[4,5] Sleep improves awareness, and also memory, as our recollections etch into cellular stone.

Yet physicians—resident physicians, in particular—often don't get much.

Resident work hour restrictions, and the effects of lack of sleep on performance and patient care, have been disputed among clinicians and consumer advocacy groups for many years. The debate has once again emerged publically, with a recent proposal[6] from the Accreditation Council for Graduate Medical Education (ACGME) to phase out a 2011 rule capping first-year resident (PGY-1) shifts at 16 hours total. As part of a larger set of proposals to be implemented in the 2017-2018 academic year, an ACGME task force recommended that first-year physicians instead subscribe to the same structure as other residents, with shifts of up to 28 hours, including 4 hours to manage transitions in care, and a maximum of 80 hours a week averaged over 4 weeks.

For the task force—and the specialty societies, certifying boards, and relevant parties that uniformly requested this repeal—the rationale was clear: They argued[6] that the differing hour restrictions for interns disrupted the synchronicity of team care, separating interns from other residents and faculty crucial to their supervision and training, and they cautioned against an encroaching "shift mentality" that could be deleterious to patients. Underlying their suggestion was the more central idea that residents must encounter and surmount fatigue if they are to become competent medical practitioners.

"Physicians need to be trained to understand their limits. They need to learn how to care for patients in circumstances of fatigue, because they will function in clinical practice after graduation in circumstances where they are fatigued," said ACGME CEO Thomas Nasca, MD.

Do we say that doctors can be drunk when they're taking care of patients because some people can handle their liquor?

Opposition to the policy change was swift, with the consumer rights advocacy group Public Citizen, the Committee of Interns and Residents (CIR), and the American Medical Student Association (AMSA) issuing immediate criticism.

"Of the twenty-something person task force, only three were residents—two from surgery and one a medicine fellow. All three were closely affiliated with the medical specialty organizations they participated in as selected resident representatives," wrote CIR executive vice president Alison Duncan, MD, in response to a question from Medscape. "We think the ACGME could have done a better job of reaching out to a broader section of the resident population beyond soliciting formal testimony from groups."

Critics see the ACGME's proposed change as erasing a modest achievement they hoped to build upon by extending 16-hour caps to all residents. They argue that in doing so, the ACGME and other groups are ignoring overwhelming data of the dangers posed to both patients and residents alike by prolonged work hours.

"It's purely a decision made by a few people at the top of the medical establishment who are convinced, despite all of the signs showing otherwise, that both they and the people they trained can somehow overcome basic human biology and safely treat patients while going without sleep for 28 hours," said Sammy Almashat, MD, MPH, a researcher with Public Citizen's Health Research Group.


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