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Polonsky also points out what he deems faulty, nonanalogous logic sometimes used by advocates for shorter shifts, who liken residents' work regulations to those for commercial pilots, who are similarly prohibited from flying more than a maximum number of hours in a stretch. "If you think of what is really proposed [by the IOM], it is like having a pilot switching over in midflight or asking him to switch over as he's about to land," he says. "'Well, your time is up, it's time for someone else to take over.'"
Defining residents' shifts solely by the tick of the clock means that more patients could end up being handed off from one doctor to another at inopportune moments, and research suggests that those handoffs are when errors may commonly occur. "If we do something like this," says Polonsky in reference to the IOM's proposed guidelines, "I want to be sure that it is primarily going to improve the outcome of our patients," and then adding, "But that's not necessarily the case here."
Even medical residents are wary of the proposed changes, and some are reluctant to give up their exhausting schedules, which many deem necessary for learning. Dr. Erika Roshanravan, a first-year resident in the family-medicine program at the University of Washington in Seattle, agrees that getting more sleep is crucial but thinks it makes little sense to mandate a five-hour nap in the middle of a shift. With patients' cases still fresh in the mind, and with the awareness of having get back to work soon, Roshanravan thinks few residents would actually get any rest. A better solution would be to shorten residents' workweeks while lengthening the term of the residency overall. In Roshanravan's native Switzerland, where she attended medical school subsidized by the government, she says the family-medicine specialty takes five years, not three as in the U.S. But that would require an even longer postgraduation period of low pay and accrual of debt in this country. "I don't think people want to have to wait to pay off all of that debt," says Roshanravan.
Dr. John Scales, a first-year resident at the University of Florida who will begin his training in radiology this summer, says more sleep would enable him to better retain everything, "to consolidate some of the learning that happens on an almost daily basis," he explains. But he worries that more mandatory rest could mean missed educational opportunities. "More days off always sounds nice, but it distances us from what is going on in day-to-day patient care. A lot can change in 24 to 48 hours," he says.
Indeed, the resident's labor-intensive schedule was not structured that way by chance, says Dr. Thomas J. Nasca, chief executive officer of ACGME. Learning to work through exhaustion is part of the training process, not merely a matter of young residents paying dues or getting hazed by veterans. "This is not indoctrination," he says. "It isn't a fraternity."
Too often, says Nasca, the debate is oversimplified to, "Would you like a doctor who is not fatigued?" But the real question is in fact more nuanced: "Do you want a competent physician who knows you to treat you, even if he is fatigued?"
Nasca is in the difficult position of helping set the rules for accredited residency programs in the U.S. ACGME held a conference in March to solicit the input of medical professionals and educators from around the globe, and in June it will host an event in Chicago in which 55 groups will present position papers on the subject. After that, an ACGME task force will meet every six weeks until the details of a new plan can be hammered out.
The issue is a complicated one, and resolution will not come easily or quickly, but policymakers and clinicians agree that increasing patient safety is the ultimate goal. "The key is that we don't want to injure patients," Johns says. "What can we do to make sure that even if [physicians are] fatigued, they can still perform at 100%? Let's do that study."