Resident Duty Hours: Loopholes in the New Regulations

If the humidity were not so oppressive, I might open up a book and start reading about emergency medicine. Instead, I will write. The recently published work hours regulations in the New England Journal of Medicine are causing a stir among physicians, hospitals, residency directors, and the community at large. Refer to NEJM — The New Recommendations on Duty Hours from the ACGME Task Force and New Rx for Young Doctors: Shorter Work Day – WSJ.com for more information. There is a wonderful caveat in the small print, which serves as convenient loophole for specialties which prefer not to abide by these regulations. It states, “Duty-hr exceptions to 88 hr per week averaged are permissible for select programs with a sound educational rationale…” It goes on to add, “In unusual circumstances, residents may remain beyond scheduled hr to continue to provide care for a single patient; justifications are limited to required continuity of care for a patient who is severely ill or whose condition is unstable, academic importance, or humanistic attention to the needs of a patient or family.”

This emphasis on the moral and professional duties of the physician and on “humanistic attention,” which are considered far more important than resident compensation or well-being, has driven this profession for many decades. The terms “resident” and “house staff” originated in the 1960s because residents lived the majority of their lives in-house, or in the hospital. Pay often included room, board, and laundry services.

In the 1960s, a climate of economic prosperity and increased government health care expenditures through Medicare, Medicaid, and the Hill-Burton Program led to increased demand for residents. Hospitals suffered from house staff shortages and sought to expand their residency programs. In the 1970s, this all changed: the focus shifted from health care expenditure to cost containment, and the demand for physicians decreased after there had been a 40% increase in the number of physicians over the last decade (Hough, DE and GJ Bassoli, “The Economic Environment of Resident Physicians,” JAMA 253 (1985): 1758-1762).

In the 1970s, several factors contributed to a decline in resident salaries, which were in the range of $20,000. First, resident salaries rose less than the 9.4% annual growth in the consumer price index. Fringe benefits declined, and often no longer included housing or meals. Educational debt rose: only 56% of medical school graduates in 1975 had educational debt; by 1982, this had increased to 80%; furthermore, the mean debt had increased from $12,400 to $21,700. This was exacerbated by increased rates on student loans and by decreased federal funding of these loan programs. (Hough 1760)

Currently, in 2010, the median resident salary ranges from $46,717 to $52,599 (AAMC, Medical Student Education: Costs, Debt, and Loan Repayment Facts). As of 2009, 87% of medical students graduate with debt, and the median student debt is $160,000. When averaged over an 80-hour work week, and accounting for 4 weeks of vacation, residents make $12 to $13 per hour pre-tax. This amounts to a take-home salary of $10.75 per hour. As a point of comparison, the federal minimum wage rate is $7.25 and state minimum wage rates range from $7.25 to $8.55. Medical residents working in the state of Washington earn less than $2/hr above the state’s minimum wage and have an average $160,000 of debt. By most standards, medical residents are some of the poorest people in the country – and we have achieved this status after 4 years of graduate education and additional years of post-graduate education.

As is clearly indicated by this number-crunching exercise, the focus of medical training  is not, and has never been, on resident well-being or financial rewards. When placed in historical context, these new work-hour regulations do not jive with the culture of medicine. Whether they pass or not, hospitals will have a difficult time financing the change. They will have an even more difficult time accepting the change.

The predominating view, which dates back to the 1960s, is that physicians-in-training should have few if any obligations outside of medical training, and that the honor of taking care of patients should take precedence over any financial rewards. The new stipulations put forth by the ACGME include phrases such as “strongly suggest” rather than “require.” They state that residents should not be “compelled” to spend extra hours taking care of a single sick patient. When this is applied in the real-life setting, the word “compelled” becomes a matter of interpretation.

Here is a thought experiment: you are a first-year resident, standing in front of a medical team which consists of senior residents, fellows, and attendings. It is the morning after an on-call shift during which you did not sleep at all. You are in the medical ICU, and not one, but two of your patients are crashing. Your peers are busy taking care of their sick patients – they have not yet met these new patients whom you admitted overnight. The attending and fellow are busy doing big-picture management of the entire unit. Your pager goes off once, then twice. One of  your patients is coding. The other needs a central line. You are past your duty hours, and you know it. But no one else is jumping in to help you, and after all, it’s your pager that’s going off, not theirs. What to do?

