It seems logical that medical residents who have graduated from medical school should be able to get a decent night’s sleep during the years they are learning a demanding medical specialty in hospitals. Surely, if they have eight hours sleeping at home, medical errors will plummet, the average person (who probably gets too little sleep himself) would assume.
But this isn’t necessarily so.
Israeli medical residents have struggled for years to reduce the length of their shift work at night and on weekends when most senior physicians are relaxing at home or doing other work. Ever since a collective agreement was signed with Israeli doctors in 2011, they were promised a pilot program for shortening the length of night shifts. But almost no job slots were added to make this possible, so the situation remains –residents do 26-hour shifts followed by 24 hours at home.
During the past year, the height of the COVID-19 crisis, something changed. Out of a need to reduce the exposure of medical personnel to the virus, groups of staff members were assigned to shifts were shortened to “only” 12 hours, giving residents a whiff of what their lives could look like if more young doctors were taken on, as was promised. The usually overworked and exhausted residents insisted that there was an improvement in the level of attention, professional performance and treatment ability — so drastic compared what they had known before the pandemic that what might have looked to others like a chaotic situation was to them a blessing of normalcy.
The proposal to limit the number of hours worked by the handful of Israeli neurosurgical residents is discussed in an article in the latest issue of Harefuah, the Hebrew-language general medical journal of the Israel Medical Association. Dr. Gil Kimchi of the neurosurgery department at Sheba Medical Center at Tel Hashomer (near Tel Aviv) discusses the controversial issue.
The New York State Department of Health Code, Section 405, also known as the Libby Zion Law, is a regulation that limits the amount of resident physicians’ work in New York State hospitals to 80 hours per week. The law was named after Libby Zion, who died in 1984 at the age of 18 under the care of what her father, Sidney Zion – a New York Times journalist – believed to be overworked resident physicians and intern physicians. In July 2003, the Accreditation Council for Graduate Medical Education adopted similar regulations for all accredited medical training institutions in the United States.
Although regulatory and civil proceedings found conflicting evidence about Zion’s death, today her death is widely believed to have been caused by serotonin syndrome from the drug interaction between the phenelzine she was taking prior to her hospital visit, and the pethidine administered by a resident physician. The lawsuits and regulatory investigations following her death and how they affected working conditions and supervision of interns and residents were highly publicized in both lay media and medical journals.
The law not only limited the work hours to residents to more than 80 hours a week but also prohibited shift work for more than 24 hours at a time and required 10 hours of rest after each shift or full day’s work, plus a weekly day off.
In 2013, the American Board of Neurological Surgery decided that residency in this specialty would require 84 months. Before that, 20% of neurosurgery residency lasted for six years and the rest for seven years.
Surveys carried out in the US and other medically advanced countries around the world, however, found that restricting shift hours of neurosurgery residents did not bring about more safety and fewer errors in medical practice. In fact, it caused a decline in self-confidence among neurosurgery residents who began independently to operate on patients’ brains and spinal cords because they felt they had not had enough hours working at the side of senior neurosurgeons.
Kimchi urges in his article that administrative work demanded of neurosurgical residents be reduced significantly so they can spend more of their time learning the specialty. Israeli medical residents testified to the fact that they spent more than half of their time on administrative duties, at the expense of treating patients; this rate was higher than those reported by medical residents in all the other countries surveyed.
Training can be made more efficient while supervising residencies without reducing the number of hours spent learning the specialty. Every field of medicine, Kimchi wrote, is unique and requires special training that must be suited to them without setting down uniform limits for all specialties. Doing so would harm training in some of the medical specialties, he concluded.