A compelling argument can be made that learning to function in stressful, tiring situations is essential for the training of every physician, because such circumstances inevitably will arise in future years. At the same time, there is a considerable body of data indicating that neither learning nor patient care is best carried out in the current environment.

- from an Editorial in American Medical News (3 September, 2001)

On 6 November 2001, Rep. John Conyers, Jr. introduced the "Patient and Physician Safety and Protection Act of 2001," otherwise known as H.R. 3236. This legislation, if enacted by Congress, would have significant effects on the daily lives of approximately 97,000 residents affiliated with roughly 8000 programs under the purview of the Accreditation Council for Graduate Medical Education (ACGME). At issue is the number of hours a resident can work in a given space of time, and there has been no shortage of debate in the medical community as to the propriety of such government regulation. The current version of the bill contains the following restrictions:

Postgraduate trainees (i.e., residents and interns):
1) "may work no more than a total of 80 hours per week and 24 hours per shift"
2) "shall have at least 10 hours between scheduled shifts"
3) "shall have at least 1 full day out of every 7 days off and one full weekend off per month"
4) "shall work no more than 12 continuous hours [when assigned to the emergency] department"
5) "shall not be scheduled to be on call in the hospital more often than every third night"

Supporters of the bill claim its passage would improve resident well-being and patient care by reducing resident fatigue, which is itself commonly secondary to sleep deprivation induced by long hours on duty and on call. Legislative precedents involving the regulation of commercial truck drivers are invoked as further support that Congress is obliged to intervene in matters impacting public safety.

Numerous examinations of the effects of such fatigue followed in the wake of a landmark legal case in New York State involving Libby Zion, an 18-year old hospital patient who died in 1984 following an apparent adverse drug interaction. The resulting media attention highlighted not only the particular decisions made in that case but also the general hazards inherent to a system that was widely believed to overwork and inadequately supervise its resident physicians. Further incentive to promote patient safety wherever possible can be found in recent regional mortality reports, which, when extrapolated to the nation as a whole, suggest, "at least 44,000 Americans die each year as a result of medical errors."

There is no dearth of scientific literature supporting strong relationships between sleep deprivation and cognitive function. Although recently contested, it remains widely held that Rapid Eye Movement (REM) sleep serves a crucial role for memory consolidation. Researchers have found that while slower performance on certain tasks can preserve accuracy, other, more complex tasks suffer more generalized impairment. In corresponding studies of residents specifically, investigations demonstrated moderate to substantial correlations between sleep deprivation (or fatigue generally) and such deficits as slowed motor execution and decision-making capacities, increased hostility , substandard performance with patients, diminished quality of educational experience . Recent inquiries into resident work scheduling find little improvement since the issue first gained prominence in the late 1980s and early 1990s. Thus, first-year residents continue to experience episodes of sleep deprivation in excess of 37 continuous hours, and although average weekly work hours reported by residents often fall within industry guidelines (see Figure 1), nearly 40 percent of residents surveyed in 1998 reported that they had observed colleagues working while impaired by fatigue . Most recently, researchers at the University of Washington found high frequencies (87/115) of resident "burnout" (particularly as reflected in self-reports of depersonalization when working); the study also found some evidence of correlations between burnout, sub-optimal patient care, and work schedule variables (days off, shifts in excess of 24 hours, etc.) Overall, however, the literature is sorely lacking in analyses the impact of various work-hour regimens on quantifiable, objective variables such as patient outcomes, length of hospital stay, or incidence of medical errors reported by housestaff.

A wide variety of groups have entered this debate in the recent years, each bringing a unique perspective, but all generally coming down strongly on one side or the other, with regard to legislative action. Surgeons' organizations , , health care industry heavyweights and the American Medical Association (AMA) have each voiced opposition to the rigid constraints of H.R. 3236, although the AMA has since moderated its stance and is currently studying the matter to better assist lawmakers. Chief among the concerns advanced are that a mandatory cap on hours would sacrifice affordability and continuity of patient care. Monetary issues, could likely play a secondary role, particularly since the government is prepared to provide financial relief for a medical industry that may find itself struggling to adjust:

There are hereby appropriated such amounts as may be required to provide for additional payments to hospitals for their reasonable.costs incurred in order to comply with the requirements imposed by this Act.

Central to the issue of continuity is the contention that immersion in medical practice yields the fledgling doctor a complete picture of the respective courses of illness and treatment. This notion, although sometimes challenged as outmoded given often-unfocused environments at many teaching hospitals and clinics, provides much of the guiding philosophy for the postgraduate experience, as it exists today. Despite an historically small voice in the debate, residents themselves now have a good many things to say about their daily routines, and not all of it bad: a young D.O. (and this author's sister-in-law) said of her experience and its impact on her professional interactions, "the long work days tend to enhance these relationships [with colleagues] because these people become your support system."

