ABSTRACT
Residency is vital part in the continuum of medical education transforming the medical student to medical practitioner (doctor). Residency is an opportunity for practical training in a medical or surgical specialty. Traditionally, residents would often live in hospital (hence the name residency) - supplied housing because they require lengthy hours of training. Working hour’s factor has a tremendous role in health service delivery. Early residents were regarded as a source of cheap labor and if their number of working hours was to be reduced the hospital would have to pay other providers to step in. There are risks that accompany working beyond limits. Working for long hours beyond the allotted time is an ethical issue since it has the potential to affect the outcome of the treatment on the patients and the efficiency of the service offered by the overworked medical practitioner. Occupational stress is also cited as a significant health problem associated with long working hours. It is argued that by working for long hours residents gain experience that is necessary for the medical profession. This is nullified from the evidence that little or no learning occurs after working sixteen hours. Overworking causes the practitioner to be compromised in problem solving, lapse in attention to detail and commit errors of omission. This puts the life of a patient at risk and also the reputation of the practitioner, the employer as well as that of the noble practice. The accreditation council for graduate medical education is the professional body that oversees residency training. The Accreditation council for graduate medical education has limited the number of work hours to eighty hours weekly, overnight frequency to no more than one overnight every third day, and 10 hours off between shifts. This paper will evaluate ethical issues surrounding the residents working for longer hours than allotted and the laws, rules and guidelines governing the issue.
1.0 INTRODUCTION
Residency is vital part in the continuum of medical education transforming the medical student to medical practitioner (doctor). Residence physicians also termed as registrars are graduates from an accredited medical school and hold a medical degree. They are termed as residents because they live majority of their lives in hospitals. Traditionally, residencies would often live in hospital- supplied housing because they require lengthy hours of training. Residency gives the doctors in training a chance to gain hands-on practical experience in the medically and/ or surgical field.
Working hour’s factor has a tremendous role in health service delivery. Registered nurses and doctors are accountable to the public for providing safe, competent and effective care for patients in a variety of settings across the continuum of health care. The role of doctors or any medical practitioner and nurses in the hospital is vital in the society since the stake of the ill patients in the hospitals and clinics is in their hands. Due to the value of life, every affected person wants his or her beloved in the hospital to receive the best of health care and examination. This creates pressure on the doctors and nurses and since it is their responsibility to deliver their best to the patient they do what they can to ensure a positive outcome. The American nurses association is in the position to establish policies and procedures that promote healthy nursing working hours and patterns that do not exceed beyond the limit of safety for both nurses and patients. A crucial issue that is of challenge in hospitals is the long working hours beyond that allotted. This has great effect on healthcare since it has the potential to affect the outcome of the treatment on the patients and the efficiency of the service offered by the overworked medical practitioner.
2.0 Ethics
Working for long hours beyond the allotted time is an ethical issue because it has the potential to affect the outcome of the treatment on the patients and the efficiency of the service offered by the overworked medical practitioner. Several other risks and ethical issues are associated with residents working for longer hours than allotted.
Working for longer hours than allotted leads to decreased energy needed for successful completion of required tasks. Prolonged hours affects the state of mind of the practitioner since the body gets fatigued which in turn causes the brain functions to deteriorate. This leads to inefficiency of the work done which in turn could put the patients in harm’s way. Sleep- deprived resident physicians reading cardiograms or interpreting any other test results are very likely to make errors in judgment. Sleep deprivation (sixteen hours of wakefulness) has been known to cause deterioration in human performance. In the case of the residents this may cost the patient’s life. Reduced energy levels brought about by overstretching time limits influences the speed of reaction to an emergency or any other activity that may demand the attention of the practitioner. The keenness and quick response of medical practitioners is vital especially in emergency situation when the prompt decision and action of the practitioner means the difference between life and death. This is compromised when the practitioner is strained beyond his limits.
Overworking also compromises the practitioner’s problem solving and leads to reduced attention to detail often resulting in errors of omission. This puts the life of a patient at risk due to possible misdiagnosis of the patients’ condition which may lead to wrong drug prescription and advice. This complicates the situation of the patient and at the same time may cause the patient and affected relations monetary losses. It also tarnishes the reputation of the resident since the trust that the public would have in him or her is betrayed, this in turn may cost the job of the practitioner. Therefore in addition to endangering patient safety it also affects the occupational life of the practitioner.
Another ethical issue regarding the issue of working for long hours during residency has to do with residents working for the actual doctors. This is tantamount to abuse of residents who go through the program to learn the art and science of medicine and not to take over tasks of doctors. The doctors on the other hand, who ought to be training the residents, slacken in their duties handing over most of the tasks to the residents. Residency is supposed to be a form of apprentice thus the doctors are supposed to work hand in hand with their protégée hence transfer knowledge and skills. When the residents are abandoned to learn without the teacher (doctor) they are short changed and inadequately supervised/trained. This could lead to “half-baked” doctors which in the long run could put more lives in danger. Furthermore this could compromise and even jeopardize the profession of the doctor when and if half-baked doctor makes a slight mistake. Unfortunately the same half-baked doctors are supposed to train others residents later and the vicious cycle continues. In the short term the residents are more like than not to feel demoralized, frustrated and abused which would definitely affect their service delivery.
Some of the medical professions are inherently hazardous and the risk increases with the number of working hours. Radiography is one such case in mind where the risk of the job increases with the number of working hours. If residents in the radiography department are pushed to work for longer hours than the allotted hours then they are exposed to higher risks of cancer and other dangers associated with exposure to radioactive substances. This is by all mean an ethical issue because the residents may be condemned to life with a terminal illness. The issue of occupational health and safety has become a matter of national debate and as such is a challenge in this phase of the medical profession. In addition the long hours of work and sleep deprivation predisposes the residents to higher chances of workplace injuries.
