The 30-hour day

Lilli Kim

Older docs may scoff, but one Emory resident’s experience shows that the present shift rules are no walk in the park 

By Lilli Kim Ivansco

December is a rough time of year to be on the wards at a teaching hospital. The interns are tired of working all the time; the residents are tired of the interns whining all the time; the attending physicians are wondering why they had to get stuck with a tired, whiny team during the holidays. Nobody wants to be there. Even the malingerers ask when they’re going to be discharged.

As an intern on the wards in December 2008, I was plenty tired and whiny. The patients were sicker than usual, which meant their care was more involved, which meant my pager went off more frequently. On overnight calls that month I rarely slept more than an hour. Even at home, in my own bed, the hospital public address system invaded my dreams, waking me with imagined code alarms in the still of the night.

So during a lunchtime conference, when the speaker mentioned a proposal to mandate naps for residents, my ears naturally perked up. That is, after the intern sitting next to me elbowed me in the ribs and hissed, “Wake up. You got to hear this.”

The proposal was that residents working 30-hour shifts be provided with a five-hour “protected sleep period” sometime between 10 p.m. and 8 a.m. It was one of a series of recommendations issued that month by the Institute of Medicine in the interest of lessening sleep deprivation among residents and ultimately reducing fatigue-related medical errors.

As an esteemed nongovernmental organization best known to the general public for sounding the alarm on medical errors in the United States, the IOM carries weight among legislators and health policy makers. Hence, residency programs across every state and specialty were scurrying to dissect the new recommendations and their potential ramifications, holding meetings like the noon conference I was trying not to sleep through.

As heartily as I would have applauded some officially sanctioned shut-eye at that moment, I found it difficult to embrace stricter limits on resident work hours without reservation, mainly because it seemed like we were still struggling to cope with the existing rules. Yes, our call shifts were limited to a maximum of 30 hours, but this meant the last six hours of call consisted of a frantic scramble to round on patients, scribble progress notes, drop orders, call consulting services, and sign out to a fellow intern, all before turning into a pumpkin at the stroke of 1 p.m. True, we were blessed with an 80-hour workweek—how sweet, only twice as long as the standard for most American employees and probably six times that of the French—but at the cost of being constantly hounded to log our duty hours in 15-minute increments and getting called on the carpet to explain violations, no matter how minor, should they occur.

But the most significant issue, as I saw it, was that resident work hour restrictions as yet had failed to effect a sea change in the culture of the teaching hospital, where dedication is measured by the zeal of one’s self-sacrifice and working past the point of exhaustion is regarded as a virtue. While residency programs by and large have risen to meet the enormous logistical and bureaucratic challenges of the new era, old attitudes die hard, as driven home by every physician who feels compelled to distinguish his or her training experience from mine. It’s not necessarily out of arrogance; sometimes the comments just slip out; that’s how ingrained the mind-set is.

“This was before duty hour rules,” they say. Or my personal favorite, “That was when we still worked all the time,” because 80 hours per week is basically the next thing to semi-retirement.

One morning on rounds after another sleepless night on call, I yawned broadly enough for the attending to admire my back teeth fillings.

“Tired, are we?” he said in a kindly tone.

I nodded.

“I remember rounding after call, wishing my attending would stop talking so much and just hurry up,” he chuckled. I squirmed and looked away. “I can’t tell you how many times I dozed off while leaning on the chart cart and woke up when it started to roll out from under me. Oh, those were the days...”

Here it comes, I told myself. Wait for it...

“Of course,” he mused, “that was before the 80-hour rule.”

Of course it was. And doctors also used to taste their patients’ urine to check for diabetes. Progress is good, right?

Nonetheless, I guarantee that at least two-thirds of the doctors reading this who trained before the advent of duty hour restrictions have referenced how much harder they worked than we do now. Come on, you know who you are: fess up. I swear if I were to win the Nobel Prize 40 years from now there probably would be an asterisk next to my name: *Worked no more than 80 hours per week during residency.

In all fairness, part of the issue may be that limiting resident work hours remains a relatively novel concept; when I started internship, duty hour restrictions had been in effect at the national level for only five years.

Lilli Kim

How much is that resident in the window?

Now you can fund a resident’s scholarship through the School of Medicine’s Adopt-a-Resident Program. The funds enable a resident to attend a national conference and pay for textbooks. Your commitment of $10,000 over four or five years is awarded to one resident and follows the resident throughout training. Contact Rachel Donnelly at 404-727-3127 or

The old “new” rules

Prior to 2003, some interns worked more than 100 hours per week. It was standard practice for medical trainees to put in 36-hour stints every three or four days, and not uncommonly residents remained on duty in the hospital, or “in-house”­—hence the term resident—for even longer.

Every teaching hospital in the nation has a legend about a resident, usually a neurosurgeon but sometimes an orthopedist, who abandoned the effort to maintain an outside life and simply moved full-time into a hospital call room, thereby not only saving on rent and laundry but also eliminating that pesky commute. Every resident claims to know someone who was so exhausted after call, he crashed his car/couldn’t find his apartment/mistook his wife for a hat stand. The stories might be apocryphal, but they illustrate the undisputed truth: residents were working far in excess of the legal and sensible limits for any government-regulated industry, let alone one in which others’ lives are at stake.

