Education

Stop Lamenting the “80-hour Rule”

Although internal medicine programs instituted an 80-hour weekly work limit in 1989, the “80-hour” duty hour limit was formally implemented by the ACGME is 2003. The purpose of the limit was to ensure patient safety and reduce medical errors while protecting the safety of residents by preventing burnout and psychological distress.  While there is conflicting data with respect to whether the duty-hour limits have resulted in improved patient safety and decreased medical errors, the duty-hour limit has been blamed for numerous deficiencies in resident education.1 The responsibility for this is often placed on the residents by older generations of surgeons.  The residents are explicitly told, or it is not so subtlety implied, that they are “weak” for abiding by the duty-hour regulations.  Residents are chastised for losing continuity of care and for “choosing shift work” instead of choosing to take care of their patients.  Many surgeons feel that there has been an erosion of the surgical skills and clinical acumen of trainees and that these deficiencies are rooted in residents spending less time in the hospital and performing fewer surgeries with less independence.

Even if the 80-hour duty limit has not improved patient safety or reduced medical errors, it is my belief that the regulations are attracting a higher quality applicant into medicine.  The days of first year trainees being “interned” in the hospital and living on the grounds for an entire year are long gone.  While some may mourn the fact that today’s medical students see their career as part of their life and not their entire life, these students have varied interests and talents that would not have been a fit in medicine 50 years ago.  Their different perspectives and values will hopefully allow for innovative solutions to our most challenging problems.

We must adapt our teaching techniques to optimize surgical education in this new era.  The 80-hour duty limit is not inherently good or bad, it is just different.  Instead of lamenting the lack of hours that residents are in the hospital, we need to make the most of those hours and stop insisting that the education of the pre-80 hour duty limit era is unquestionably superior to education of the post-80-hour duty limit era.  Given the exponential growth of medical knowledge and surgical techniques, it is no longer enough that residents and fellows “learn by osmosis,” simply by being present in the hospital and watching senior mentors perform surgeries.  Medical and surgical education in the post-80-hour era must be more efficient.  Many programs have already instituted bioskills labs, and our understanding of how to measure surgical competence continues to evolve. It is my plea that we stop “lamenting” the 80-hour rule but rather rise to the challenge of improving how we teach the future generations of student, residents and fellows.

  1. Philibert I, Nasca T, Brigham T, Shapiro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med. 2013;64:467-483.

Article written by:

John Fowler is an Assistant Professor in the Department of Orthopaedics at the University of Pittsburgh. He completed his residency in Orthopaedics at Temple University Hospital in Philadelphia and a hand fellowship at the University of Pittsburgh. His research passion is the use of musculoskeletal ultrasound. When not working, he tries to spend as much time as possible with his amazing wife Amy and three children: Alexis, Kyle and Eliana.

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  1. Paul Guidera MD FACS

    The predictable outcomes of implementation of trainee work hour limitations have been the “hand off” and the sculpting of physician-employees. Those who tell us to “stop lamenting” are in an advanced state of denial or are true believers who have finished training within the last 10 years or so and are therefore victims of this dumbing down of American medical education. Academic medicine is the perp. The patient is the victim.

    Surgical trainees of the 21st century no longer have the opportunity to follow every step of a deathly ill patient from the emergency room entrance to the morgue refrigerator. He (or she) will never have to experience the unpleasant truth of getting to know a family and face with them the soul-shattering reality of the unexpected and imminent loss of a loved parent or spouse….or child. That would be too uncomfortable…get a nurse to do that!…I’m going to my safe place!

    We’ll have much happier residents and therefore much happier ‘providers’ or ‘caregivers’ or whatever it is the emasculated doctors of the near future are called. They will be better rested because they will be employees, with strict limits on the number of hours they will be required to spend being a doctor before punting their problems to the next robodoc coming on shift. They will have the well-deserved luxury of dropping everything and going home and they will of course enjoy preplanned and guaranteed-uninterruptible vacations.

    And that’s just great for the entitled new generations of children America is now producing. We don’t want our new state-of-the-art doctors to have to fret about a patient after hours, or to experience anxiety because that they might miss their evening or weekend plans when a patient is circling the drain.

    We don’t want our young doctors to worry…at all. After all, they are our children! We just want them to be happy, well rested, polite and nicely scented.

