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More on resident work hours

Assuming for the moment that excessive resident work hours is a problem, it would seem to be one of those problems that isn't likely to be solved by either professional self-regulation or by the market.

Daniel Goldberg's nice post about resident work hours reminds me that even if residents weren't as accepting of their brutal schedules as they seem to be, they probably wouldn't be able to do very much about it. As Goldberg points out, medical students and residents don't have a lot of bargaining power compared with their hospital employers, who benefit economically from low-cost resident labor. Moreover, there aren't a lot of other players in the current health care market who should be expected to argue forcefully for reduced work hours. Insurers and employers in our fragmented system would find it hard to capture the economic benefits of fewer medical errors made by overworked residents.

Professional self-regulation shouldn't be expected to solve the problem either. The medical professional societies and hospital groups that comprise the ACGME (the organization that regulates work hours) are all served nicely by the current system. The professional societies benefit because the total number of residents is kept small. Residents in training may suffer, but after graduation they benefit from larger salaries. Hospitals of course like cheap resident labor paid for mostly by the government. Although each additional resident usually means more money for the hospital, in the face of restrictions on the number of residents Medicare will pay for and the relatively higher costs of PAs, NPs, and attending MDs, the hospitals are not going to support limiting resident work hours. Residents are the cheapest hospital laborers available.

So if the market won't fix things, and professional self-regulation won't fix things either, who's left? Yep, the government. What's the likelihood that the government will step in to limit resident work hours? Almost nil, because "patients" as a group aren't as focused a lobbying group as are the hospitals and the professional societies. So absent another high-profile case like Libby Zion's, nothing is going to happen.

Of course, I've ignored the serious argument that shorter work hours do not directly correlate with increased patient safety. There is evidence that medical errors are more likely with an increasing number of handoffs and signouts -- the happy medium between overworked residents and too many handoffs hasn't been identified yet. Add to the fact that this happy medium is likely to be different depending on the specialty, the severity of illness, the number of patients, and the stability of the resident's schedule, even if the government did want to do something, it wouldn't be clear what exactly it should do.

This uncertainty about how to solve the work-hour problem doesn't mean that I dislike excessive hours any less. It doesn't make me any more sympathetic to the simplistic non-arguments advanced by traditionalists that amount to "more time in the hospital = better training." It just means that I'm glad to be going into a specialty where I can limit my own hours if I want. And I think we ought to spend more time and money gathering information about what kind of training systems work best.

Comments

Interesting read.

What is also interesting is that airline pilots have very strict duty hour restrictions that are significantly less demanding than a resident's (I don't know the numbers off-hand, but it's well under 80 hours!). And as I understand it the idea of violating these duty hours is unthinkable. Some would argue that they are responsible for more lives than a typical resident (that's questionable), but I would argue that flying a modern airliner under normal circumstances requires less aptitude than taking care of dozens of ailing patients.

My older brother stopped by for a drink last night. He had been on call (ICU) the night before. He hadn't slept at all and couldn't keep his eyes open during our conversation. To think he had been caring for patients just a few hours earlier...

Please keep the posts on duty hours and schedules coming!

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