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.