More sleep required for docs-in-training

Resident duty hours took effect July 1

As of July 1, first-year medical residents may be getting a better night's sleep. New rules limit duty hours for interns to a 16-hour shift, ban them from moonlighting, and require them to have at least 8 hours free between duty hours.

The rules, issued and enforced by the Accreditation Council for Graduate Medical Education (ACGME), were designed to address concerns about fatigue-related errors. They limit other residents, though to a lesser degree. The maximum shift for residents after their first year dropped from 30 hours (24 hours on duty plus six hours for patient hand-off, paperwork and education) to 28 hours (24 plus four). Moonlighting will count toward their maximum work time of 80 hours per week, averaged over four weeks.1

The rules protect patient safety and ensure "that the next generations of physicians are well-trained to serve the public and that residents receive their training in a humanistic learning environment," ACGME chief executive officer Thomas Nasca, MD, MACP, said in a statement.

Yet as hospitals began implementing the new rules, the changes remained controversial. A survey of residency program directors in pediatrics, internal medicine and surgery found that 86% opposed the 16-hour limit for first-year residents, though they agreed with other workload rules.2 Consumer advocates and unions said the rules didn't go far enough to reduce fatigue, and they petitioned the U.S. Occupational Safety and Health Administration to regulate resident work hours.

"We believe the rules should be consistent for all types of residents in training," says Michael A. Carome, MD, deputy director of the Health Research Group at Public Citizen, a Washington, DC-based consumer and health advocacy group that was among the petitioners.

Fatigue in sensitive occupations has been in the public eye recently with news of air traffic controllers falling asleep during their night shifts. Carome asserts that the medical field should heed the risks of sleep deprivation. He also notes that in a recent tax-related case, the U.S. Supreme Court said medical residents are hospital employees, not students.

"That bolsters the arguments that residents should be protected [from sleep deprivation] in the same way other workers are," he says.

Drop in adverse events may outweigh $

Reducing resident work hours will require some significant changes for some hospitals. They may hire more physician assistants or nurse practitioners to handle some of the residents' duties, or they may use more hospitalists or increase the number of medical residents. An Institute of Medicine panel, which supported even tougher rules limiting work hours to reduce fatigue, estimated the cost could total $1.7 billion.3

An analysis of the new, more limited ACGME duty hour changes found that it would cost about $381 million to implement nationwide, although the costs could vary greatly depending on how hospitals chose to make up for the lost work time. If preventable adverse events declined by 2.4%, the policy would be cost-saving for society, the study authors found, and if the preventable adverse events declined by 10.9% as a result of the change, it would be cost-saving for major teaching hospitals.4

Hospitals began preparing for the new rules when they were adopted in September 2010. For example, the Mayo Clinic in Rochester, MN, set up pilot projects with different team structures and call schedules. They monitored patient outcomes and asked residents about their experiences. "What we've learned from these pilots is that there's no obvious formula," says Darcy Reed, MD, MPH, associate program director of the internal medicine residency at Mayo. The best work schedule design will differ by unit or sub-specialty, she says.

"Everyone has the goal of protecting patients from error and harm, protecting residents from injury and improving the quality of life for residents," she says. "The question is how to best implement this to achieve the outcomes we want to achieve."

The answer is not a simple one. Reed served on a panel that conducted a systematic review of literature related to 2003 ACGME changes in duty hours. They found that about a third of a resident's shift is spent on tasks of "marginal educational value."5 Those tasks could be delegated, but then a resident would face increased intensity throughout the work shift, which could lead to increased burnout, she says.

"You need a little bit of that downtime in your shift. It's a difficult balance," she says.

No harm to education or care

Studies of sleep deprivation clearly show that lack of sleep is associated with a decline in cognitive functioning. For example, one study found that medical residents working a traditional schedule in an intensive care unit made 36% more errors than those who worked shorter shifts.6

Yet critics of stricter duty hour rules contend that residents will not necessarily use their free time to get more sleep. Even when the ACGME established less restrictive rules in 2003, critics expressed concern that it would harm medical education and patient care.

"There was a lot of doom and gloom predicted," says Reed, who was part of a team that reviewed the literature on duty hours changes. "Largely, things are unchanged or better."

Some studies showed patient mortality improved, while others showed no change. The effect on medical complications was mixed. Of 10 studies included in the review, none showed that longer shifts results in improved resident education. Shorter shifts were associated with fewer medical errors and greater resident well-being.5

"How have [the 2003 restrictions in duty hours] affected patients? If you look at the studies as a whole they're mixed," says Reed.

"Our review shows the one thing that is consistently improved with these limits is residents' well-being," she says. "The magnitude of that improvement is pretty small in more of those studies. Burnout is still a problem with doctors in training, at worrisome levels."

Focusing the limits on first-year residents makes sense as a way to prevent fatigue-related errors or injuries, Reed says. "Interns are also the least experienced. When you combine inexperience with fatigue, there's a greater safety risk than in someone who has a lot more experience behind them," she says.

The American College of Surgeons had argued against further restrictions on duty hours, asserting that it could cause "irrevocable damage to a surgical residency training system that is already severely stressed."7 Yet a systematic literature review of the effect of the 2003 ACGME duty hours limits on surgical residencies concluded: "Limitations had a positive effect on residents but a negative effect on surgical faculty. Importantly, duty hours limitations did not adversely affect surgical residents' operating-room experience."8

With the 2011 rule changes, there will be further research on the impact of duty hour limits, says Reed. "Since we've had the experience with the 2003 limits, people are in a better position to study this is a more rigorous way," she says. "I think we'll see higher quality research coming out with these new recommendations."

References

1. Accreditation Council for Graduate Medical Education. Common Program Requirements, July 2, 2011. Available a http://bit.ly/aARcqt.

2. Antiel RM, Thompson SM, Reed DA, et al. ACGME duty-hour recommendations — A national survey of residency program directors. New Eng Jrl Med August 4, 2010. Available at http://bit.ly/qTS4kb.

3. Institute of Medicine. Resident duty hours: Enhancing sleep, supervision, and safety. National Academies Press, Washington, D.C., 2009.

4. Nuckols T and Escarce JJ. ACGME Common Program Requirements: Potential cost implications of changes to resident duty hours and related changes to the training environment announced on September 28, 2010. Available at http://bit.ly/nLXSV4

5. Fletcher K, Reed D, and Arora V. Systematic review of the literature: Resident duty hours and related topics. Accreditation Council for Graduate Medical Education. Available at http://bit.ly/njBncy

6. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351:1838-1848.

7. Jamal MH, Rousseau MC, Hanna WC, et al. Effect of the ACGME duty hours restrictions on surgical residents and faculty: A systematic review. Academic Medicine 2011; 86:34-42.