Residency is a stage of graduate medical training. A
resident is a physician who practices medicine generally in the 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 an unrestricted license, they can practice medicine in many

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 traditionally required to be present for set shifts,
and set their own schedule outside them, working long additional hours in the
hopes of improving patient care, their training, their career prospects and
acquiring more critical skills. The flexibility of this system makes it easy for
the trainees to abuse.

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

There are financial motives for overworking junior doctors.
Since they are the least-experienced staff members, residents are usually paid
less. As a result, it is cheaper to assign paid overtime to them. Intentional
understaffing, paid, and sometimes unpaid overtime for junior doctors is
therefore used to reduce costs for medical facilities, although this may also
reduce the quality of care, which can be extremely expensive.

Effects on workers

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

The results of
studies examining the effects of extended hours on residents’ performance are
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 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.

evaluating the effects of duty hour restrictions on patient outcomes have been
somewhat ambivalent. Duty hour restrictions have brought about
more problems than solutions. In part to avoid federal legislation, the ACGME
approved new resident duty-hour regulations that became effective on 1 July
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 July 2011, the Common Program
Requirements state that duty hours must be limited to 80 hours per week,
averaged over a four-week period, including in-house call and moonlighting.
The 2011 reform also stated that duty
periods of interns must not exceed 16 hours. (Romano and Volpp,

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 could be a small step toward reducing fatigue and potentially decreasing
errors and malpractice. 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 circadian rhythm sleep disorder characterized
by insomnia and excessive sleepiness affecting people whose work hours overlap
with the typical sleep period.) include avoiding abrupt changes in shift time,
getting more sleep, which makes the sleep schedule more flexible, and the use
of caffeine and ambient light of specific wavelengths. (Borman,
Jones and Shea, 2012)

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