Endless Days and Sleepless Nights : Do Long Work Schedules Help or Hinder Medical Residents?

Allan Brill has collected enough recent material to write a screenplay that might be titled “Night of the Zombie Doctors.”

Among his findings:

-- A medical resident stitching up a patient after a Caesarean delivery pitches face-forward in a state of exhaustion.

-- After many hours on duty, a resident takes a moment to rest but is awakened by a nurse requesting instructions for a patient. When the doctor awakens again later, she has “absolutely no recollection” of giving the orders.

-- Still another resident is telling a man he has six months to live--but the doctor falls asleep during the discussion.

According to Brill, administrator of the California Assn. of Interns and Residents, these incidents and many others he has gathered from around the state occurred because the doctors involved were too tired to do their jobs properly.

Some Groups Disagree

However, several medical organizations and many residents do not believe that sleep-deprived doctors pose a significant threat. They maintain extended stretches on duty allow for continuity of care and provide a valuable learning experience for young doctors.

A 1987 survey by the American Medical Assn. found that medical residents work an average of 75 hours a week, with shifts in excess of 100 hours not uncommon.

But that may be changing. California is among a handful of states--the others are New York, Pennsylvania, Massachusetts and Hawaii--considering limits on residents’ working hours.

A bill specifying limits will be introduced sometime this year in California by Assemblywoman Jackie Speier (D-San Mateo), according to her aide, Michael Thompson. State Sen. Joseph B. Montoya (D-Whittier) introduced similar legislation (S.B. 858) in the California Senate last year, but the bill died in January after passing a legislative time limit.

Although Speier’s office has not worked out details of the proposed bill, Brill’s organization has recommended guidelines similar to those recently adopted in New Zealand. These include a maximum workweek of 72 hours, averaged over a four-week period, along with work limits of 12 consecutive hours in the emergency room and 16 hours in other departments.

Brill said the rules should remain flexible to allow residents in the midst of a procedure to continue their work. “It’s not like your 16 hours are over and you leave, like a factory worker,” he said.

People on each side of the legislation debate agree that young doctors work long hours during residency, a three- to five-year period of on-the-job training following graduation from medical school.

Advocates of regulation maintain that it’s difficult to learn in a somnambulist state. “No one has ever shown that (working long hours) is of benefit to doctors or patients,” said Dr. Eugene Robin, professor of medicine at Stanford University and an authority on sleep deprivation.

Robin cited 22 studies showing that sleep deprivation leads to “difficulty with cognition and reasoning,” as well as “almost stereotypical emotional hazards: anger, paranoia, an inability to recognize when errors are made.”

Said Robin: “A significant percentage of the accidents that occur in hospitals are related to (resident fatigue.)”

Death Sparked Legislation

The current push for legislation was sparked by the death of an 18-year-old Bennington College student at New York Hospital-Cornell University Medical Center on March 5, 1985. A grand jury investigation determined that mistakes made by overworked residents contributed to the death of Libby Zion, who had been admitted to the hospital for a fever and earache and died eight hours later of cardiac arrest.

Dr. Jonathan House, administrator of the National Federation of Housestaff Organizations ( housestaff is another term for residents), said that as a result of the Zion death, the New York State Department of Health is close to adopting a proposal that would limit residents to an 80-hour week, averaged over four weeks. The proposal, expected to be implemented in July of 1989, also includes a work limit of 24 consecutive hours and at least one 24-hour period off each week.

Mary Bobay Robinson is among those who oppose such legislation. “I would not agree with a statement that patient care is being seriously compromised (by tired residents),” said Bobay Robinson, administrative director of the California House Officer Medical Society, an organization of interns and residents affiliated with the California Medical Assn.

The latter organization also opposes legislation. Said spokesman Ken Todd: “The CMA is not in favor of legislation that would specify hours for residents or interns, but we’re certainly desirous of finding a way of dealing with the problem--if there is a problem--of patient care.”

Both the CMA and the California Assn. of Hospitals and Health Systems, which represents more than 450 hospitals in the state, maintain that if limits are needed, they should be set by the profession and not by legislators who don’t understand the scheduling requirements of various specialty programs.

In fact, Bobay Robinson said studies of hours are currently being conducted by the Accreditation Council for Graduate Medical Education, which accredits residency programs nationwide.

While the threat of patient harm is propelling the push for legislation, doctors are also at risk, according to California residents’ rights advocate Brill: “There is no doubt that this kind of grueling regimen is devastating to the individual,” he said.

Resident workloads differ according to specialties, with radiology and psychiatry averaging 51 hours a week, according to an AMA survey.