    Tragically, they will never know what they don’t know, because they missed 67% of the clinical material they could have managed while in training…because they were resting. They simply can not and never will have the depth of experience that battle-hardened surgeons had who were fortunate enough to have trained before we placed more emphasis on our trainees’ comfort than on the learning potential inherent in staying awake past 8 pm.

    In addition to the astonishing volume of difficult cases that I managed as a resident on shifts that were often 36 hours, and the invaluable intuition that I gained from 8 years of staying awake, an enduring quality that I gained, and consider a gift from my attendings, remains, after 22 years of practice. It’s my own personal WWJD: trust no one, check everything yourself.

    That mantra doesn’t exist in medical education now. It’s already all gone. Instead, they “hand off”. Our new surgeons will go from coddled residency to hospital or large group employment where they will have corporate shields protecting them from accountability that they never knew they should have. Made a mistake? Corporate counsel will manage that, Doctor. Don’t you worry. It was probably the patient’s fault anyway.

    In the unfortunate 6 years that I spent recently in a large orthopedic group, I do not recall attending a single meeting in which patient care was discussed. The only issues on the agenda were…
    money,
    contracts,
    upcoding strategies,
    CMS and…
    of course…
    more money.

    Let’s not kid ourselves: Medicine is no longer a healing profession. It’s a for-profit industry and our rested but sadly lobotomized new doctors are being trained to be subservient to those interests. They want those guaranteed hours and bonuses, even if means that they will inevitably be pitched out of the company after a couple of years to make room for cheaper talent.

    I’m not judging of course. That would be bullying.
    I’m just appalled.
    And my flight is about to land.

    • John Fowler

      Paul,

      Thank you for your comments. I am glad that my post generated some discussion!

      Your comments are a perfect example of the “we walked uphill both ways to school every day, in the snow” phenomenon. Everyone always feels that their training was harder than every one else’s training. You state at the end of your post that you “aren’t judging”, but you clearly are doing just that. Today’s residents are “weak” and “aren’t good doctors anymore.” Your comments are just flat wrong. I did complete my training within the last 10 years and I can guarantee you that I am “not in denial” as you have suggested.

      It is not the absolute number of hours that we work, it is what we do with those hours. My intern year, we had to print x-rays every morning (taking 1-2 hours) and draw all of our own blood for patients on our service (1-2 hours). The following year we had digital x-rays and a phlebotomy team. That saved 4 hours a day right there! Surgery is more efficient now than ever. Surgeries that once took 2 hours to complete are now routinely performed in 1 hour or less. We are completing more surgeries in less time. ER’s are more efficient and get patients in and out and/or admitted quickly. I would argue that today’s residents have as many or more patient encounters than your generation.

      Your comments about the 36 hour shifts are simply misguided. Numerous sleep experts will tell you that you can’t really “train” yourself to “work tired”. It is probably an increase in knowledge and efficiency that gives the illusion of “getting better at working while tired”, but the evidence would show you clearly make worse decisions when tired, regardless of how many hours you worked 30 years ago as a resident. I could counter your 36 hours argument with, “why didn’t you work 40 hour shifts”? It is an empty argument. The hours themselves don’t matter as much as what you do with those hours. It would make more sense to learn efficiently in less time than to learn inefficiently and take twice as long.

      The other comment I would like to make is that while service is a large part of residency, the purpose of residency is to learn. Your comments drip with the sentiment that residents are merely a means an end to get all the work done.

      John

      • Paul M Guidera MD

        Dr. John,

        With all due respect to your many outstanding accomplishments , you sound like the predictable end result of exactly the dumbed down medical education that you are defending. Medicine is dumbed down. It’s not your fault, necessarily. Of course you can’t see it. You cannot see it because you don’t know what you don’t know. Is that too obtuse?

        Trivializing the opinions of better trained and far more experienced senior surgeons is nothing more than petulant arrogance. Again, it’s just you not knowing what you don’t, and never will, know.

        Getting the work done? John, the learning is in the work and those are hard lessons. Perhaps shocking to you, we had to perform many trivial tasks like drawing blood from NICU babies, working up a fever in a combative patient at 2 am and doing our own Gram’s stains, but those exercises were lessons in humanity and humility, qualities that you evidently successfully dodged by getting some rest instead.

        Your argument again hard work is circular and self serving. The logical response to it is simple: You can’t learn if you are not there. Even you cannot argue that basic truth.

