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How many hours?

In July 1989 the New York State Department of Health enacted regulations that limited hours worked by residents, increased supervision by attending staff, and augmented ancillary services. The plan, proposed by the Bell Commission, has radically transformed postgraduate medical education by paring down the work week to eighty hours and by restricting shifts to twenty-four hours. The state believed that improved supervision and shortened hours would improve patient care, foster medical education, and reduce resident fatigue and stress.

Prompted by developments in New York, state legislators and policy-makers across the country are reexamining the grueling schedules traditionally worked by physicians in training. Although New York is still the only state with mandated restrictions, Iowa, Massachusetts, Michigan, and Pennsylvania have similar bills pending. Proposed legislation in Connecticut, Hawaii, Illinois, and Missouri that sought comparable reforms has been unsuccessful. Legislators in California and New Jersey are studying the issue in more detail.

Although these reforms represent a long overdue correction of residency training first introduced nearly a century ago, the commission's recommendations may have hidden liabilities that could threaten fruitful post-graduate medical education and compromise patient care.

Forcing house officers to leave after twenty-four hours on call may deprive them of an educational process that continues into the day after admission. A resident's preliminary clinical impressions are often refined by instruction from senior staff bolstered by laboratory results available only the morning after admission. This critical period of instruction could be jeopardized by state relations.

Continuity of care is often compromised by shortened shifts which require that more physicians participate in an individual patient's management. Under the Bell regulations, patients admitted overnight to the hospital might expect their care to be provided by three different physicians over the first twenty-four hours of hospitalization. When a group of physicians replace an individual practitioner, the risk of miscommunication is heightened. Sign-out procedures between physicians are unfortunately unable to replace first-hand knowledge of a patient.

The intricate "cross coverage" system needed to comply with the Bell reforms also requires residents to cover for patients they have never met. When residents do meet their colleagues' patients it is generally because of an acute problem that requires them to distinguish the unimportant complaint from the critical symptom. Deprived of any previous exposure to the patient, save for the sign-out sheet, inexperienced physicians will often order additional medical tests "to play it safe." This problem, only partially mitigated by increased supervision, can lead to unnecessary tests that can be costly, inconvenient, and at worst, place the patient at unnecessary risk - By shortening the work week the Bell Commission reforms created staff shortages that have not yet been met. If policy-makers were to extrapolate from similar reforms in New Zealand, when the work week was reduced to seventy to eighty hours, they might anticipate a 22 percent increase in staffing (Boyd A- Swinburn, "Correspondence: Looking at the Training of House Staff," New England./Journal of Medicine 319:11 [1988], 718-22). The rapid enactment of regulations in New York, without timely funding to meet man/woman power needs, has created critical staffing gaps that may prove dangerous.

The most troubling concern of the regulations, however, is their threat to the traditional doctor-patient relationship. The wrong message is being conveyed to physicians when they are told they cannot personally care for patients once the clock runs out. To imply that a doctor's obligation is governed by a schedule and not by patient needs runs counter to long-valued concepts of physician responsibility. The ability to sign over difficult or unpleasant patients may well erode the young doctor's developing commitment to patient care.

A basic and flawed assumption in the Bell Commission report is the inference that one physician can be summarily replaced by another. To fulfill the law's requirements, a physician simply has to sign over care to another comparably trained physician. Unfortunately, mere compliance with the law can jeopardize the bonds of healing between a doctor and patient by disrupting the trust engendered when responsibility for care is first assumed. Although physicians cannot be expected always to be at their patient's side, regulations should not interfere with this sacred trust. For those patients too poor to have their own private physicians, these regulations make continuity of care especially problematic.

While public safety dictates that the state should correct conditions which contribute to poor medical practice, it is not clear if these reforms will actually improve the delivery of health care. Although the Bell Commission's goal is laudable, the reforms may lead to compromised care and to the abandonment of time-honored notions of physician responsibility and the sanctity of the doctor-patient relationship. Many physicians fear that we would be forsaking our professional stewardship if we abandoned either our patients or our value system.
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Title Annotation:New York state regulations limiting the working hours of medical residents
Author:Fins, Joseph Jack
Publication:The Hastings Center Report
Date:Mar 1, 1990
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