At the other end of the spectrum are obstetrics/gynecology and surgery, which average close to 90 hours a week.

“No one could have warned me about this,” said Heidi Nicoll, a fourth-year resident at Harbor-UCLA Medical Center who chose obstetrics and gynecology. “I didn’t have any preconception that (ob/gyn training) would be this hard and long.”

Nicoll typically works 120 hours a week and may go for more than a month without a day off, she said. Before going into medicine, she wrote poetry and music but has shelved those pursuits to spend almost all her waking hours in the hospital.

Not Much Togetherness

There are times, she added, when she doesn’t see her husband, John, an orthopedic resident at Harbor, for a week.

Neglecting virtually everything but work is “probably not healthy,” she conceded. “At 30, I’m a little tired of not knowing how the world works.”

Ann Kelley, a third-year internal medicine resident, said she came down with the flu four times during her intern year (first-year residents are also called interns) at Harbor. “It gets to be very, very wearing,” she said of residents’ hours.

Kelley and her husband, David, also a resident in internal medicine, agreed not to discuss divorce during their internship year, she explained, “because we would not be competent to make that decision.”

Now that they have survived that particularly arduous time, their marriage is still compromised by the fact that they’re usually exhausted, the Kelleys said.

“I’m more critical of my husband when I’m tired, and my outlook on the world is worse,” said Ann Kelley, 40.

David Kelley said he manages to stay awake and alert at the hospital. The fatigue “doesn’t hit me until I get home,” he said.

The Torrance couple conserve energy by going into a mode Ann Kelley calls “parallel play,” a term borrowed from child psychology. They eat tuna sandwiches together, watch “L.A. Law” on television or play with their puppy, without really interacting.

Brill attributes residents’ long hours to “a sort of hazing that has gone on for many decades.”

Older doctors, especially, believe: “We made it through and it made us stronger people, so we don’t see any reason why you shouldn’t do it too,” Brill said.

That may be true, he added, but “the amount of medical technology and knowledge was minuscule then compared to what it is today.”

Dr. J. E. Hardison, writing in the June 26, 1986, issue of the New England Journal of Medicine, explained the difference this way: “Medicological and ethical matters were relatively uncomplicated (in an earlier era.) There were no medical intensive care units, no coronary care units, no respiratory care units, and no arterial lines, subclavian lines, Swan-Ganz catheters, pacemakers, Holter monitors, bedside monitors or cardio-verters. . . . There was no renal dialysis and organs were not transplanted.”

In addition to keeping up with a barrage of technical and ethical developments, residents in 1988 tend to be treating patients who are far sicker than the hospital population of 30 or 40 years ago, Brill said.

Critical Judgments

Ann Kelley, for instance, said she is so busy during overnight shifts that she may sleep one or two hours but often gets none at all.

In addition, a resident today is not simply managing relatively clear-cut cases but is making critical judgments at all hours of the night, according to Brill.

The combination of fatigue and constant stress sometimes gets expressed in resentment directed at the unsuspecting patient who arrives in the emergency room just when the doctor most needs rest, said Geoffrey Renk, a second-year emergency medicine resident at Martin Luther King Jr. Medical Center.

“Almost routinely I’d say there are people whose care suffers because a resident is tired and just doesn’t care at that point,” Renk said.

There have been other attempts to change residents’ work schedules, one “as far back as the ‘30s,” said House. At that time, the term resident was coined to describe a medical apprentice who actually resided in the hospital.

But the first major effort came in 1975, when the Committee of Interns and Residents went on strike against the League of Voluntary Hospitals, made up of private hospitals in New York City.

“It was a victory,” House said, resulting in an agreement that residents be on call no more than every third night.

The every-third-night rule “swept the country,” House said, but residents were still putting in 100-hour weeks and sleepwalking through the halls.

And “in recent years the situation has gotten worse,” he said, because hospitals, under greater pressure to keep labor costs down, prize residents as a cheap-labor pool. Although salaries range from $21,000 annually to $35,000 for fourth- and fifth-year residents, on an hourly basis the figure often works out to less than $5 an hour, according to Brill.

Those who advocate regulating resident hours say much of what they do is “scut work” that does not contribute to their medical training and could be performed by non-medical personnel.

Ann Kelley, for example, said she could triple the number of patients she sees in a clinic setting if she had adequate ancillary help to fill out requisitions, schedule appointments, transport patients and perform other such tasks.

Though she recognizes the problems with the current system of training, like many of her peers Kelley also feels privileged to participate in the enduring rite of passage known as medical residency.

“It’s not necessarily good to work all day and all night,” she said, “but it is exciting.”