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Culture Shift Underway at US Teaching Hospitals - 2003-08-27

A culture shift is underway at the nation's teaching hospitals, publicly funded facilities that provide hands-on experience for new doctors. Known as "residents," these doctors in training spent 15-hour workdays treating patients, prescribing medications, assisting in surgeries. They were 'on call' 24 hours at a time. Surgical residents were often on the job as long as 140 hours a week.

But that grueling schedule has changed there are new mandatory limits on how long residents can work. The new 80-hour workweek is designed to reduce fatigue and improve patient safety. But residents are worried they won't learn enough during their training. And administrators worry about having enough medical personnel when they're needed.

Harborview is the Pacific Northwest's regional trauma center. Patients who arrive here have been shot, stabbed, burned, or broken into pieces. It's the job of the surgical residents to put them back together.

This day, it's a man who was shot in the stomach at close range.

"Surprisingly he's been alive for the last four days. Because of that we'll continue to take him to the operating room, clean out his abdomen, do little things here and there," says third-year surgical resident Stephen Sullivan, who has been on the job for more than 24 hours. He says he feels rested. But it's not always that way, especially, he says, in the emergency room.

"During that 24-hour period, you don't eat, you don't drink and you don't go to the bathroom and you sure as heck don't sit down or sleep," he says.

Concerns over resident fatigue and patient safety are the impetus behind new regulations put in place this July by the Accreditation Council for Graduate Medical Education. Now residents like Stephen Sullivan, who used to work more than 100 hours a week, are limited to just 80.

It is a huge paradigm shift.

Trauma surgeon Avery Nathans runs the critical care unit at Harborview. He says putting in long hours is an expected hardship in medical education. But sometimes residents are pushed too far. He points to the well-publicized case of Libby Zion, 20 years ago. The 18-year-old was admitted to a New York hospital for a high fever. She died the next day. Investigators concluded decisions made by an overworked, sleep-deprived resident contributed to her death.

Dr. Nathans supports the reduction in work hours, especially given the condition of patients today, compared to years past. "A lot of these patients who are in hospital now wouldn't have survived several decades ago because we didn't have the technology to support them," he says. "And because of that, the care these patients require is far more intense. So a 12-hour workday for a resident now is far more intense than a 12-hour workday for a resident 20 years ago. The patients are much sicker. The decisions they make now are far more critical than they were two decades ago. There's far less room for error."

Still, the journey to the 80-hour workweek isn't easy. Residents have to accept that they can no longer care for a patient from the emergency room all the way to recovery. That's hard for Stephen Sullivan. "I noticed it especially this week when the attending called me and said 'Steve, go home.' And I said, 'I don't want to go home!' So that was my first kind of culture shock sensation. The reality check that, my God, they really are going to make us leave," he says.

Dr. Sullivan's concern is that his education will be compromised. The fewer surgeries he can do, the less experience he'll have when he gets his license.

This day, with great reluctance, he hands off the case of a boy who was hit by a car while riding a 4-wheel off-road motorcycle. "Okay. This kid did not have a helmet on. Did have loss of consciousness. His whole right side is crunched," he says.

It's not just the residents who face a tough transition. Hospitals have no money set aside to fill the void created by doctors who now work one-third fewer hours.

"Because this is an un-funded mandate, we're doing it but at the same time our revenues for patient services are shrinking," says Johnese Spisso, Chief Operating Officer at Harborview. She says it will cost Harborview and Seattle's two other teaching hospitals $4 million to hire enough nurse practitioners and physician assistants to make up for the cuts in resident hours. "It just makes it very difficult to continue to run a hospital and operate in the black with continued regulations that end up adding cost," she says.

Ms. Spisso says she's also concerned about continuity of care. Nurse coordinator Andrea Gaul worries about that too. She anticipates that residents will have to transfer their patients to other doctors more frequently and fears that could lead to miscommunication, and possibly, medical errors. "So there's just a lot of, you know, there's a lot of opportunities where you hope things don't get missed and kind of that's what my job is, too, to go through with a fine tooth comb to make sure all those details are taken care of," she says.

The next decade will likely be dominated by research into the 80-hour workweek to see if the new system produces surgeons who are just as good, or better than in generations past.