“I had a tough go,” says Dr. Cina, now a second year resident of internal
medicine at the medical center. “I started in the medical intensive care unit, one of the most demanding and stressful rotations.” Because Dr. Cina was caring for the most critically ill patients in his first rotation, the learning curve was huge. “In my first month as a resident, I worked 100 to 115 hours a week,” he says. Nearly all of Dr. Cina’s waking hours were spent in the hospital. When he wasn’t treating patients, he was on rounds with the attending physician, going over case details, filling out admissions forms, updating charts, or attending a required lecture or conference.

This grueling grind has been repeated by the physician resident for more than a century. During a three- to seven-year apprenticeship, residents were often required to work 36-hour shifts. The total for the week routinely topped 100 hours. Certain specialties were even more demanding. For general surgery residents, 130 hours a week was not uncommon.

“I was extremely tired, and I wasn’t getting enough sleep or exercise,” recalls Dr. Cina, whose physical condition deteriorated quickly in his first weeks as a resident. In addition to the sleep deprivation, Dr. Cina didn’t eat well, lost weight, and developed a urinary tract infection—probably due to the difficulty in finding time for bathroom breaks. The long hours and constant state of fatigue also took an emotional toll. “Looking back, I was probably borderline depressed, says Dr. Cina. “There was a lot of pressure, a lot of stress, and I could not see my wife.” During most of his year as an intern, Dr. Cina’s wife was pregnant.

For Dr. Cina, the baptism by fire was only temporary. Maryland had already begun phasing in new controls designed to dramatically reduce resident working hours. The new standards, instituted by the Accreditation Council for Graduate Medical Education (ACGME), officially took effect on July 1, 2003. All 7,800 resident programs in the United States are required to comply with the new standards, considered by many to be a revolutionary change in medical training. Among the specific provisions:

• Residents are limited to a maximum of 80 duty hours per week, including in-house call, averaged over four weeks.
• Duty periods cannot last for more than 24 hours, although residents may remain on duty for six additional hours to transfer patients, maintain continuity of care or participate in educational activities.
• Residents should be given at least 10 hours for rest and personal activities between daily duty periods and after in-house call.
• Residents must be given one day out of seven free from all clinical and educational responsibilities, averaged over four weeks.
• Residents cannot be scheduled for in-house call more than once every three nights, averaged over four weeks.

“We are set up to be in 100 percent compliance,” says Susan D. Wolfsthal, MD, associate professor and director of the internal medicine residency training program at Maryland. When a 24-hour on-call shift starts at 7 a.m., the resident has to leave the hospital by 1 p.m. the following day. That includes a six-hour transition period to allow residents to handle late admissions and transfer cases to the next shift. Residents who were once on call every third night, are now on call no more than every fourth night. Bottom line: A resident can work no more than 30 straight hours.

In general surgery, where residents historically worked up to 130 hours per week, the new standards had an immediate and positive impact on morale. “Residents are happier, and they are not resentful about being in the hospital,” says Barbara L. Bass, MD, professor of surgery and director of the five-year residency program in general surgery. Dr. Bass says residents are less irritable and more civil in their daily interactions with colleagues and patients. Complaints related to resident behavior have all but evaporated, and participation in educational activities suddenly improved. “Our residents are spending more time in the clinic, and they actually stay awake during educational conferences,” says Dr. Bass.

Implementing the new work rules not only required a completely new staffing model, it necessitated a dramatic change in culture. Ironically, one of the biggest challenges with the new system is getting residents to go home. “Residents are so committed that it can be tough to get them to leave,” explains Dr. Wolfsthal. “They want to stay and take care of their patients, and they don’t want to dump work on fellow residents.” Sometimes, Dr Wolfsthal has to play the roll of the cop on the beat, patrolling hospital wards at the end of a shift to make sure the residents adhere to the new work limits.

The transition from medical student to resident has never been easy. Established in the 1890s by William Osler—the first physician in chief at Johns Hopkins Hospital—the resident system required medical school graduates to continue their training by working side by side with experienced doctors. During their training, the graduates were expected to exhibit total devotion to duty. They were called residents because they were required to live at the hospital while honing their skills. In many programs, marriage was forbidden. As the system caught on in teaching hospitals throughout the country, this complete commitment would come to characterize the residency experience.