This last point became the crux of legal and media firestorms ignited by an outraged Sidney Zion after his daughter Libby died at a New York teaching hospital. A college freshman, Libby Zion suffered a fatal cardiac arrest while under the care of an intern and a second-year resident on call. Whether Zion’s 1984 death was attributable to the exhausted state of the trainees remains a matter of debate, even today; it is generally agreed, however, that her unfortunate case was the seminal event that ultimately led to the development of formal rules limiting resident work hours.

These restrictions, developed by a commission led by and named for Bertrand Bell, were put into practice within the state of New York in 1989. It took another 14 years and the added threat of federal legislation and regulation for the rules to be implemented nationally by the Accreditation Council for Graduate Medical Education (ACGME), which governs medical residency programs throughout the United States.

In broad terms, the 2003 ACGME restrictions stipulated that residents could work up to 30 hours per shift and an average of 80 hours per week, with in-house call limited to every third night. The rules also required that residents have a minimum of 10 hours off between shifts and a total of four days off per month.

The IOM recommended increasing the latter to five days off per month, including one 48-hour period. Under the existing rules, such “golden weekends” are a gift rather than a birthright. As a corollary to the proposed five-hour nap for 30-hour shifts, the IOM also suggested limiting shifts without a protected sleep period to a maximum of 16 hours.

In reality

It looked good in PowerPoint. But an inherent flaw in the 2003 ACGME rules as well as the IOM recommendations is that giving people more time to sleep doesn’t mean they’ll actually use the time to sleep, even if they’re bone tired. During my months on the wards I felt so guilty about neglecting my husband and my then 2-year-old son, any so-called free time went toward trying to make it up to them. Okay, so I ended up falling asleep on date night and while reading Green Eggs and Ham, but at least I tried.

Ironically, I couldn’t sleep well after overnight call, between hearing phantom code alarms and agonizing over whether I’d handled certain situations correctly. Typically I found myself awake after a few fitful hours. Sleep scientists undoubtedly have an elegant explanation for this phenomenon, but my personal theory is that my body gets confused. Usually I just got up and pretended to be refreshed.

Another conundrum stems from the unalterable fact that a hospital is a 24-hour operation whose patients require around-the-clock care. To bring resident work hours into compliance with the 2003 ACGME rules, many institutions moved toward nighttime “cross-cover” systems in which interns and residents on overnight call cover patients on several other teams besides their own. The advantage is that fewer trainees have to work overnight; the disadvantage is that those on call barely know most of the patients for whom they are responsible. Shorter shifts translate into more frequent transfers of care, which in turn have been shown to be a source of delays in medical diagnosis and management as well as errors.

Furthermore, cross-cover is based on the erroneous theory that covering several dozen patients should be manageable because most of them sleep quietly all night. The reality is that the complicated patients go right on having complications, while even the straightforward patients find ways to wreck.

“My patients won’t give you any trouble,” an intern once assured me while signing out his patients. I winced. We are a superstitious lot, and saying something like that aloud is just inviting the wrath of the gods.

Sure enough, around 3 a.m. my pager went off. I finished dealing with another patient before finding a phone.

“Cross-cover, returning a page,” I said when someone picked up.

“This patient has lice!” hissed an angry voice without preamble.

“I’m sorry?”

“This patient has li—”

“Lice, okay, I got it. I was just hoping you said something else.”

I still haven’t quite forgiven that intern for jinxing me.

A third and utterly serious issue is the question of adequate training. If I sound a touch defensive about my luxurious 80-hour workweek, it’s because I’m acutely aware that reduced work hours perforce means fewer learning opportunities. I may chafe at having to work nights and weekends, but I want to be ready for the real world when I finally enter it.

The question is not whether today’s medical trainees receive the same amount of experience as their predecessors—we don’t, end of story—but whether we receive enough training to prepare us for independent practice upon graduating from residency. This is especially a concern for surgical specialties in which skill level often directly corresponds to the number of procedures performed, but all areas of medicine will have to pay close attention to the quality of training in the years ahead.

It seems attention to the quality, not just the quantity, of the time residents spend at work will become even more critical in the near future. In September 2010, after months of information-gathering and review, the ACGME approved revisions to the work hour restrictions, to take effect in July 2011 at the start of the academic year.

The new rules make no mention of a fifth day off per month or a guaranteed golden weekend. The overall 80-hour rule remains more or less intact, based on the determination that the 80-hour limit achieves a reasonable balance between “service, education, and rest.” And the ACGME stopped well short of mandating five-hour naps on call, although “strategic napping…is strongly suggested.”

But the new restrictions do include a major change that actually goes beyond the IOM recommendations: Interns no longer will be permitted to work longer than 16 hours per shift. In other words, I’m about to become an anachronism. I’ve already started rehearsing my lines.

“When I was an intern,” I’ll say, “we worked all the time. And I never complained. Not once.” EM

Lilli Kim Ivansco is now a resident in radiology and doesn’t have to worry about running afoul of the 80-hour limit.

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Emory Medicine Winter 2011