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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 105-109

Resident doctors’ duty hours: A questionnaire-based study in national and international perspective


Department of Obstetrics & Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Navi Mumbai, Maharashtra, India

Date of Submission21-Jul-2020
Date of Acceptance21-Jul-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Dr. Sushil Kumar
Department of Obstetrics & Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Kamothe, Navi Mumbai, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_70_20

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  Abstract 

Introduction: Most serious patients among the poorest of the poor class are treated in the hospitals attached to medical colleges. Although there are senior and experienced doctors available, there is no denying the fact that resident doctors are the backbone of medical care. We cannot even dream of running these hospitals without them especially when coronavirus disease-2019 (COVID-19) is spreading like a wildfire across the globe. As far as the mental health of the resident doctors is concerned, often there are complaints of burnouts, depression, medical error, suicidal ideation, and leaving the course halfway, among them. We carried out a small questionnaire-based study to find out the viewpoint of the residents. Materials and Methods: An anonymous survey in respect of work hours and call schedules was administered to 50 junior residents. The results were analyzed. The faculty viewpoint, regulations in different countries, and regulatory bodies were also taken into account to present a balanced view and recommendations. Results: A total of 50 residents were surveyed. 64% of the residents worked for around 81–100h per week. 58%residents get 6h of uninterrupted sleep per day. 86% of the residents felt that extended working hours do not improve patient care. 82% of residents felt that there is no gain of skills with extended working hours; also, it does not leave them any spare time to study. 64% of the residents (mostly first-year postgraduate [PG] students) felt that most of their time is used for paperwork, which has no bearing on their skill development or knowledge. 16%–24% of residents felt that the extended working hours are affecting their mental health. Some of the residents felt that their relationship with coresident also affects their work. 74% of the residents admitted that they were asked to work more than 24h continuously quite often. 84% of the residents felt that they should get more time for leisure activities. Conclusion: There is a need to formalize working hours and to reduce paperwork for the residents to keep them in good mental health. A structured and supervised work schedule for the residents especially for the first-year PG students is the need of the hour. We need to balance education, patient care, and health of the young resident doctors while considering their work schedule.

Keywords: Evolution of the residency program, medical errors, postgraduate training in clinical medicine, resident doctors working hours


How to cite this article:
Kumar S, Gupta A. Resident doctors’ duty hours: A questionnaire-based study in national and international perspective. MGM J Med Sci 2020;7:105-9

How to cite this URL:
Kumar S, Gupta A. Resident doctors’ duty hours: A questionnaire-based study in national and international perspective. MGM J Med Sci [serial online] 2020 [cited 2020 Dec 3];7:105-9. Available from: http://www.mgmjms.com/text.asp?2020/7/3/105/292381




  Introduction Top


Long and unpredictable working hours have been a staple of medical training for centuries. The medical profession is stressful and is associated with the prevalence of depression, burnout, and mental health problem.[1],[2],[3] Medical residents’ duty is demanding. It has been under criticism and gained worldwide interest over the last several years.[4] The resident doctors are at higher risk of mental stress as compared to experienced doctors due to the recent transition in professional life and lack of adequate skills and experience.[5],[6] The appropriate time management of the resident duties is necessary for the quality of services provided by them. It is said that “A tired doctor is a dangerous doctor.” The long working hours and sleep deprivation result in exhaustion and underperformance. 24 x 7 working hours also increases the chances of medical errors. Burnout is a universal problem for postgraduates. The recent study also showed that sleep deprivation causes the same levels of impairment as alcohol intoxication. Long working hours also leaves the residents with little time for family commitments, recreation, and personal growth. This study was conducted to have a relook at the duty hours of resident doctors.


  Materials and methods Top


An anonymous survey regarding resident work hours and call schedules were administered to 50 junior residents working in MGM Medical College, Navi Mumbai. The survey contained questions on-call schedules, post-call clinical responsibilities, knowledge, and attitudes toward limits of work hours for the residents. Duty hours per week, duration of uninterrupted sleep, and the effect of stress on patient care as well as personal life were also recorded. The data were analyzed as trends and percentages. Faculty response (verbal communication) was also recorded. The faculty viewpoint, regulations in different countries, and regulatory bodies were also taken into account to present a balanced view and recommendations.


