Journal of Medical Systems, Vol. 18, No.

5, 1994

A Scheduling Model for Hospital Residents

Irem Ozkarahan

When medical students finish their school they must go through a horrendous apprenticeship
known as hospital residency to be able to practice medicine. During residency, they work at least
16-hr a day, 5-days a week, with 2 or 3 nights on-call. These can turn into 36-hr shifts. This
means that many patients are being treated by exhausted novices, who are therefore much more
likely to make mistakes. It was one such mistake, leading to the death of a New York woman,
which led to serious attempts to reforming working hours of residents. In this paper, we devel-
oped a decision model which attempts to schedule residents based on the requirements of the
residency program as well as the desires of residents as to days-off, weekends, on-call nights,
etc.

OVERVIEW OF RESIDENCY TRAINING

During the residency, the physician occupies a unique position as both a learner and a
provider of services. This combination is achieved by involving the residents in the care
of patients under the supervision of a more experienced physician. While the resident is
both a student in training and provider of medical services under supervision, residency
programs should be established and conducted for educational purposes. The educational
purpose, however, must not be allowed to diminish the quality of service received by
patients.
The death of Libby Zion, an 18-year-old girl who died while undergoing treatment
for a high fever at New York Hospital in 1984, has changed residency training forever.
The public was outraged that life-and-death decisions are being made by residents work-
ing 36-hr shifts and 100-hr weeks. The medical community debates the merits of the
present system, but the general public overwhelmingly disapproves of it and expects
residency reform.
Residents too are demanding changes. The effects of endless hours, low pay, menial
tasks, terrifying responsibilities on their lives are apparent, including depression, chronic

Current address: Dokuz Eylul University, Department of lndustrial Engineering, Izmir, Turkey; on leave from
the Bloomsburg University of Pennsylvania, College of Business, Bloomsburg, Pennsylvania 17815.

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0148-5598/94/1000-0251507.00/0© 1994PlenumPublishingCorporation
252 Ozkarahan

exhaustion, dissatisfaction with personal life, substance abuse, cynicism, and marital
problems. 5 For this, one must spend four years of slaving in a medical school and
acquiring a debt that averages more than $68,000 for private and $45,000 for public
medical schools. 7
Another reason for residency reform is the threat of malpractice liability. 5 The public
believes that long working hours and sleep deprivation harm patient care. Hospitals that
continue to overwork residents can expect lawsuits alleging that tired residents provided
poor care. Teaching hospitals could pay multimillion dollar settlements.
For decades, physicians have argued the merits of medical residency. Senior phy-
sicians defend the traditional residency as a necessary part of the toughening-up process
for professionals who must deal with emergencies and late-night awakenings throughout
their careers.
On the other hand, during the past decade the health service delivery system has
accommodated dramatic changes in medical technologies, patient expectations and pay-
ment systems. Adjustments to these changes affected teaching hospitals and their medical
staff. Some patients who used to be admitted to hospitals are now treated only as outpa-
tients. As a result, the patient admitted to a teaching hospital had a shorter length of stay,
during which the patient receives numerous diagnostic and treatment services compressed
into a very few days. These new patterns in the ways patients are cared for in teaching
hospitals have significant implications for residency programs. Residents participating in
the admission of patients often see more patients, order and coordinate more ancillary and
treatment services, perform more procedures, and experience more calls to assist in the
care of patients.
Training practices that were appropriate in an earlier time may need to be reexamined
to ensure that they meet sound objectives of both patient service and medical education.
This makes it appropriate to reassess the traditional operating characteristics of residency
programs. The Executive Council of the Association of American Medical Colleges
(AAMC) supports examining and reevaluating current practices on resident supervision
and on the number of assigned hours.
In making recommendations for hospital policies on resident supervision and assign-
ment, the AAMC is appreciative of the different characteristics of the individual hospital
and the requirements of individual specialty disciplines. Accordingly, the recommenda-
tions are presented as guidelines which each hospital and program should consider and
utilize in a manner appropriate to its setting, and resources.
Since the focus of this paper is residents' scheduling, let us now focus on the
discussions on the residents' working hours.
Residency programs are very intense learning experiences. While each of the spe-
cialty disciplines may impose different requirements on its residents, the resident benefits
by being exposed to patients throughout the course of their illness. This allows observa-
tion of both the natural history of the illness and the impact of the medical intervention.
To experience all of the learning opportunities the resident would have to be on-duty 24
hr a day. Clearly, such a schedule is unrealistic and does not recognize the possible
adverse impacts of fatigue or the resident's commitments to other activities and interests.
Therefore, assignment schedules must be balanced between competing objectives and
constraints. The AAMC recommends2 (p.423):