        I understand that being spoon fed is easier, it’s just that the gains are minimal. Arrogant arguments against hard work as a means to expertise is exactly what one would expect from the unfortunate generations of doctors hitting the streets now. It’s no different than handing a child a trophy for every soccer goal scored. We just want everyone to feel good about themselves, even if the end result is a self-absorbed and minimally competent adult who whines about working too hard and denigrates those who disagree.

        A few years ago I watched an orthopedic resident (perhaps it was you) walk out of an osteochondral knee reconstruction being performed by one of the best surgeons I know because…

        …his shift was over at 2 pm. Following your arguments to their logical conclusion, the opportunity to experience technical virtuosity for an hour or two was no reason to delay getting home to…snapchat…Netflix…rest?

  2. Anonymous

    Those of us who were in the middle of the discussions about the 80-hour rule knew exactly what would happen if instituted. The comments by Dr. Guidera are harsh, but correct. When I interact with residents now, 23 years since my fellowship, the “hand-off” is the most dreaded time of the day. A consult is called of me, and there is no one with whom to discuss my findings; they have left for the day, even if my findings dramatically alter the course of the patient’s course or status. Its when patient care becomes secondary to ones supposed tiredness and the clock ticks 80. Its an attitudinal shift from taking care of what needs to be done despite the long hours that propels the work day. The emphasis therefore becomes me. Its not the Hippocratic Oath anymore. Nowhere is there any comment about taking care of the sick, if you have enough time. In fact, it is only after we take care of the sick patient that: “If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter.”

    • John Fowler

      Thanks for your comments.

      I disagree that Dr. Guidera’s comments are “harsh, but correct.” I think they are ignorant to the current training environment.

      I am confused about your “hand-off” comments. Why could you not make a mental note and follow-up the next day with that trainee.

      The current generation of trainees are not trying to break the Hippocratic Oath as you have suggested. The vast majority would work 120 hours a week if we asked them to. The point is that there should be a system in place that when they leave, there is another person there to take care of the patient. Just like when you leave for the day, the resident is there to take care of things …..

  3. DWT, MD

    Dr Fowler,

    Why did you actively solicit opinions about your topic and then personally attack each physician who responded? That’s really inappropriate. You should consider apologizing to the respondents and then reboot your ego to something approaching civility.

    I think it is an example of a “snowflake” mentality on your part. As far as your personal attack on Dr. Guidera, it is deplorable and unwelcome in a setting such as this.
    As he put it, you REALLY don’t know what you don’t know…about a lot of things.

    Shame!

    • John Fowler

      Disagreement does not equal “attack”. In any discussion/debate, there can/should be a certain level of disagreement. I respectfully disagree that I personally “attacked” either of the posters above. I assume that by posting comments to the opinion piece, those physicians were interested in having a dialogue and I would argue that nothing that I posted was in any way an attack or uncivil as you have suggested.

      Name calling (“snowflake”), however, does seem “deplorable and unwelcome” in a setting such as this and perhaps you are the one who “should reboot your ego” and apologize.

      John

  4. Sal M, MD, PhD

    Just came across this, so maybe out of date and pointless, but:

    I met Dr Guidera in a DMAT facility in Port au Prince, Haiti just after the January 2010 earthquake. I was just touring as part of an NGO. If you don’t know about these federal teams, you should research it.

    It was like the tent hospital in the old TV show MASH and was right in the thick of the disaster zone, surrounded by refugee camps. The air was filthy black smoke and there was raw sewage flowing. The temps were in the 90s and so was the humidity.

    The team there was tasked with providing basic medical services because infrastructure was literally gone. The day I was visiting there were hundreds of patients/families seeking care.

    The doctor you seemed to be so intent on denigrating here was the only surgeon on the team. He was operating on horrific cases, amputations, open fractures, compartment syndrome, head and body wounds, in a tent. Everybody was clearly exhausted and all of us were dripping sweat because of the heat and humidity. The whole thing was being run on generators belching diesel fumes.

    The anesthesiologist told me they had been working since 9pm the prior night when a caravan full of people injured in a shootout on wheels showed up just as they were hitting their cots and when they were done with those cases, had just continued on with the patients who showed up at dawn.

    He was making do with basic instrument sets and an Army medic for an assistant who had never scrubbed before. I hadn’t seen a Gigli saw or a skin graft knife since I was an intern. The sterilizer was a purple solution in a tub and the instruments were being cleaned outside in a portable sink. Dr. G was helping the nurse clean the instruments in between cases. He was setting up his own cases while the nurse was helping the anesthesiologist. He examined each patient (stethoscope!) befor induction.

