Amid the discussion and recognition of the vital role residents play in our healthcare system, little has been said about the 26-hour shifts they are required to work.
But as Resident Awareness Week comes to a close today, how many patients and their families are aware that residents are among the only workers in society required to cover single or back-to-back shifts totaling 26 hours or more, with no protected breaks or sleeping periods? And that these marathon shifts can sometimes occur multiple times during a regular work week?
There have long been debates about the pros and cons of this harsh system, centering on patient safety, educational necessity and the well-being of residents. The National Steering Committee on Resident Duty Hours recommended in 2013 that “duty periods of 24 or more consecutive hours without restorative sleep should be avoided.”
Many studies have come down on one side or the other on the effectiveness of these conditions, but we believe there are key moral and political questions that have been left out of the conversation. For example, what are the historical and political reasons for residents to work 26-hour shifts without breaks? Shift work has been classified as a Class 2A carcinogen (i.e., a probable carcinogen) by the International Agency for Research on Cancer since 2007. If the long-term harms of such shifts haven’t been studied, and are likely to be more harmful than benign, shouldn’t we exercise caution and limit them? Given what we know about the harms of sleep deprivation, shouldn’t hospitals have the burden to prove unequivocally that such shifts are safe for resident mental and physical health?
The reality is that resident physicians are caught in a system that leaves them without several basic labour and employment protections. In Ontario, for example, they are not entitled to minimum employment standards such as sick leave, mandatory rest and meal breaks, maximum hours of work, overtime and minimum wage. This is partly the result of a haphazard historical bargain whereby physicians shielded themselves from employment regulations to maintain independence as a self-regulating profession. Resident physicians fell through the gaps of this unprincipled system. While collective agreements have achieved important protections for residents, they are still left without key basic protections of a typical employee.
The debate about resident working hours encompasses larger issues. The way that a healthcare system treats its workers is a reflection of the values of the larger society. The current pandemic has illustrated that public health and social justice are intimately connected and mutually reinforcing. The justice that healthcare workers seek in their workplace also benefits patients and the public.
Alternatives to the status quo exist. In Quebec, 26-hour shifts were abolished based on residents’ human rights concerns, not on the efficacy of such shifts. A review of practices in various jurisdictions shows that quality healthcare and medical education do not require mandatory 26-hour shifts and unlimited hours.
The way we organize our workplaces is not inevitable; it is rather a reflection of collective values and historical and political struggles. Change can happen if we engage with the moral and political dimensions of the debate. Practices that we are now quick to condemn, such as child labour and slavery, were not abolished because of definitive evidence from randomized control trials; they were challenged on moral grounds because they were morally objectionable and did not accord with the kind of society we strive for.
The working conditions of resident physicians should place human needs and rights at its core rather than force residents to adapt to antiquated and inhumane systems in the name of “necessity” or the “lack of a better alternative.”
It is time to treat resident physicians like humans, not heroes.
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Wholeheartedly subscribe to the idea!
The reason for abusive 26 hour shifts is monetary. The hospitals and government loves this.
Imagine the government having to pay attending level incomes to cover inpatient wards? Imagine them having to pay nurse practitioners and deal with union politics?
When I was a resident I calculated my hourly income at 3 dollars roughly. If that doesn’t make one cynical…
Residents are easy targets. They can’t quit, they can’t complain, and because it is a temporary time in their careers, nobody works to change it after they’re done.
Even more reason today with the introduction of competency based medical education to abolish militaristic and inhumane training of our residents.
When you’re a staff physician, you’re an independent contractor. You have a level of independence that residents don’t have. You can quit your job at a given hospital, set up your own independent practice with your own hours, or work as much or as little as you want. You do not have that flexibility or freedom as a resident given your residency training requirements.
What are these residents going to do when they’re staff a few years later and are required to work not only 24-26 hours, but 30-35 hours or longer and there won’t be a post-call day for them?
We could make an argument about the need to cut down hours for all physicians, but to only focus on residents just sets them up for failure.
Absolutely needs to be a system wide change for all humans practicing medicine, not just residents.
I did longer shifts than these 35 years ago as a resident. Cruel as hell, inhumane and not suited to learning. These NEED to stop now. 12 hours max, 60 hours/week max.
My daughter Mj Murphy is a EM resident in Brooklyn I sence she is tired and works through it because she learns and tolerated the stress particularly with COV-ID HOSPITALS are stressed financially and clinically and I know they are paid to conduct resident training .They should design programs to allow reasonable recuperative periods for the residents patients and staff. No one wants an exhausted physician, patients co worker or malpractice carriers , I am not sure about Lawyers who may view them as low hanging fruit.
Thank you for penning this cogent, eloquent refutation of the practice of 26-hour shifts. The practice is cruel, antiquated, and unjustifiable on moral grounds. As you so clearly expressed, the structures that govern our working lives are not untouchable, cosmological diktats handed down to us by unknown forces; on the contrary, they are the product of deliberate action (or inaction) and as such are amenable to change. Quebec has demonstrated that alternatives are possible – and that was a decade ago! The abolition of 26-hour shifts is long overdue.