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Residency is the first stage of post-graduate medical training. A resident is a physician that practices medicine generally a hospital or clinic setting under the supervision of an attending physician. Medical residents hold one of these three degrees: Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine (D.O.), Bachelor of Medicine, Bachelor of Surgery (MBBS). When they have successfully completed a residency program, which is a requirement to obtain a license, they can practice medicine in various jurisdictions.

Medical interns and residents often work long shifts throughout the duration of their medical residency. In numerous location, many residents commonly work 80 to 100 hours a week. Occasionally, surgical residents log 136 (out of 168) hours week when they are able to.  These young doctors are often not paid on an hourly basis, but on a fixed salary; in some places, they are paid when they are booked for overtime. There have been laws and rules put in place to limit how many hours residents are allowed to work without a break. (Gupta, 2001) Limits on working hours have led to misreporting, where many residents work more hours than they record. Due to the increase of negative effects on medical residents and patients because of long work hours, medical resident’s work hours should be cut shorter and strictly regulated.

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Causes of high workloads

In their role as medical care providers, residents work with other members of the healthcare team to provide direct care to patients. As physicians, one of their chief responsibilities is diagnosing patients’ medical problems and formulating appropriate management and treatment plans. In most residency-related settings, residents are supervised by attending physicians who must approve of their decisions before they are made. However, some residents legally practice medicine without supervision in settings such as urgent care centers and rural hospitals.

Medical residencies generally require long hours of trainees. Residents are normally required to be work in set shifts and set their own schedule outside them. They are eager to work long additional hours in the hopes of improving patient care, get more training, their career prospects and acquiring more critical skills needed to progress in their field. The flexibility of this system makes it easy for the trainees to abuse rules and regulations.

The new doctors often lack negotiating power and have difficulty changing employers. As a result, they are left with little say about their working conditions. This has been repeatedly brought to the attention of critics who despise long residency hours and note that resident physicians in the United States have no alternatives to the position that they are matched to. This means that residents have accept all conditions of employment, including very long work hours, and that they must also, in several cases, deal with poor supervision. This process reduces the competitive limitations on hospitals, resulting in low salaries and long, unsafe work hours for these young doctors.

In addition, finances motivate residents to overwork themselves. Since they are the least-experienced staff members, they are usually paid less. Therefore, it is cheaper to assign paid overtime to them. Intentional understaffing of the hospital or clinic, paid, and sometimes unpaid overtime for residents can therefore be used to reduce costs for medical facilities, although this may also reduce the quality of care.

Effects on workers

The evidence for harm to people who are sleep deprived due to irregular work hours is solid.

The results of studies examining the effects of extended hours on residents’ performance have been continuously ambiguous. One study noted deficits in grammatical reasoning in a group of five physicians after sleep deprivation. In another study, 33 surgical residents were given a comprehensive psychometric test battery. Results of this study showed no differences in performance between sleep-deprived and rested residents. Other studies have found decrements in some measures of performance. For example, a study in England found decreased mathematical abilities among sleep-deprived residents. Other studies involving sleep-deprived interns have found increased errors in reading electrocardiograms (EKGs) and increased time required to complete the task. In one of these studies, a mood scale was administered simultaneously, and results indicated that the rested interns felt more elation, social affection, egotism, and vigor and less fatigue and sadness than sleep-deprived interns.

Research from Europe and the United States on nonstandard work hours and sleep deprivation found that late-hour workers are subject to higher risks of gastrointestinal disorders, cardiovascular disease, breast cancer, miscarriage, preterm birth, and low birth weight of their newborns. In a study, pregnant women residents reported working twice as many hours per week as wives of male residents (in some residents’ cases more than 100 hours per week), with pregnant residents averaging 6 to 7 on-call nights per month. Premature labor requiring bed rest or hospitalization was nearly twice as common among the residents as among the wives, as was preeclampsia or eclampsia. However, placental abruption was less likely to occur in residents.

There are a substantial number of stresses associated with graduate medical education, and working long duty hours is one of them. Cultivating and sustaining a healthy relationship with a spouse or significant other can be tricky when a resident is constantly tired. Recognizing that sleep deprivation can be a stressor, one study detected no relationship between gender and stress among internal medicine residents. However, a separate study found that women residents reported more stress than men residents but were more likely to mobilize external support to cope with it. Divorce and broken relationships often result from the stresses of residency. (Biological Rhythms: Implications for the Worker, 1991)

Effects on Patients.

Public and the medical education establishments acknowledge that long hours can be counter-productive since sleep deprivation increases rates of medical errors and affect attention and working memory. Chronically sleep-deprived people also tend to strongly underestimate their degree of impairment. Competence is affected by the number of work hours, number of continuous work hours, regularity of sleep, and frequency and speed of handovers to the next shift. A 2004 landmark study found reducing sleep deprivation substantially reduced errors in intensive care units. The study redesigned first-year junior doctors’ schedules to minimize the effects of sleep deprivation, circadian disruption, and handover problems, assigning four shifts where there had been three and allowing an hour’s overlap for handovers at the ends of shifts. Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit. (“Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units”, 2004)

Duty hour restrictions.

Recent studies evaluating the effects of duty hour restrictions on patient outcomes have been somewhat inconclusive. Duty hour restrictions have brought about more problems than solutions. To avoid federal legislation, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hour regulations that went into effect on July 1, 2003. The regulations limited resident workweeks to 80 hours or fewer and limited continuous duty to 24 hours, with 6 additional hours for transfer of care the first duty hour reform. The second duty reform became effective in July of 2011, the required that duty hours must be limited to 80 hours per week, averaged over a four-week period, including on-call days and moonlighting – activities that are not performed during their residency program. The 2011 reform also stated that work shifts of interns must not exceed 16 hours. (Romano and Volpp, 2012)

Proposed Solutions

The most supported proposed solution is reducing the workload of residents, but this is ineffective if regulations are ignored. Whistle-blower protection laws, protecting residents who report violations of working-hour regulations from losing their residencies and thus their route to professional accreditation, have been proposed. Increasing the bargaining power of residents has been proposed, on the argument that they would then choose the best training programs. Where there is a shortage of doctors due to the lack of recruitment, proposed solutions include reducing the costs of medical training and more extensive training for nurses, who then take over duties formerly done by doctors. Although strategic napping is recommended by the Accreditation Council for Graduate Medical Education (ACGME), no studies have concluded the effect of napping as a fatigue mitigation technique. Requiring naps during long shifts may result in a slight step toward reducing fatigue and potentially decreasing errors and malpractice of resident doctors. Resident surveys suggest that a “greater emphasis on education, decreased workload, and more upper-management support would better improve patient outcomes.” Shift work sleep disorder (SWSD) is a disorder that causes insomnia and excessive fatigue. It effects people whose work hours overlap with the typical sleep schedule. Other small solutions that may positively impact the healthcare industry include avoiding abrupt changes in shift time, getting more sleep, which makes the sleep schedule more flexible, and the use of caffeine and the use ambient light in healthcare facilities. (Borman, Jones and Shea, 2012)

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