Starting this year, the Accreditation Council for Graduate Medical Education (ACGME) implemented an 80-hour workweek restriction for interns. Interns are now allowed to work a maximum of 80 hours a week and no shifts are to exceed 16 hours at a time. These work restriction requirements blossomed out of the Libby Zion case of 1984, where an 18-year-old girl died under the care of what her father believed to be overworked residents and interns. The night of Libby’s death, the intern who treated her had been covering 40 patients on a 36-hour shift. The ensuing litigation came to the conclusion that medical mistakes are more likely when a provider is tired and overworked. This conclusion was the basis of the new work-hour restrictions.
Unfortunately, overall patient workload continues to grow in contempt of these work-hour restrictions. I am currently a third-year medical student, and my first rotation was with the liver transplant surgical service. While the interns were forced to leave after eighty hours, there was no such restriction placed upon medical students. As a result, I regularly worked 90-100 hour workweeks during my five weeks, including several 36-hour shifts. My surgery rotation was the first time I had been awake and alert for so many hours on end. Generations of health care providers will attest to the experience: you are tired, but patients are still sick and you still need to be there. Your team is there for you, and you need to be there for them.
Emerging research on medical mistakes has not yet established a strong connection between mistakes and long hours. Though not ideal, the long hours seem not to be the only culprit for medical mistakes. Although I was more tired during my rotation than I’ve been in my entire life, the complications I observed were less from exhaustion and far more from the challenge of handing off a patient from one clinician to another or organizing and accessing information. The first thing I learned on the wards is that one pinpoint number, such as a lab value or the patient’s vitals, is meaningless without the constellation of yesterday’s numbers and the clinical picture that surrounds it. Timely and easy access to patient information is crucial to a physician’s ability to provide proper care. Vanderbilt has one of the best electronic medical record (EMR) systems in the country. Still, every day after rounds, I watched my residents wait on slow servers and waste time dealing with frustrating communication systems between services and teams. Every medical team has an individual, usually a medical student or intern, that comes to the hospital an hour before rounds every morning to distill relevant patient numbers onto a handwritten page so the team can have quick access to the information during rounds. With crushing health care costs, growing inefficiencies in delivery of care, but unsurpassed levels of data sharing and untapped potential with every provider connected to the internet and each other with smartphones, there is no more crucial time than now for someone to rise to the challenge of creating a robust data management system to help manage care.
A careful look at the Libby Zion case reveals that while her tragic death happened while her intern was on a 36-hour shift, the intern also did not have access to the list of drugs that Libby was taking, and prescribed a drug that triggered an adverse interaction that ultimately led to her death. Timely and accurate information saves lives.
Still, the 80-hour workweek honors the changing nature of the medical profession. Even if the data do not currently show a strong correlation between overworked residents and adverse medical events, there are ten thousand reasons why we shouldn’t overwork residents. For example, we should care for their overall well-being as humans. We should also care for their families and support systems; my intern had not seen his one-year-old son awake in weeks. Most critically, though, we should not overwork residents by wasting their precious time and not providing them with the best health information systems we can design.