  Results Top


A total of 50 residents were surveyed. Of this, 26 were female and 24 were male. 64% of the residents worked for around 81–100h per week or more and 18% of them worked for 61–80h. 78% of them were getting weekly off. As far as sleep was concerned, 58% resident got 6h of uninterrupted sleep per day, whereas 34% got 4h of uninterrupted sleep and only 8% of them got more than 8h of uninterrupted sleep. 82% of residents said that they were getting adequate leave per year.

Eighty-six percent of the residents felt that the extended working hours do not improve patient care. In-fact, it is affecting their mental health and there is no proportionate gain by extended working hours. Most of the residents felt that it’s hard to spare time to study. In the survey group, 70% of them said that they get time to study only once a week, 14% of them twice a week, and only 4% of them more than twice a week. 82% of the residents said that there was no gain of skills despite extended working hours. 64% of the residents felt that 50%–90% of their working hours are dedicated to the paperwork. 16%–24% of residents felt that the extended working hours causing mental stress and occasional depression. To some extent, residents felt that their relationship with coresident affects their work negatively due to long duty hours. 74% of the residents were asked to work more than 24h continuously. Almost 84% of the residents felt that they were not getting enough time for leisure activities.


  Faculty viewpoint Top


Though no formal questionnaire-based survey was carried out for the faculty members their viewpoint is taken, most of them stressed the following points:

  1. In clinical specialty, it is extremely important to see, examine, diagnose, and manage emergencies. If the resident doctors spend more time in hospital they will see more emergencies and will become better doctors.


  2. Unexpected long working hours are a part of consultant life in clinical medicine. If the postgraduate (PG) students get used to long working hours, now it will condition them for the future.


  3. Some of the senior faculty members felt that in their time (as a PG student) they worked for >120h in a week with almost no leave during the course. Today the working hours for the residents have already been reduced over the years. Therefore, no change is needed.



  Discussion Top


Before coming to the discussion on this small study would like to give a brief on history and subsequent changes in the residency program to understand “working hours” controversy.

History of residency program and different perspectives on work hours

The first formal residency training program started in 1890 by Sir William Osler at the John Hopkins Hospital.[7] This system was for training physician after graduation from medical college. It required “just passed out doctors” to reside in the hospital and learn about patient care under the close supervision of senior physicians and surgeons. Although these were unpaid positions, with long working hours, they were extremely popular. Early in the twentieth century, North America “resident doctors” frequently worked more than 90h per week, with each week comprised of 36-h shifts separated by 12h or less of rest.[8]

An initial catalyst for formation of new guidelines in North America was the death of a college student, Libby Zion, in 1984. Since then, “the residents work hours” have been reduced gradually. In 2011, the province of Quebec in Canada ruled that shifts of 24h or more contravened both the provincial and national charters of rights and freedoms. As a result, duty hour schedules in the province were limited to no more than 16 continuous hours. In the United Kingdom, working hours for doctors in training were also gradually reduced, finally reaching a maximum of 48 per week in 2009, with no more than 13 consecutive hours of work.[9]

Supreme court of India ruling

The directive of Honorable Supreme court of India judgment on 25.9.87 mentioned that

  • a. A junior resident doctor should not work for more than 48h a week.


  • b. The continuous working hour should not be more than 12h.


  • c. Minimum of 11h rest period granted between the 2 shifts.


However, this order is not found to be practical by most of the professional institutions as well as the students and so far there have been no signs of its implementation on the ground.

Accreditation council for graduate medical education guidelines

In July 2003 Accreditation Council for Graduate Medical Education (ACGME) in the United States instituted new guidelines for “resident duty hours” standards to promote higher quality service and patient safety.[10] This included clinical and educational work hours.

  • a) Working hours should be limited to 80h a week. This will increase hours of uninterrupted sleep, in turn, reduce the chances of professional error.


