Employee Relations: The Doctor Is Still In

Many resident physicians routinely work more than 100 hours a week. Are long hours a necessary rite of passage or an obsolute practice that endangers patients?

Before Risa Moriarty resigned her plastic surgery residency two-and-a-half years into a seven-year program at Johns Hopkins Hospital in Baltimore, she was routinely working 110-130 hours per week, and sometimes worked a 60-hour shift.

That’s three days and two nights on call in the hospital with no sleep other than brief, catch-as-catch-can naps. “It takes an altered state of mind to get through it,” she says. “Residency turns you into a very efficient machine.

“I stayed longer than I should have,” says Moriarty, now an executive at HealthCite Inc. in Baltimore. “It was a difficult decision to make and one that I spent a lot of time thinking about. I considered changing to another specialty, but I was just completely burned out.”

Moriarty says she is not alone in her reaction to the relentlessly long work hours in some hospitals. She believes many physicians are bitter, even the older ones. “After I resigned, two attending physicians called me and said they were envious of my decision.”

‘Clinical Clerks’

The practice of medicine has changed dramatically during the last century. But the residency and intern system has changed very little since the legendary Dr. William Osler initiated this method of training newly minted doctors at Johns Hopkins University more than 100 years ago.

Osler was a pedagogical innovator who brought students out of the classroom and onto hospital wards as “clinical clerks.” These first residents lived a monastic existence, actually residing in the hospital, and were paid no salary.

Today’s residents receive a salary and benefits, but still may feel as if they live at the hospital. Work hours exceeding 100 per week are not uncommon, and 36-hour shifts often are routine. Sleep-deprived residents—the least experienced physicians—are likely to be the first doctors to examine a patient in a hospital emergency room. And today’s patients often are sicker even as they spend less time in the hospital than in years past.

Why do doctors persist in continuing such onerous and dangerous training and staffing practices?

“Medicine is a militaristic culture,” says Moriarty. “It’s a hierarchical, macho fraternity, and hospitals hide behind the argument that doctors know best.”

Older doctors who went through the same rite of passage may believe that it weeds out those who don’t have “the right stuff.” However, Moriarty points out that modern-day residents probably are seeing 50 to 60 patients in a 100-hour workweek—versus 20 in 1950—and the patients present a significantly more complex workload than in the past.

Because of today’s longer lifespans, patients are more likely to be older and have multiple illnesses. And medical advances have created an exponentially greater number of potential diagnostic tests, test results requiring interpretation and follow-up treatment decisions than earlier generations of doctors faced. “We can treat things we couldn’t treat before,” says Rick Carpenter, R.N., patient care services manager for the medical intensive care unit (MICU) at the University of Virginia Hospital. “You have ‘multi-system failures’ in aging patients suffering from more than one ailment.”

Finally, the growth of managed care protocols has hastened time and cost pressures on doctors. Sick and recovering patients are hustled out the door many hours or days earlier than before, affording less time to observe and treat them in the hospital setting.

The confluence of these trends requires residents to run constantly and do even more on the little sleep they get.

Employees or Students?

Resident physicians are doctors who are completing their training to acquire board certification in a specialty by treating patients under the supervision of attending physicians. Hospitals have historically considered them to be students. Legally, however, these doctors-in-training are employees.

The National Labor Relations Board (NLRB) ruled in 1999 that, since residents work long hours, make medical decisions and earn salaries and benefits, they are employees. The ruling, which responded to a petition filed in 1997 by residents at Boston Medical Center, granted collective bargaining rights to more than 90,000 interns, residents and fellows who work in private hospitals nationwide. “Interns, residents and fellows ... while they may be students learning their chosen medical craft, are also ‘employees’ protected under the National Labor Relations Act,” ruled the board.

They are, however, employees with a difference. Hospital human resource departments have no hand in their hiring as they do in hiring nurses, technicians and other medical personnel. Resident physicians are recruited by individual residency programs. Applicants compete for places in the residency of their choice, ranking programs and hoping to be matched with their No. 1 choice. Hospitals, in turn, rank the applicants. On “Match Day” each spring, a computer spits out the results, and applicants are notified whether or not they made a “match.”

