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Some Rest for Medical Residents

New rules cut the brutal workweek to 80 hours in bid to be more humane and to lessen mistakes.

June 30, 2003|Tracy Weber and Charles Ornstein | Times Staff Writers

For generations, doctors in training have endured a grueling boot camp, often working in hospitals 100 or more hours a week -- at times becoming so overtaxed that they dozed off at the bedside of a patient or the wheel of a car.

Beginning Tuesday, the brutal apprenticeship of the nation's medical residents will become more humane -- and, those who support the change said, safer for patients.

New rules will limit residents to an average workweek of 80 hours and to no more than 30 hours of work at a stretch. Though still a demanding schedule, double the typical worker's week, the changes represent a cut of up to 40 hours a week in some specialties.

Besides reducing the potential for mistakes, the changes are intended to focus the training of young doctors less on labor and more on learning. The rules are being imposed by the group that accredits doctor training programs.

Many doctors said the change signals the demise of the macho era of medicine, worn as a badge of fortitude by some physicians and an emotional scar by others.

"It was torture," recalled Dr. Sharon Ashley, an anesthesiologist and the director of graduate medical education at Martin Luther King Jr./Drew Medical Center, remembering her 15-month-old daughter nudging her awake as she drove home during her training. "We're a kinder, gentler world."

But residency directors worry that the new rules may promote a punch-the-clock mentality and cut too deeply into training time in specialties such as neurosurgery and orthopedics -- perhaps requiring doctors to spend another year practicing their techniques.

Doctors who wish to specialize in an area of medicine now spend up to seven years in training after getting their medical degrees.

The changes also deliver a blow to cash-starved public hospitals, especially in Los Angeles County, where the health department faces a crippling budget crisis. Hospitals won't be able to rely as much on residents, who are relatively low-paid, to aid overburdened nurses, transport patients and draw blood. Instead, the facilities must spend millions on higher-paid staff to cover those duties.

Whether they support the changes or oppose them, many doctors consider them the most important shift in physician training in decades.

"This is a culture change," said Dr. Lawrence Opas, director of graduate medical education at Los Angeles County-USC Medical Center, who noted that the term "resident" came into vogue because young doctors used to live and work at hospitals.

Medical educators said a variety of factors forced them to reassess doctor training, from changing notions of what it means to be a physician to pressure from the federal government and unions.

The new rules reflect evolving attitudes about work and family. Many of today's medical residents are focused as much on the quality of their lives as their educations -- in part because of the increasing number of women in the programs, doctors said.

"People's attitude about what being a doctor is all about ... has changed over time," said Kristy Wolff, a third-year obstetrics-gynecology resident at County-USC and a residents union delegate. "The flexibility and the autonomy and the potential income from being a doctor has changed dramatically, so it has become more like a job -- and people don't want to be working 110 hours at their job."

Another impetus for change was the death in a hospital of Libby Zion, the 18-year-old daughter of a well-known New York newspaper columnist. He alleged that overworked residents were negligent. In 1989, the state cut residents' hours to an average 80 hours a week after a grand jury, although finding no criminal fault on the part of doctors in the case, expressed concerns about overworked and under-supervised residents.

The national push for similar restrictions began a decade later, after an influential government advisory body, the Institute of Medicine, suggested that fatigue might cause medical errors. That year, the National Labor Relations Board gave residents permission to unionize, and their leaders made working conditions a top priority.

With a move afoot in Congress to restrict residents' hours, the Accreditation Council for Graduate Medical Education, which regulates medical education, last June announced the rules that take effect Tuesday.

The change will be especially dramatic in certain specialties. In a 2001 survey at four of Los Angeles County's public hospitals, neurosurgical and urology residents said they worked more than 120 hours per week in their first four years. Residents in pediatrics and obstetrics-gynecology reported working at least 90.

After completing medical school, doctors typically enroll in residency programs to gain in-depth experience in a particular specialty, such as neurology or surgery. During those programs, their work is overseen by a teaching physician. At the end, they take an exam to become certified in their specialties.

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