    During a break, he took me to the surgical clinic tent. There was a long line of patients waiting for evaluations, wound checks, minor procedures etc. The nurses and a PA were running the show but had been waiting all morning for Dr G to present the complex cases. Every provider was incredibly respectful to the patients and families and I was touched by how no one was rushing the patients through, how they never stood over a seated patient, always sitting down or crouching down to be at the same level. The nurses were nothing short of incredible in every way.

    It was a profound experience to see how America had responded to this horrible disaster and how these professionals made it all work. There was a giant Americsn flag hanging from a tree branch. No one complained, no one rested. It was like an organism of caring. A culture of caring in the worst environment. I left that afternoon a different and moved person.

    These professional leave their practices, their jobs and their families at a moment’s notice to respond to these disasters. They do it because they feel a moral obligation to do so. It’s very harsh and very uncomfortable and yet, as Dr G put it, they meld into an organism instantly because they have have a defined mission handed to them by the U.S. government.

    The point is that I don’t think I could have been doing what I saw Paul or the other professionals doing there, making countless decisions with limited facilities, him performing operations using techniques that didn’t require advanced imaging, hi tech implants or devices etc etc etc, and doing it in terribly harsh conditions. Adaptability, ingenuity, empathy. None of the sarcasm and cynicism rampant in our hospitals these days.

    You have to ask yourself, Dr. Fowler (if you are still there)…could that have been you? Could you have been an effective part of a team like that? Leaving your university credential behind, checking your ego at the door, practicing without your colleagues, residents, medical students, textbooks, internet access, air conditioning, music, comfy bed or plenty of rest? Using only the knowledge and experience gained through a rigorous and unrestricted residency and fellowship and then 20 some years of practice?

    I’ve read that orthopedists trained since limits were imposed are not competent as surgeons until they have practiced for 5-7 years, so I’m guessing the answer might be no.

    Next time you ask a loaded question, and then want go after someone who responds frankly but whose response embarrasses you, find out who you are attacking first. He might be a better doctor than you.

    • John

      Hi Sal. It is exciting that my post continues to generate replies over 2 years after it was posted!

      I remain shocked that multiple posters have accused me of attacking (or “denigrating” to use your word) Dr. Guidera. I have gone back and read my reply to him several times and I see disagreement about the issue of the 80 hour work week, but I don’t see any personal attacks. As I stated to another poster, disagreement does not equal an attack.

      I am thankful that Dr. Guidera was able to serve in Haiti after the 2010 Earthquake. I spent a week in 2014 at L’Hopital Albert Schweitzer in Haiti and it was a wonderful experience.

      Where did you read that about it taking residents 5-7 years to become competent? Would love to see the data.

      I think your last two paragraphs really sum up the point of your post and show your true colors. You are basically saying that I am not a competent surgeon and that Dr. Guidera is a better doctor than me. Happy Holidays.

  5. S.

    Dr Fowler,

    I think you proved my point. Unintentional and quite ironic, but still…

    I painted my picture of Gheskio for you because it is an example of how worthwhile non-hour-limited medical training is to society as a whole: Forming and performing, as they say, in austere, unpredictable environments with limited resources for a mission that is fundamentally humanitarian.

    Seeing what I saw there was startling for me, and I have worked for NGOs for my entire career, currently in Switzerland. Reviewing my journal before posting my initial comments here was like reliving that day. I still marvel at the competence, the kindness and the mutual respect I saw, not just from the docs, nurses and medics, but everyone involved in that endeavor.

    In other words, you posed a question and a “plea”. I answered it. The 80 hour rule created a disconnect in competence.

    You responded by telling me about your one week experience at HAS Desjardines. That’s a revealing non-sequitur.

    I was on an advisory board there for several years and worked there before it became a working vacation. I’ve mentored several fine visitors such as you. I am also well aware of the foundation’s relationship with the institution that employs you.

    As you and I both know, Schweitzer is a curated experience that, in recent years, has been modified to compensate for the skill sets of recently trained visiting American surgeons. There is nothing austere going on but a week there can nonetheless be a gratifying volunteer experience for those courageous enough to visit. That in and of itself serves an important purpose for the foundation, since it is a proven fundraising technique.

    I’m not at all belittling the experience that an otherwise sheltered and possibly unfulfilled doctor can have there. Many have told me they received more than they gave, and that is really the point…highly compensated American docs need to be humbled once or twice in their careers. Schweitzer is a charming and safe way to do just that, and you can leave healthy, unharmed, feeling good about yourself and then show your powerpoints to residents for years afterward.