With salaries averaging in the mid-$30,000 to mid-$40,000 range depending on area of the country, residents are a cheap source of labor. Moriarty says actual earnings many not be much above minimum wage when you consider the number of hours worked. She believes “the people in charge often recognize that residents are working too much, but they are hampered by financial pressures and the complicated managed care system.”

Various groups, including the Chicago-based Accreditation Council for Graduate Medical Education (ACGME) and the American Medical Students Association (AMSA) in Reston, Va., have proposed solutions including shifting more of the work done by residents to nurses or physicians’ assistants (PAs). However, the persistent nursing shortage and a scarcity of financial resources make this difficult to implement. As for hiring more PAs, Moriarty says they command high salaries and “they aren’t going to work the kind of hours residents work. They will refuse.”

The Housestaff Office

HR functions for residents often are handled by what is commonly known as the “housestaff office.” At the University of Virginia Health System in Charlottesville, Va., the Medical Staff and Residency Office reports to the associate dean for graduate medical education, not to the HR department.

Sixty-five programs, each with a director, have 650 residents and fellows, says Residency Office Director Margaret Vandermark. Each residency program has its own requirements based on those established by the ACGME, and each program sets the duty hours for its residents.

Children’s Hospital of Philadelphia takes a “collaborative” approach with HR, according to Andrew McGill, director of employee and labor relations at the hospital. “We are focused on structuring the best possible learning environment for interns and residents.” Working with the traditional housestaff office at Children’s is a graduate medical education committee, chief residents from each program and a program manager who is a social worker.

HR brainstormed with the housestaff office two years ago and came up with the concept for the program manager’s job, McGill says. “We recognized that the administrative position we had in place wasn’t adequate to meet our needs. When the administrative person moved on, we looked into making a change.”

McGill says Children’s Hospital prefers not to have a formal limit on residents’ work hours because “our approach allows for residents to work with the support network we provide to insure hours are not excessive.” Their program is working well, he believes, and he is confident that residents are aware of and feel comfortable taking advantage of all the resources available to them.

Although she had little contact with the HR department at Johns Hopkins, Moriarty says more involvement could be a good idea, because HR could be “more reasonable and objective. I knew a resident who went to the director of his program and asked for a week of paternity leave. The director said no, so he went to the hospital’s legal office to find out just what rights he had” and was told that he was entitled to paternity leave.

Vandermark says the medical community tends to think that decisions such as how long residents should work “are better left to those who know the situation, i.e., the doctors. Surgeons, for example, really are a different breed. The people who go into this specialty tend to be very driven individuals. They would rather live in the institution than anywhere else on the planet.”

However, Moriarty remembers living “in a fog” during her residency. She recalls a time when she was operating on a patient and was so sleepy that “I couldn’t even talk. I slurred my words like a drunk.” (See “Sleep Deprivation and Medical Errors”).

One State Limits Hours

After a young woman died in Cornell Medical Center’s New York Hospital in 1984 as a result of an adverse reaction between two medications ordered by a sleep-deprived medical resident, the woman’s father, a reporter, convinced a New York district attorney to begin a grand jury investigation. The jury found neither the hospital nor the physicians at fault, but cited the system that permitted overworked, sleep-deprived residents and a lack of adequate supervision of these residents.

As a result, New York became the only state to pass a law regulating work hours for residents. In 1989, it adopted the “Bell Regulations,” named for Dr. Bertrand Bell, who chaired the committee that recommended the regulations.

The regulations mandate that residents work no more than an average of 80 hours per week over any four-week period and no more than 24 consecutive hours. That is still a grueling schedule, of course, but Dr. Diane Hartmann, associate dean of the University of Rochester Medical Center’s School of Medicine and Dentistry, says the law has improved resident education. Such hours are manageable and are not uncommon after doctors have finished their training, she notes.

Another strategy the hospital has implemented—the night float system of teams working in shifts—is not perfect, either, Hartmann says. Rotating shifts “alter the continuity of patient care. A patient may be passed off to three different doctors over a 24-hour period, and you can lose things in the passoff.” A “shiftwork mentality” can take hold that can diminish commitment to patients, she says.

New York’s regulations have some enforcement teeth, and hospitals can be fined if residents exceed the work limits. State regulators spend a week at each hospital once a year, question residents and attending physicians and impose fines for noncompliance. Hartmann says her hospital does internal reviews twice a year as well because she wants to be ready for the state inspections.