  • b) Guidelines specify that any clinical work done from home must be counted towards the 80h maximum work limit. Preparation for day cases, studying and research done from home will not be included in these 80h.


  • c) The scheduled program should also include a minimum of 8h of mandatory free time from Clinical and Education work after 12h of shift for the personal well-being of the resident.


  • d) The resident must have at least 14h free of clinical and educational work after 24h of the in-house call.


  • e) Residents must be scheduled for 1 day off from clinical and education work in a week, averaged over 4 weeks. Off call day will be free from any call related to clinical work


  • f) Maximum clinical and educational period length should not exceed 24h of continuous schedule. Residents must be scheduled for in-house call no more frequently than every third night when averaged over 4 weeks’ period.


Working hours for resident doctors in the United States of America

Following the ACGME’s proposed regulation of duty hours the American Osteopathic Association (AOA) followed suit. This is a simplified version of ACGME guidelines and can be adopted by other medical bodies with minor modifications. Below are the requirements adopted by the American osteopathic association:[11]

  1. The trainee shall not be assigned to work physically on duty in excess of 80h per week averaged over a 4-week period, inclusive of the in-house night call.


  2. The trainee shall not work in excess of 24 consecutive hours inclusive of morning and noon educational programs. Residents may not assume responsibility for a new patient after working 24h.


  3. The trainee shall have on alternate week 48-h period off, or at least one 24-h period off each week averaged over a 4-week period.


  4. Upon conclusion of a 24-h duty shift, trainees shall have a minimum of 10h off before being required to be on duty again. Upon completing a lesser hour duty period, adequate time for rest and personal activity must be provided.


  5. All off-duty time must be totally free from assignment to the clinical or educational activity.


  6. Rotations in which trainee is assigned to Emergency Department duty shall ensure that trainees work no longer than 12-h shifts.


  7. The trainee and training institution must always remember the patient care responsibility is not precluded by the work hour policy. In cases where a trainee is engaged in patient responsibility which cannot be interrupted, additional coverage should be provided as soon as possible to relieve the resident involved.


  8. The trainee may not be assigned an in-house call more often than every third night averaged over any consecutive four-week period.


“Working hours” rules in other industries (aviation)

In December 2011, the FAA (Federal Aviation Administration of the United States) established a final rule for airline pilot duty and rest requirements in an effort to combat the risks of fatigue in aircrews. The final rule for flight crewmember duty and rest requirements became effective on January 4, 2014. The new regulation includes:

  1. a) A resting period of at least 10h between the 2 shifts with the opportunity of minimum 8h uninterrupted sleep.


  2. b) Flight working hours are restricted to 14h.


  3. c) The standard off-duty period for recovery should be a minimum of 36 continuous hours, including two consecutive nights of recovery sleep, within a 7-day period.



  The present survey Top


This study is a survey of the postgraduate resident doctors (3years residency program after graduation) to find out the influence of work stress on young physicians’ health and satisfaction with life. Residency is known to be a stressful time, especially in the beginning. During the first year of residency program, they lack clinical experience, have difficulty in establishing the doctor-patient relationship, struggle with the administrative demands of their work and often cannot meet the expectations of their seniors.

In our survey, only 29 residents out of 50 were getting 6–8h of uninterrupted sleep. The studies show that sleep deprivation has been shown to be negatively correlated with satisfaction with the experience among first-year medical residents in the United States[12] and sleep loss has been suggested as an important predictor of stress and depression among general practitioners in England.[13] Sleep deprivation increases the risk of developing of diabetes.[14],[15] Sleep restriction also alters the levels of leptin and other hormones involved in the regulation of appetite.[15],[16]

As far as weekly working hours are concerned, 32 residents worked for 81–100h a week, whereas 18 residents worked for 61–80h. An earlier study concluded that 85% of residents working for more than recommended 80h per week and 65% of them working for more than 100h per week.[17] It shows that there has been a gradual reduction in work hours for the residents over a period. Out of 50, 39 residents got weekly off most of the time. Only 8 residents felt that leave per year to visit hometown is inadequate. 43 out of 50 postgraduate doctors believed that their performance, behavior, attitude, and practices in patient care would improve if their duty hours were regulated. Gonzalo et al.[18] conducted study in 2015 points out that medical error rates increases, as well as physician-patient satisfaction, decreases with respect to long working hours.

