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February 14, 2017

Your residents might be lying about their hours, op-ed argues

Daily Briefing

Many resident physicians exceed the strict limits on how many hours they can work at a time, but lie about doing so, Christopher Lee Bennett writes in an opinion piece for STAT News.

Bennett is an emergency medicine resident at Massachusetts General Hospital and Brigham and Women's Hospital.

Time limits

Resident physicians are supposed to follow rules that dictate how many hours they can work in a single stretch and over the course of a week. Developed by the Accreditation Council for Graduate Medical Education (ACGME), the rules aim to prevent errors made by tired, young doctors, Bennett writes.

Currently, an intern—or first-year resident—is not supposed to work more than 16 hours in a day and more than 80 hours in a week (averaged over a four-week period). More senior residents can work for 24 hours in one stretch, but they are also capped at 80 hours per week.

When residents report that they worked beyond those restrictions, their residency program gets a so-called "work hour violation," Bennett writes. Enough of those violations can result in a warning from ACGME, and, in some extreme cases, residency programs can lose their accreditation, Bennett writes.

ACGME first imposed hour limits in 2003, revised them in 2011, and is now mulling more changes. Under the latest proposal, interns could work on shifts for up to 28 hours. But the 80-hour weekly limit would remain in place—"at least for the moment," Bennett writes.

Some residents may lie about exceeding the limit

Despite the rules, Bennett writes that many residents work longer than they're supposed to and "keep quiet about it. Others lie."

He points to national surveys showing that about 60 percent of medical residents underreport their time, as well as his own research, published in the New England Journal of Medicine, that found more than 70 percent of residents "worked longer than they should have at least once without reporting it." And "60 percent of that group reported routinely exceeding their work hours on an average week," Bennett writes.

In his study, Bennett and colleagues also explored why residents exceeded their work hour limits. They found that "a significant number of residents" did so "because of external pressure from authority figures," while others "blame it on internal pressures, such as guilt about leaving the hospital or feeling they are expected to work beyond their limits." Bennett writes, "These internal and external pressures are alarming given the high rates of burnout, depression, substance abuse, and suicide among resident physicians across the country."

Physician deaths by suicide prompt calls for action

Bennett acknowledges that many in the medical community oppose the current time restrictions and are calling for the rules to be eased. For instance, ACGME CEO Thomas Nasca has said the proposed new rules would "improve the coordination of clinical care by the interns and residents in the teaching environment."

Longer shifts, Nasca said, are the best way to prepare young doctors for the reality of being a physician. "Residents must develop the skills and the confidence to manage challenging situations, under supervision, and must learn to care for patients over extended hours, and during night-time hours, because these are circumstances they will encounter after graduation," he said.

And Bennett acknowledges that the "most recent research on resident work hours," pulled from a clinical trial of general surgery residents enrolled in the FIRST Trial, "showed that less-restrictive work hour policies, compared to the current more-restrictive ones, did not result in worse patient outcomes." But he also points to other research showing that "long work hours puts patients—and providers—at risk for serious medical errors."

Bennett: Medical community should address underreporting

Bennett contends that the medical community should focus on "addressing underreporting or the culture of guilt and coercion within residency training that drives residents to lie about how long they work," instead of increasing the hours residents work. He argues that ACGME's latest proposal to increase residents' shift hours "misses an opportunity to address why residents feel pressured to lie about their hours, an issue that has been ignored for far too long."

Before the medical community thinks about "ask[ing] doctors to work longer," it must first "address the guilt and external pressures in residency programs that already drive residents to work longer hours than they should," Bennett writes (Bennett, STAT News, 2/1).

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