Mary Killackey, a fourth-year surgery resident at the University of Rochester Medical Center, says it can be frustrating to be forced to leave the hospital when time limits are reached. Especially in the field of organ transplantation, which she hopes to go into at the end of her general surgery residency, she says a doctor wants to stay with her patient as long as necessary.

The limits mean residents don’t see the quantity and variety of patients and situations they would see if they spent more time in the hospital. Killackey says she’s worked on too many routine surgeries and too few unusual operations. “If I’ve seen 100 hernia operations, it’s no advantage to me to see 125 such cases.”

Nevertheless, Killackey believes there are more pluses than minuses to limiting residents’ work hours. “I attended a very academic medical school [Columbia University Medical School], and I’m interested in research. The New York system allows me to do more than just clinical duties.”

Hartmann says many residents choose to come to New York because of the Bell Regulations. They may have some anxiety about seeing fewer patients, and they may feel oversupervised at times by attending physicians, she says, but on balance the New York rules are an attraction.

Ken Kruger, former president of the American Society for Healthcare Human Resources Administration (ASHHRA) in Chicago and former vice president of human resources and labor relations at New York’s Mount Sinai Hospital, says, “Organizations need to self-regulate.” Kruger, currently president and CEO of the Healthcare Human Resources Consulting Consortium in New York, believes that “Many top hospitals, including Mount Sinai, do a good job of this. The main issue is, how much do we want to set general standards? One size doesn’t fit all.”

The New York law prohibits residents from moonlighting if such work will exceed the 80-hour maximum per week or the 24-hour consecutive work limit.

Although he says the law probably helps prevent some abuses, “many residents want to moonlight because they want to make contacts for their future medical practice or because they have large medical school loans to pay back.”

Hartmann believes that “nobody wants to moonlight. They do it to help pay off their loans.”

Federal Regulatory Efforts

At the federal level, various groups are lobbying for regulation of resident work hours similar to restrictions for airline pilots and truck drivers. Last April, the advocacy group Public Citizen, AMSA and the New York-based Committee of Interns and Residents—a union representing 10,000 residents—jointly filed a petition with the Occupational Safety and Health Administration (OSHA) asking it to adopt federal regulations limiting residents’ hours.

The petition calls for OSHA to limit residents’ hours to 80 per week, with at least one 24-hour off-duty period per week, and to limit shifts to a maximum of 24 consecutive hours. It also calls for on-call shifts to be no more frequent than every third night with at least 10 hours off between shifts. Those are essentially the limits imposed in New York.

Although the ACGME sets accreditation standards for hospitals, the petition said that these standards are voluntary guidelines and alleges that “a significant proportion of hospitals across the U.S. have failed to meet them.” The ACGME can shut down a program that violates its standards, but “it’s hard to get accurate data with just one site visit lasting only one day,” says Hartmann.

In a statement responding to the OSHA petition, the ACGME noted that its standards broadly address education, resident safety and safe patient care, and acknowledged that “it is rare that a program’s accreditation is withdrawn because of failure to comply with any single standard.” However, the council says it has helped bring programs up to standard by monitoring compliance and citing programs. It points out that hospitals that lose their accreditation will lose some of their Medicare reimbursements and will drive away talented residents.

Public Citizen and the medical student groups plan to lobby Congress for legislation to limit resident work hours and require mandatory or voluntary reporting of medical errors. Some members of Congress have begun developing such legislation.

These health and safety issues aren’t likely to go away, and more regulation could mean more future involvement by HR in the administration of work hours and conditions in hospitals. Moriarty believes that would be a good thing.

“The ACGME has had its chance,” she says, “and it hasn’t been effective. HR could do a lot if it was given jurisdiction over housestaff.” She urges individual hospitals to involve HR more directly, saying “There’s no legal reason not to.”

Moriarty’s husband is a neurosurgery resident at Johns Hopkins, and she says his program is very family-friendly.

But “everyone is damaged by the kind of residency experience I had,” she says. “I feel like I got my life back [since leaving the residency]. I feel normal now.”

Ann Pomeroy is managing editor of newsletters for SHRM Professional Emphasis Groups.