The ACGME’s viewpoint is that you should, if you so desire, state that you are beyond your work-hour limits and cannot provide further care. Tell your bosses to refer to the ACGME table of “suggestions” if they have any questions. Turn off your pager, relay the message to someone else, and go home to sleep. That would be a bold move, to say the least. The physicians’ viewpoint – and therefore your colleagues’ viewpoint – is that these are your sick patients, and therefore you have a moral and professional responsibility to provide for them the best care that you can. So even though the guidelines give us a “choice,” there is no choice in practicality.

And therein lies the dilemma: work-hour regulations will not be enforced unless physicians, and the medical community at large, accept them as beneficial to both residents and patients. Rather than spending $15,000 on surveying hospitals in order to ensure they abide by these regulations, it would be much more informative to go undercover and get the candid opinions of attending physicians about these new work hour regulations.

Part of the inherent problem with physicians is that we have a difficult time accepting our own limitations – even though pilots and truck-drivers abide by strict duty-hour regulations, we are above that – we are physicians. Our duty is to surpass all expectations, to be the most noble and the most educated, to ignore the basic human needs of sleep and food, in order to serve our brethren. I think we may be too sleep-deprived to devise these duty-hour regulations after all.

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5 Responses to Resident Duty Hours: Loopholes in the New Regulations

  1. Pingback: Between a Rock and a Hard Place: ACGME Passes New Duty Hour Regulations « A Medical Resident's Journey

  2. Pingback: Patient Perceptions in the Emergency Department: Physicians, Physician Assistants, Nurse Practitioners « A Medical Resident's Journey

  3. Brian Clay, MD says:

    I would be cautious against characterizing the two aspects of the new regulations that you quote as “loopholes.”

    The 88-hour per week exception must actually be approved by the individual Residency Review Committee (RRC) for that specialty. To date, only Neurosurgery has successfully applied for and received this exception. Most other programs’ RRCs have kept the limit at 80 hours (some specialties even set a lower maximum).

    Under the new proposed rules, a resident may stay longer than 24 hours (plus 4 hours for transition of care) to participate in the care of a single patient — true. However, the rules also go on to state that each such instance must be reported to the training program director in writing.

    Your thought experiment is provocative; however, it suffers slightly from several assumptions: first, that the attending physician and fellow on the team only worry about “big picture” issues; second, that, even if the first assumption were always true, there is “no one” available to help you.

    As an academic hospitalist (and an associate program director for an internal medicine residency program), I can tell you that both I and the other hospitalists in my division are found much more in the trenches of direct patient care alongside the housestaff as opposed to merely issuing directives with an old-school professorial style, removed from the action. The work hour regulations brought into being by the ACGME in 2003 has cause the job of the attending physician to evolve toward a set of more hands-on responsibilities for direct supervision.

    As to the other assumption, it would be poor planning on any training program’s part to not have another intern or resident scheduled to pick up the responsibility of any intern or resident who is coming to the end of their shift. Again, with the advent of the rules in 2003, the prevalence of the “day float” and “night float” types of rotations has increased substantially.

    I thank you for the historical overview on resident salaries in the context of the economic history of the prior 50 years — I myself recall calculating my own hourly pay rate as an intern ten years ago. The lay public really doesn’t realize the financial stress that trainees are under.

    • Thank you for your comments – it is quite refreshing to hear your perspective on how the hospital runs. From my experience (which is somewhat limited, as I have not yet had the chance to work at several different hospitals), the support of residents from fellows and attendings can vary depending on the individuals and can also vary depending on communication styles among the group. Although I have had many frustrating experiences due to a lack of support, I have also worked with people who provide support and are willing to get down “in the trenches” as you say – and it makes a world of difference.

      • Brian Clay, MD says:

        It can make a difference; however, not all attending physicians are especially enamored of becoming “extenders” of the housestaff in order to perform tasks historically designated as “resident work.”

        That said, the ACGME, with this new proposal, is going to shift the residency culture further in a direction where it is imperative that the hospital processes run efficiently so as to not waste the residents’ precious (fewer) hours on the wards.

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