    But, having said that, conflating your brief, guided experience in a curated environment such as HAS with what I saw happening at Gheskio in Port au Prince’s Red Zone immediately after an earthquake that leveled the city and killed more than 150,000 people, many still noticeably rotting beneath the concrete, is really quite ridiculous on your part.

    To make it all about you is really quite millennial.

    So, you proved my point, and I thank you for that, even if it was unintentional.

    There’s a common thread in this discussion of people responding to your question who then get slagged off because they disagree with you. What’s missing are responses from people who do agree with you. That is potent silence.

    And to anyone else reading this uncivil old thread: regardless of your faith, I wish each of you a peaceful holiday season. I push myself every day to find God in everyone I meet, even in these troubled and dangerous times. I urge everyone to try it, however difficult it may be.

    • Jason W

      I think it’s worth pointing out that there are still young attendings and current trainees who have a hard-nosed attitude, who stay after call to do extra cases, who are “available x3,” who couldnt tell you how long their “shift” has been (since they arent paying attention), who roll their eyes when a co-resident disappears immediately “post-call,” and who just want to maximize their training and become the best damn doctors they can be. They exist. I have seen them come through training programs even within the last few years. They are the “all stars”, the ones who read for every case and are always prepared. The ones who cover for their colleagues. The ones who never look at the clock.

      Painting with such a broad brush, assuming all the young doctors out there are hopeless millennial worker bees (minus the work ethic) just makes us gray haired surgeons sound crotchety. Sure many of the new doctors are exactly that. But if you pay attention, there are some standout young trainees who “get it”, and some of it undoubtedly has to do with where they trained. Inner-city, trauma-heavy university programs with busy call services always have at least one of these per year. But the rest of it is just who they are. Not every trainee today is a wimpy “snowflake,” I assure you.

      And be honest, not every one of your co-residents/chiefs/interns back then had the same attitude and strengths you did. Be honest. Eventually it got beaten into them, maybe. Or they somehow survived other ways.

      The bottom line is that the way residents train today is completely different than a few decades ago. Is it kindler? Yes. Gentler? Yes. The mold has changed and a different doctor emerges from it compared to the one that emerged from our crucible. Is that doctor objectively a worse doctor? That’s debatable. I certainly would prefer to have Dr. Guidera running my field hospital during a humanitarian crisis.

      But is a millennial doctor going to have worse outcomes or harm their patients in their future practice environment because they trained in the 2010s rather than the 1990s? I don’t think it’s fair to say that they will. On a day-to-day basis, the grizzled and steely 1990’s-graduate surgeon doesn’t need to use those old battle techniques. At least, I sure hope not… if so, they may need to change their practice! Sure maybe once every few months you get killed on call and need to run a full day and you call upon that skill set, but I have seen residents of today do exactly this without batting an eye. Certainly not all of them are willing or capable. But some are, and then some even relish it.

      It seems like you work with trainees, but I wonder where? What is this environment in which a resident taps out at 2pm?? I have not seen such brazen laziness (“self-care”) in the name of work hours – where I work, any resident who did that, even in 2019, would be a laughingstock – at the very least behind their back and possibly to their face.

      The other side of this is: Is today’s young doctor TO BLAME for their shortcomings? To say that they are seems a bit unfair. We didn’t choose the more difficult path, it was the only path available. Any “millennial” resident that comes out of today’s system and has the characteristics we recognize in ourselves is all the more praiseworthy, that’s for sure. And as I said, they certainly do exist.

      As far as lamenting the 80-hour-rule… I think it’s fine to lament certain aspects of training gone by the wayside. Continuity of care being replaced by hand-offs, sure. Go ahead. But many of today’s residents still log just as many cases as I did during residency, however, that’s while publishing far more, reading more and doing better on the in-service than I or my buddies did. We didn’t need to retain anywhere near the amount of random factoids that they do (not that this is what makes anybody a better doctor).

      Again, the point is that it’s different. And it’s not going back anytime soon, so I’m not sure it’s worth complaining. Train the ones you can, and the others – the hopeless snowflakes – will eventually have their shortcomings identified, one way or another.

      • John Fowler

        Jason,

        Thank you for your comments. I think you captured the spirit of my initial post but explained it much more eloquently that I did.

        John

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