In this study, very few resident doctors felt that long working hours experienced affected their mental health in the form of depression (only 4 among 50). Probably most of them do not want to admit that they are suffering from depression or any other mental illness as it is considered a stigma in India. A study conducted by Goebert et al.[19] on two thousand medical students had shown major depression in 12% doctors and mild to moderate depression in 9.2% doctors due to short sleep and long work hours. Another study of 125 residents (Obstetrics and Gynecology) recruited from 23 randomly selected programs across the United States found that more than one-third of participants (34.2 percent) were depressed.[20]10% of the residents felt that the relationship with other residents gets affected to some extent due to extended working hours and it disturbs them.

Among survey group, 32 residents believe that 50–90% time of the working hours is dedicated to paperwork. None of the residents believed that there is any productive gain in proportion to working hours. 35 of 50 residents believed that they get one day per week for study and 7 residents believed that they get study time twice a week. 84% of the resident doctors felt they do not get enough time for recreational activities and they wanted more time.

Fifty percent of the residents felt that there is a mismatch between expectations from the course prior to joining and their experience after joining the course. As there is no way to change the course it affects them mentally and also affects their performance. It is suggested that there should be some mechanism for the first-year residents to change the specialty after 3 months of joining the course so that they do not get stuck with the course they do not have an aptitude for.

Residents are full-time caregivers in medical college hospitals; their health is vital to patient care and those around them. Duty hours regulations are vital for their training and wellbeing.

Over the years the working hours have been reduced substantially around the world. But in India, more changes are needed and regulated to reduce the stress on the resident doctors.


  Recommendations Top


  1. Total working hours in a week should not be >80h.


  2. Paperwork to be reduced with printed case sheets, operation notes, labor notes, and consent forms.


  3. The frequency of notes on the case sheet may be reduced without compromising patient care and legal requirements.


  4. Residents must have at least 14h free of clinical and educational work after 24h of the in-house call.


  5. Continuous duty without sleep should not be >16h.


  6. Minimum 8h off between the next 12h scheduled duty.


  7. Weekly compensatory off for 24h must be given to recoup it could be averaged over consecutive 4 weeks.


  8. One day in-house call in 3 consecutive days, averaged over consecutive 4 weeks.


  9. Head of the department/senior faculty member should be in direct touch with first-year residents to understand their problems and take remedial measures.


  10. There should be some mechanism for the first-year residents to change the specialty after 3 months of joining the course so that they do not get stuck with the course they do not like or have an aptitude for.



  Conclusion Top


In the year 1890, Sir William Osler[8] started a residency program at the Johns Hopkins Hospital, USA. It required young doctors to reside in the hospital and learn about patient care under the supervision of senior doctors. They were not paid, there was no limit to working hours and there were almost no leaves. The students joined the residency program out of love for medicine and they were happy doing so in spite of all odds. Today, as teachers we must admit that the time has changed and the class of students has also changed. To adjust to the new era, we also need to change.

Our study shows that resident doctors do not feel that extended duty hours benefit them anyway. Various studies have shown an adverse effect of long working hours on the resident doctors. The countries like the USA, have limited the working hours for the resident doctors to the maximum of 80h per week. Not only in the medical field, the airlines have structured working hours for the pilots so that they get adequate sleep and rest and do not commit fatal errors. We need to balance education, skill development, patient care, and health of the young resident doctors while considering their work schedule.