Occupational stress is cited as a significant health problem. The culture of medicine training is attached to the idea that by residents working for long hours they gain experience and thus extol the virtues of heroic lone physician despite the proven safety of team-based care. This is nullified from the evidence that little learning occurs after working sixteen hours. Occupational stress for the residents may be contributed by prolonged working hours among other factors like the interdependence of work life and family life. There is a high chance of there being a conflict between work life and family life and especially to the female gender which leads to stress leading to illness. This leads to absenteeism and turnover which detract from the quality of care. The stress does not also put the practitioner in any good position to handle responsibility with the required passion and dedication. The social life of the residents is often stifled which is a major ethical concern is given the fact that social support systems help in managing occupational stress. Every person is entitled to a balanced life and denying the residents this right by overworking them is unethical.
Working overtime is normally compensated with an increase in the pay which is a percentage of the regular pay. A practitioner may willingly accept to work extra hours with the extra pay. Since this is not under coercion, the practitioner will have programmed his or her mind to working longer hours. Realizing what he or she has committed to, they will handle the extra hours like the normal hours of work. Unfortunately residents are often not paid for the overtime which is nothing short of exploitation.
3.0 Rules , guidelines and laws relating to residents’ working hours
Medical practitioners are governed by a code of ethics. The American Medical Association (AMA) ethics group puts effort to improve health of the public and patient care by promoting and ensuring professionalism. The Accreditation Council for Graduate Medical Education (ACGME) is the professional body that oversees residency training and stipulates the rules and policies. Among the issues that these and other regulatory bodies look at are the number of working hours for the medical practitioners because of the definite potential to negatively affect healthcare outcomes. The issue of residents working for longer hours than allotted is common because the residents are often regarded as cheap labor and the long hours invested by the residents’ saves hospitals money. Before the 1984 death of Libby Zion at a New York hospital there were no regulations to govern the residents’ working hours. Following this case and the subsequent ruling of the jury investigating the case New York became the first state to introduce such regulations. This led to great public awareness on the patient safety in relation to residents working hours prompting a lot of research and public concern on the issue.
In cognizance to the negative effects of residents committing mistakes and errors due to long hours of working and sleep deprivation ACGME has been regularly reviewing the resident’s working hours, training programs and work environment. In September 2011 the accreditation body set up a work group to review the residents’ work duty hours and study their learning environment. The work group was mandated to develop guidelines mainly defining the responsibilities/roles of residency, the appropriate learning environment as well as measures to ensure patient safety and care. The workgroup made recommendations that were adopted by ACGME and AMA as regulations and guidelines in 2003.
In reference to common program requirements, duty hours for the interns must be limited to 80 hours per week, averaged over a four week period, inclusive of all in-house call activities and moonlighting. Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program. The interns are not permitted to moonlight. The residents are scheduled for a mandatory time free of duty. They are entitled to at least one day off per week without home calls being allocated on the free days.
For interns their duty periods are not meant to exceed sixteen hours in duration. For PGY-2 and above, may be scheduled for not more than 24 hours of uninterrupted duty in the hospital. The regulations strongly suggested strategic napping especially after sixteen hours of continuous duty and between hours of 10pm and 8am. It is essential for resident education and patient safety care that effective transitions in care occur. Residents are allowed to remain on-site for at most 4 hours in order to accomplish these tasks. Residents are not to be assigned clinical duties after 24 hour uninterrupted in-house duty.
With regard to the least time off separating scheduled duty periods, interns are supposed to have ten hours and compulsory 8 hours off in between the planned duty periods. Following every 24 hours of in-house duty they should have at least 14 hours free of duty. Residents in the last years of study ought to be prepared for the medical working environment which is unsupervised and is often associated with irregular and prolonged working hours. Residents are also not supposed to be assigned six consecutive night shifts. More recently (2010) ACGME reviewed this regulations reducing shift hours from 30 in 2033 to 16 and stipulating that residents be granted 8-10 hours free between shifts and that work hours be at most 80 per week. The regulations still leave a lot to be desired.
There are laws that govern the working hours. The federal laws are enforced by the wage and hour division of the department of labor employment standard but they do not place the same limits on resident work hours. The Accreditation council for graduate medical education has limited the number of work hours to eighty hours weekly, overnight frequency to no more than one overnight every third day, and 10 hours off between shifts. The institute of medicine recommends that duty hours should not exceed sixteen hours per shift.
It is worth to note that prior to ACGME adopting these regulations the federal government had attempted to establish legislation to restrict resident’s working hours. This is despite the Occupational Safety and Health Administration declining to restrict the resident’s working hours after a petition in 2001. The patient and physician safety and protection Act 0f 2003 provided similar provisions to those provided by the earlier ACGME and AMA regulations. However the Act placed a penalty of up to a hundred thousand dollars on any training program found in violations. The same Act provides protection of whistleblowers on violators and awards funding for costs incurred as a result of compliance to the law. The federal government established this legislation in realization that the principle of self-regulation can be easily abused and the government’s role in protecting the citizenry. Albeit the legislation there is still debate on whether the federal government should regulate the medical profession especially with ACGME having already provided guidelines on the matter.
In conclusion it is unethical for residents to work for more hours than they are allocated as this compromises the safety and health of both the patient and the residents. ACGME and AMA have established guidelines for resident training which include the number of duty hours. The federal government has also instituted legislation restricting the working hours while providing penalties for violations and awards for compliance. With enough time to rest between long working hours, the residents get to be efficient in their training. The management of health care facilities and hospitals must be accountable for making changes that espouse their value of high quality patient care and safety.
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