Conversely, some interns and resident physicians, through such groups as the American Medical Students Association, have voiced their concerns that "excessive hours worked by resident[s] are known to impair performance," and that "the medical community has not adequately addressed this issue." Separate, but parallel debates have erupted in which residents insist that hours worked when combined with the low salaries offered do not constitute a "living wage" for highly indebted postgraduates. Others claim they are themselves endangered by added risks of sleepiness when performing routine but dangerous tasks, like handling biohazardous materials or driving an automobile. Voluminous anecdotal evidence is submitted as proof that no substantial amelioration of the problem has occurred, of late, despite many years of study by various groups. This upwelling of frustration, accompanied by accounts of "erosion of professional values and behavior," physicians' attitudes that "compromise patient care in a pervasive and insidious way," and work environments approximating "one continuous disaster triage" , is likely to have fueled both the legislative push as well as a 2001 petition submitted to the Occupational Safety and Health Administration.

Attempts to correct the issue through self-regulation of residency programs began with a resolution passed in 1989 by the AMA, which recommended on call duty be limited to once every third night and that four-week averages of time on duty be no more than 80 hours. The ACGME promptly co-opted the AMA recommendations and is currently charged with ensuring the compliance within the programs it oversees. Following the introduction of H.R. 3236, that body has pledged to re-examine the issue, and adopted the position that "there is no need for federal regulation of resident duty hours, because the ACGME through its accreditation has already established and enforced standards for duty hours." The current ACGME regulations vary widely by the type of postgraduate program addressed, with some program requirements peppered liberally with the word "must" and others merely indicating targets deemed "desirable." On the legal front, the aforementioned Zion case is instructive. In the wake of that tragedy, the Commissioner of the New York State Department of Health implemented new regulations, commonly known as Section 405, which contain many of the same provisions as the bill now before Congress. Subsequent review of the effectiveness of Section 405, as perceived by postgraduates and their attending physicians, yielded mixed results, with residents perceiving the regulations as beneficial and attendings less enthusiastic.

Indeed, the feeling among many residency program administrators is that housestaff relieved from call at one institution would not hesitate to moonlight at another. Program directors will doubtless be first in line to implement changes and deal with problems inherent to the adoption of H.R. 3236. Here at the University of Illinois at Chicago, Dr. Linda Lesky, a director for the Internal Medicine Residency Program, believes that the adoption of hard caps on continuous and weekly work hours would force the program to expand some 20% to 30% in size (and likely end the current "every sixth night" call policy) to address manpower shortages. The law would also likely add six months to a year to the graduate education of each resident in the program, due to educational goals prescribed by the ACGME. For a program already engaged in the supervision and education of over 120 residents, the added costs are daunting. While Dr. Lesky conceded "program directors need to be held accountable for the amount of stress in their program," she dismisses a universal, legislative solution as "naïve." The ACGME, she argues, recognizes the fundamental differences in the goals of a given type of residency program and the demands typically placed on the housestaff of such a program in order to provide sufficient levels of care to patients and sufficient educational experiences to postgraduates. Reform would therefore be more effective in that forum and would still permit chief residents and program directors to manage issues of stress and fatigue as they arise. Dr. Lesky went on to say that further research is needed to establish a reliable, generalized metric of resident stress that functions well across multiple educational programs, and is sensitive to difficulties arising from overwork or from other sources such as family troubles or financial pressures.

New approaches will soon be applied to this problem and their benefits and detriments assessed; public sentiment, as evidenced by the activity of lawmakers, seems to favor sweeping changes. Despite the seeming imperviousness of the problem to resolution by recommendation, or self-enforced institutional reform, reasonable arguments for slow, but consistent, progress can still be supported empirically. Individual postgraduate teaching facilities have proven themselves capable of some innovation addressing excess fatigue. The successful introduction of night float as an alternative to every-fourth-night call arrangements and even the advancement collaborative "hybrid" call structures designed and evaluated by residents and faculty both certainly offer some hope of reform from within the system or in collaboration with it. Resident workload can arguably be further reduced by providing more ancillary staff, such as physician assistants, in health care institutions. Such personnel would relieve physicians of extraneous tasks that do not require specific medical training, such as filling out paperwork and transporting patients. Finally, extensive research has been conducted in military and industrial settings to determine techniques that enhance productivity and safety following sleep deprivation ; these resources, and the implicit human limitation they suggest, will hopefully be given more sway in crafting resolution the resident work hours debate.

Clearly, no one wants the practice of medicine to be seen as "shift labor," and all parties would like to keep the patient, and not the clock, at the center of efforts to reform the present system. With or without the imposition of work hour limitations, a balance must be struck between many competing, and at times mutually exclusive, variables in conducting the business of medical care. Escalating health services costs, shrinking coffers at teaching facilities, legal liabilities, finite head counts, and the ultimate quality of life for patients and doctors must carefully enter the dance of public policy and private industry if all are to emerge untrampled. The music, it seems, has already started.

Dominic holds a B.A. in English and psychology and is currently a senior at UIC majoring in biological sciences. He expects to be a happy, if somewhat sleepy, resident in pediatrics and general surgery starting July 2007.