Financial support and sponsorship

MGMIHS.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hisamura M Physician stress: Sex differences in stress tolerance, depressive tendency, and burnout. Sutoresu Kagaku (Jpn J Stress Sci) 1997;12:61-4.(in Japanese).  Back to cited text no. 1
    
2.
Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout among U.S. Medical students, residents, and early career physicians relative to the general U.S. Population. Acad Med 2014;89:443-51.  Back to cited text no. 2
    
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Kimura T, Maeno T, Ozaki M, Otaki J, Matsumura S, Bito S, et al. Qualitative research for searching for the stressor of junior resident in Japan. IgakuKyouiku (Med Ed Jpn) 2007;38:383-9. (in Japanese).  Back to cited text no. 3
    
4.
Collier VU, McCue JD, Markus A, Smith L Stress in medical residency: Status quo after a decade of reform? Ann Intern Med 2002;136:384-90.  Back to cited text no. 4
    
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Maeno T, Nakamura A, Maeno T, et al. Resident stress in the new postgraduate clinical training system. IgakuKyouiku (Med Ed Jpn) 2008;39:175-82. (in Japanese).  Back to cited text no. 5
    
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Srijan S, Henry RK, Krystal JH, Speller H, Chan G, Gelerner J, et al. A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatr 2010;67:557-65.  Back to cited text no. 6
    
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Baldwin DC Jr, Daugherty SR, Tsai R, Scotti MJ Jr. A national survey of residents’ self-reported work hours: Thinking beyond specialty. Acad Med 2003;78:1154-63.  Back to cited text no. 7
    
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Ludmerer KM Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. New York: Oxford University Press; 2015. p. 431.  Back to cited text no. 8
    
9.
Temple JG Time for Training: A Review of the Impact of the European Working Time Directive on the Quality of Training. London, UK: Department of Health; 2010. [Google Scholar]  Back to cited text no. 9
    
10.
Wen T, Attenello FJ, Cen SY, Khalessi AA, Kim-Tenser M, Sanossian N, et al. Impact of the 2003 ACGME resident duty hour reform on hospital-acquired conditions: A national retrospective analysis. J Grad Med Educ 2017;9:215-21.  Back to cited text no. 10
    
11.
Medical Resident Work Hours (category Medical regulation in the United States) Retrieved 2015-12-02. Accreditation Document for Postdoctoral Training Institutions and the Basic Document for Postdoctoral Training Programs. 2006. Page 43 KB (5,367 words). Available from: https://en.wikipedia.org/wiki/Medical_resident_work_hours. [Last accessed on 2020 June 7 at 17:38].  Back to cited text no. 11
    
12.
Daugherty SR, Baldwin DC Jr, Rowley BD Learning, satisfaction, and mistreatment during medical internship: A national survey of working conditions. JAMA 1998;279:1194-9.  Back to cited text no. 12
    
13.
Firth-Cozens J, Greenhalgh J Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med 1997;44:1017-22.  Back to cited text no. 13
    
14.
Ayas NT, White DP, Manson JE, Stampfer MJ, Speizer FE, Malhotra A, et al. A prospective study of sleep duration and coronary heart disease in women. Arch Intern Med 2003;163:205-9.  Back to cited text no. 14
    
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Spiegel K, Tasali E, Penev P, Van Cauter E Brief communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med 2004;141:846-50.  Back to cited text no. 15
    
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Guilleminault C, Powell NB, Martinez S, Kushida C, Raffray T, Palombini L, et al. Preliminary observations on the effects of sleep time in a sleep restriction paradigm. Sleep Med 2003;4:177-84.  Back to cited text no. 16
    
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Kumar S Duty hours for post-graduate resident doctors need for change. J Marin Med Soc 2013;15:76.  Back to cited text no. 17
    
18.
Gonzalo JD, Kuperman EF, Chuang CH, Lehman E, Glasser F, Abendroth T Impact of an overnight internal medicine academic hospitalist program on patient outcomes. J Gen Intern Med 2015;30:1795-802.  Back to cited text no. 18
    
19.
Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, et al. Depressive symptoms in medical students and residents: A multischool study. Acad Med 2009;84:236-41.  Back to cited text no. 19
    
20.
Becker JL, Milad MP, Klock SC Burnout, depression, and career satisfaction: Cross-sectional study of obstetrics and gynecology residents. Am J Obstet Gynecol 2006;195:1444-9.  Back to cited text no. 20
    




 

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  In this article
Abstract
Introduction
Materials and me...
Results
Faculty viewpoint
Discussion
The present survey
Recommendations
Conclusion
References

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