Overworked?

Their stories are legion: young doctors-in-training, bleary-eyed from long shifts, crashing their cars or falling asleep during procedures. One family medicine resident tells shamefacedly of nodding off while delivering a baby. For Dr. Michael Mazzini, now a cardiology fellow at Boston Medical Center, the near miss came while he was a fresh-faced intern who had just pulled a string of 36-hour workdays.

"I parked my car outside on a small hill and was going around to the back to get my doctor's coat when I realized the car wasn't in gear," he said. "I watched my 1996 Buick Skylark slowly accelerate down the hill to where the physicians' parking garage was, coast right into the garage and disappear from view."

Public concern about such stories prompted the association that oversees residency programs -- the three- to seven-year training periods doctors undergo at the beginning of their careers -- to limit work hours to 80 per week. The controversial 2003 change, perhaps the biggest shift in residency since doctors stopped living full-time in hospitals, came over the objections of many older physicians. They worried it would create a generation of slackers with limited clinical experience. Patient care could suffer, they argued, as doctors handed off patients more frequently.

Four years later, anecdotal evidence and the first round of studies on the impact of the rules suggest that they have produced a modest benefit for doctors and patients. Yet, while the most dire predictions haven't come true, Boston-area teaching hospitals, which employ about 4,000 residents at about $50,000 a year each, still face problems as they struggle to comply.

The new rules "have basically transformed residency from an obstacle course to something that's actually sustainable and enriching," said Dr. Hasan Bazari, director of the internal medicine residency program at Massachusetts General Hospital. "But at the end of the day we still have the question of what is the right mix of experiences and exposures to train a doctor. And if you cut back work hours, can you still train people in the same period of time?"

Hospitals have responded to the rules by hiring more resi dents, shuffling schedules, and shifting some of the workload to more experienced doctors. Cambridge Hospital instituted a computerized sign-out system for residents to share data about their patients, while Children's Hospital and Boston Medical Center offers taxi vouchers to staff members at the end of long shifts so they don't drive home exhausted.

Largely gone are the 100-plus-hour weeks that Bazari worked as a resident in the mid-1980s. Now, budding doctors in Bazari's program begin their overnight shifts at noon instead of at dawn, leaving the morning to sleep in, do laundry, or play with their children.

"We're much more functional, and people are not as worn down as they used to be when they were waking up at 4:30 a.m.," he said. "I see much less of the end-of-rotation fatigue that people have and I think they're better doctors, much more compassionate, and thoughtful."

New research backs him up. In a study published in the July 17 issue of the Annals of Internal Medicine, researchers at Stanford University found a small but significant drop in mortality rates for medical patients at teaching hospitals compared with nonteaching hospitals in the first year of the rule change. There was no impact for surgical patients. A companion study at Yale-New Haven Hospital linked the regulations with a decrease in medication errors, fewer patients needing intensive care, and more patients being able to return directly home at the end of their stays.

But spotty implementation makes it hard to judge the effectiveness of the regulations, which also cap at 30 the number of continuous hours a resident can work and require 10 hours of rest between shifts.

In 2003-2004, the period the Yale and Stanford studies tracked, the Accreditation Council for Graduate Medical Education found that about 3 percent of residents worked more hours than the rules allowed. An independent survey by researchers at Harvard's Division of Sleep Medicine, however, found that more than 80 percent did.

And, sleep researchers say, 30-hour shifts are still too long to make a dramatic difference in patient safety.

"Shifts of 24 hours or longer and the resultant sleep deprivation are unsafe to the interns themselves, the patients they care for, and other motorists on the road," said Laura Barger, an instructor at Harvard Medical School.

But even the fairly modest changes often clash with a hard-driving professional culture that encourages doctors to take sole responsibility for every sick person under their care. Some programs that tried to eliminate overnight shifts had to backtrack as doctors, torn between violating the rules or abandoning a patient, chose to stay on the job.

"When you admit a patient overnight and you're concerned about them, it's hard to give them up to someone who doesn't know them," said Dr. Lindsay Freud, a pediatrics resident at Children's Hospital.

While many residents say they are happy with the work rules, some also report spending an increasing portion of their time on night shifts, where they miss out on conferences and interaction with older doctors.

Faculty, too, say they notice that their residents spend more time on paperwork and less on educational activities. A survey in the July 23 Archives of Internal Medicine found that the majority of faculty felt the regulations had compromised residents' education: 73 percent said there are fewer opportunities for bedside teaching, and 57 percent said there is less chance for residents to perform clinical procedures.

Frustration with the rules, specialists say, stems in part from the fact that cash-strapped hospitals have failed to make fundamental changes on their already overburdened wards. "It's a foolish thing to respond to work hour limitations by saying to residents, please do the same amount of work in less time," said Dr. Leora Horwitz, lead author of the Yale study. "But that's how most programs have responded."

With most doctors accepting the principle of work hour limits, at least publicly, debate continues over how many hours residents can safely work in a single stretch. Several residency directors said they ultimately expect a further crackdown as residents press for more free time.

The union that represents residents wants to limit shifts to 16 hours, while state legislators are considering a bill to study doctor fatigue and develop ways to combat it. The moves could eventually bring Massachusetts more closely in line with the European Union, which bars trainee doctors from working more than 56 hours per week.

That prospect worries some surgeons. Dr. Stanley Ashley, director of the surgical residency program at Brigham and Women's Hospital, said he fears his residents would have to extend their seven-year training if work hours are further reduced.

In Europe, Ashley said, "they've extended the concept of hand-offs in some places to where people leave operations in the middle. . . . Most of us can't imagine that and I think most of the public can't either."