Medical Interns Could Work Longer Without A Break Under New Rule

Nov 4, 2016
Originally published on November 4, 2016 6:31 pm

For years, medical interns have been limited to working no more than 16 hours without a break to minimize the chances they would make mistakes while fatigued. But that restriction could soon be eased.

The group that sets the rules for medical residents proposed scrapping the 16-hour limit for interns, doctors in their first year of on-the-job training after finishing medical school. The new rule would let these new doctors work for as many as 28 hours at a stretch.

The Accreditation Council for Graduate Medical Education proposed the change based on research that found that the relaxed rule wouldn't increase risks for patients, officials say. In fact, the ACGME says, the longer work hours could make patient care safer and would also improve medical training by giving young doctors more realistic experience.

"Just as drivers learn to drive under supervision in real life on the road, residents must prepare in real patient-care settings for the situations they will encounter after graduation," said Dr. Thomas Nasca, ACGME's chief executive officer, in a written statement announcing the proposed change.

The longer shifts could improve patient care by minimizing the number of times interns have to pass their patients onto someone else to continue their treatment, the council says. Mistakes can occur as a result of those hand-offs, the group says.

The new rules would limit interns to working no more than 24 hours at a stretch plus four hours to "manage transitions in care, promoting professionalism, empathy and commitment," according to the announcement.

"Training to become a practicing physician can be compared to training for a marathon," Nasca says. "You must learn how to pace yourself, take care of yourself and recognize your limits."

But the proposal is controversial. Critics argue it would be put patient safety at risk because the first-year residents would become too fatigued.

"Study after study shows that sleep-deprived resident physicians are a danger to themselves, their patients and the public," says Dr. Michael Carome, director of Public Citizen's Health Research Group. "It's disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health."

The rules will continue to limit interns to working no more than 80 hours per week averaged over four weeks.

Some specialties, such as emergency medicine, anesthesiology and internal medicine, would continue to have more restrictive rules, according to ACGME.

The group will take public comments on the proposal for 45 days before making any changes final.

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Medical residents work long hours. So how long exactly should they go without a break? That question is being debated again now, nearly 30 years after the issue first burst into the national spotlight. NPR health correspondent Rob Stein has the details.

ROB STEIN, BYLINE: Back in 1984, no one had ever heard of Libby Zion, a college freshman from New York. But then she was admitted to a hospital and her name exploded in news reports around the country.


UNIDENTIFIED WOMAN #1: Libby was admitted to New York Hospital with a high fever and earache. She went into convulsions last night.


UNIDENTIFIED WOMAN #2: Eight hours later, Libby Zion was dead. Libby's father later charged that her death was the result of inexperience and exhaustion.


UNIDENTIFIED WOMAN #3: ...Make a big change in state law. New York was the first state to limit the work hours of interns to 80 a week.

STEIN: Libby Zion's death triggered an intense national debate about how long doctors who just graduated from medical school should be allowed to care for patients without getting some sleep. Among the reforms that were eventually adopted was a rule that restricted first-year residents, interns, to no more than 16 hours without a break. But the group that set that rule now wants to relax it. Thomas Nasca heads the Accreditation Council for Graduate Medical Education.

THOMAS NASCA: The new rule says that they can work up to 24 hours.

STEIN: Twenty-four hours without a break, plus another four hours if necessary. Nasca says research clearly shows the change would not increase any risks for patients and would actually make things safer by giving doctors more flexibility and reducing the number of times interns have to hand off their patients to someone else.

NASCA: The transitions in care are a jeopardized period of time where errors can be introduced, and they can be introduced in many different ways - a failure to convey key information, misunderstanding in receiving key information.

STEIN: And, Nasca says, allowing interns to see more cases through, which would provide patients with better care and make interns become better doctors.

NASCA: The idea that all physicians would always be optimally rested in the real world is a flawed idea. We need to teach clinicians how to recognize their limits, how to understand how to function best in circumstances that are less than optimal.

STEIN: Nasca stresses that interns are always supervised by more experienced doctors and most of the time would get at least some sleep, even if they end up working long stretches straight. But critics say the change is just too risky.

MICHAEL CAROME: This proposal is misguided and dangerous.

STEIN: Michael Carome is with Public Citizen's Health Research Group, a consumer watchdog.

CAROME: We don't let truck drivers - we don't let pilots fly when they're tired or drive when they're tired. Residents working longer hours are more likely to make serious medical errors.

STEIN: Others agree. Kelly Thibert is president of the American Medical Student Association. She also just graduated from medical school. She worries longer hours could cause interns like her to make mistakes that could cost the lives of more patients like Libby Zion.

KELLY THIBERT: Am I awake enough for either this procedure? Am I really making clear choices based off of the amount of sleep that I have or have not had in the past two days? We might see patients' lives at stake here with us not getting the sleep that we need. This is really a life-or-death situation.

STEIN: The public has 45 days to tell the council what it thinks about all this, but the council hopes to make the changes for next year's interns like Thibert. Rob Stein, NPR News. Transcript provided by NPR, Copyright NPR.