The Doctor is still in: Many resident physicians routinely work more than 100 hours a week. Are long hours a necessary rite of passage or an obsolete practice that endangers patients? - Employee Relations

HR Magazine, Feb, 2002 by Ann Pomeroy

Before Risa Moriarty resigned her plastic surgery residency two-and-a-half years into a seven-year program at Johns Hopkins Hospital in Baltimore, she was routinely working 110-130 hours per week, and sometimes worked a 60-hour shift.

That's three days and two nights on call in the hospital with no sleep other than brief, catch-as-catch-can naps. "It takes an altered state of mind to get through it." she says. "Residency turns you into a very efficient machine.

"I stayed longer than I should have," says Moriarty, now an executive at HealthCite Inc. in Baltimore. "It was a difficult decision to make and one that I spent a lot of time thinking about. I considered changing to another specialty, but I was just completely burned out."

Moriarty says she is not alone in her reaction to the relentlessly long work hours in some hospitals. She believes many physicians are bitter, even the older ones. "After I resigned, two attending physicians called me and said they were envious of my decision.

'Clinical Clerks'

The practice of medicine has changed dramatically during the last century. But the residency and intern system has changed very little since the legendary Dr. William Osler initiated this method of training newly minted doctors at Johns Hopkins University more than 100 years ago.

Osler was a pedagogical innovator who brought students out of the classroom and onto hospital wards as "clinical clerks." These first residents lived a monastic existence, actually residing in the hospital, and were paid no salary.

Today's residents receive a salary and benefits, but still may feel as if they live at the hospital. Work hours Exceeding 100 per week are not uncommon, and 36-hour shifts often are routine. Sleep-deprived residents-the least experienced physicians-are likely to be the first doctors to examine a patient in a hospital emergency room. And today's patients often are sicker even as they spend less time in the hospital than in years past.

Why do doctors persist in continuing such onerous and dangerous training and staffing practices?

"Medicine is a militaristic culture," says Moriarty. "It's a hierarchical, macho fraternity, and hospitals hide behind the argument that doctors know best."

Older doctors who went through the same rite of passage may believe that it weeds out those who don't have "the right stuff." However, Moriarty points out that modern-day residents probably are seeing 50 to 60 patients in a 100-hour workweek--versus 20 in 1950--and the patients present a significantly more complex workload than in the past.

Because of today's longer lifespans, patients are more likely to be older and have multiple illnesses. And medical advances have created an exponentially greater number of potential diagnostic tests, test results requiring interpretation and follow-up treatment decisions than earlier generations of doctors faced. "We can treat things we couldn't treat before," says Rick Carpenter, R.N., patient care services manager for the medical intensive care unit (MICU) at the University of Virginia Hospital. "You have 'multi-system failures' in aging patients suffering from more than one ailment."

Finally, the growth of managed care protocols has hastened time and cost pressures on doctors. Sick and recovering patients are hustled out the door many hours or days earlier than before, affording less time to observe and treat them in the hospital setting.

The confluence of these trends requires residents to run constantly and do even more on the little sleep they get.

Employees or Students?

Resident physicians are doctors who are completing their training to acquire board certification in a specialty by treating patients under the supervision of attending physicians. Hospitals have historically considered them to be students. Legally, however, these doctors-in-training are employees.

The National Labor Relations Board (NLRB) ruled in 1999 that, since residents work long hours, make medical decisions and earn salaries and benefits, they are employees. The ruling, which responded to a petition filed in 1997 by residents at Boston Medical Center, granted collective bargaining rights to more than 90,000 interns, residents and fellows who work in private hospitals nationwide. "Interns, residents and fellows ... while they may be students learning their chosen medical craft, are also 'employees' protected under the National Labor Relations Act," ruled the board.

They are, however, employees with a difference. Hospital human resource departments have no hand in their hiring as they do in hiring nurses, technicians and other medical personnel. Resident physicians are recruited by individual residency programs. Applicants compete for places in the residency of their choice, ranking programs and hoping to be matched with their No. 1 choice. Hospitals, in turn, rank the applicants. On "Match Day" each spring, a computer spits out the results, and applicants are notified whether or not they made a "match."

With salaries averaging in the mid-$30,000 to mid-$40,000 range depending on area of the country, residents are a cheap source of labor. Moriarty says actual earnings many not be much above minimum wage when you consider the number of hours worked. She believes "the people in charge often recognize that residents are working too much, but they are hampered by financial pressures and the complicated managed care system."