As the decades passed, the requirement to live in the hospital was dropped, and the ban on marriage disappeared. But resident working hours remained brutally long, pushing the boundaries of human endurance. Dr. Wolfsthal described her residency as a phenomenal learning experience, but she went months without a break. “I started my first year of residency in July and didn’t have a day off until November,” she recalls. When Dr. Wolfsthal did the math, she found that on a per hour basis, she made less than the minimum wage during her residency.

It was the same for Dr. Bass. “I had a great time, but it was an all-consuming job, and you paid a price for it. For three or four years of my life, I don’t remember doing anything out of the hospital. I don’t remember going on vacation, or going out to dinner,” says Dr. Bass. “I can remember that feeling of being so tired that your body hurts.”

The effort to reform resident working hours has its roots in the state of New York, which implemented an 80-hour-per-week limit in 1989. The state law—the first and only one of its kind—was prompted by the death of an 18-year-old girl who was initially hospitalized with flu symptoms. Her family claimed that negligent residents, working without enough sleep, prescribed improper medication. A grand jury investigation found no criminal fault on the part of the doctors, but the panel expressed concerns about resident working hours and supervision.

Contending that resident working hours were unsafe for patients and inhumane for doctors, advocates for reform lobbied for nationwide limits. The effort gained momentum with the formation of the Committee of Interns and Residents, a union of 11,000 medical residents, and the support of the American Medical Student Association, a national organization representing over 30,000 physicians in training. In 2001, the consumer advocacy group Public Citizen joined the fight and petitioned the federal government to impose restrictions on resident work hours. In 2002, the ACGME voted to approve the New York regulations and promised to impose sanctions on programs that failed to comply.

Citing sleep deprivation studies, advocates for work hour limits have long argued that exhausted residents are more likely to make medical mistakes that could endanger the lives of their patients. An informal survey published in the Journal of the American Medical Association in 1988 found that six out of seven surgical residents had fallen asleep at the wheel while driving to and from work. Researchers at Wayne State University surveyed 700 emergency medicine residents about their driving experiences, and found that 17 percent had been involved in crashes. A study in the journal Nature determined that residents who had been awake for 24 hours had the hand-eye coordination of someone with a blood alcohol level of .10 (above the legal limit for driving in most states).

The connection between adequate rest and job performance is well recognized in other industries. For example, the Federal Aviation Administration does not allow pilots to fly more than 30 hours a week or eight hours in a single day. Commercial truck drivers are limited to a 15-hour shift with a minimum of eight hours rest per day. Work limit supporters say physicians are no different than pilots and truck drivers. Extreme fatigue impairs judgment, concentration and coordination.

While Dr. Bass acknowledges that extreme fatigue has an effect on cognition, she remains unconvinced that the old model of resident training put patients at greater risk. “There are no studies that document an increase in medical errors associated with surgical fatigue,” says Dr. Bass, who is also vice chair of the American Board of Surgeons. Dr. Bass believes training, adrenaline, and intense focus all kick in to protect the surgeon from the effects of fatigue.

Some medical educators worry that the new work limits will prevent young physicians from getting the experience they need to handle the complexities of modern medicine. In some cases, that concern has been echoed by the residents themselves. “There is some anxiety among our residents that they are not going to get the same breadth of training as the surgeon who finished a residency just five years ago,” says Dr. Bass. On the question of patient safety, Dr. Bass believes the jury is still out. She says it will take careful study of patient outcomes to determine if the new work limits actually improve the standard of care.

The new limits reflect changing attitudes about the role of the work and its impact on quality of life. “I am
very happy for the changes,” says Dr. Cina, who says he is healthier and more energetic in his second year as a resident. “Don’t get me wrong. I still work a lot of hours,” explains Dr. Cina. “But the new system is much more humane. I feel like I can get my work done without being deprived of the basic necessities of life, like eating, sleeping and spending time with my family.”

Even with the reforms, residents don’t enjoy bankers’ hours. But for the first time in decades, residents are finding time for a more normal life outside hospital walls. “Residents are happier than they ever were before, and the new hours are more conducive to learning,” says Dr. Wolfsthal. “And in the end, that’s better for the patient.”