by Vadim Shteyler
On the wards, resident duty hour restrictions were a frequently recurring topic of heated discussion. Effective July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new limitations on resident work hours for all ACGME-accredited residency training programs, furthering the existing limitations from 2003 reform. Current policies restrict workweeks to 80 hours. Residents must get at least four days off every four weeks. Shifts are reduced from 30 consecutive hours to 16 consecutive hours for first-year residents and to 24 hours for all other residents. First-year interns must have eight hours off between shifts. And residents after 24-hour call must have at least 14 hours off.
Proponents argue that exhaustion contributes to medical errors, such as the death of Libby Zion (whose tragedy prompted the conversations and the policies limiting duty hours). Longer hours can lead to poorer quality of life, ultimately harming patient care. And inefficiencies in the more frequent handoffs are reasons to focus attention on handoffs rather than lengthen shifts.
Opponents have an unlikely ally, many residents and physicians. During my rotations, many argued that fewer hours on the wards translates to less real-life patient exposure and under-preparedness for independent practice. Surgical residents worry that they would be unable to participate in as many surgeries as their seniors, leaving them less well trained. Another common criticism I heard from residents was that shorter shifts meant that a greater number of hours are spent on handoffs and catching up on interim events, meaning that an even smaller fraction of the 80 hour workweek is devoted to direct patient care. This also leaves less time for educational activities. More frequent handoffs are also argued to increase likelihood of information transfer errors. Further, first-year interns often complained that they preferred working 24-hour shifts and having more time off than 12-hour shifts. They felt 24 hours was a reasonable span to remain alert and functional and that having more time off in between shifts gives them an opportunity to get more sleep and leaves some time for personal matters. Others believe that shortening duty hours does not address the real cause of resident exhaustion—increasing work intensity. Between 1990 and 2010, the number of admissions at teaching hospitals has increased by 46 percent. The number of residents, however, had only increased by ten percent. With shorter hospital stays, the patients who have remained hospitalized have been sicker and in need of more involved care. They argue that shortening duty hours, decreasing total time spent on direct patient care, just gives residents fewer hours to do more work.
Two recent retrospective studies, published in the Journal of the American Medical Association (JAMA), examined the effects of the 2011 duty hour restrictions on patient outcomes. The first study showed no difference in general surgery patient mortality and serious morbidity or surgical resident board examination scores between the two years before and after the reform. The second study showed no change in 30-day mortality and readmission rates for certain common conditions from the two years before the reform to the year after. Though these studies imply no difference in patient outcomes since the implementation of duty hour restrictions, it is important to note that they do not measure rates of complications or patient safety indicators. The studies do not verify hospital compliance to the new restrictions. And they are retrospective in design, limiting their generalizability.
So, what policy conclusions may be drawn from these studies? This, too, is debated. Those who believe that duty hour restrictions offer residents a better quality of life without the sacrifice of patient safety feel that the restrictions are justified. Others argue that the initial justification for these restrictions has been to improve patient safety. Without better measurable outcomes and concern among residents, such strict restrictions are not justified. As the debate continues, we await the results of a randomized control trial (the FIRST trial), already underway, of surgical residents with and without duty hour restrictions.