Do duty hour limits work for residents?

Residents, program directors say no

A mid concerns about the impact of fatigue on medical errors, the governing body of medical education sought to make sure the least experienced medical residents get the most sleep. But a new survey indicates that other residents and program supervisors believe the rules are just creating problems for other residents without improving medical education.

Two years ago, the Accreditation Council for Graduate Medical Education (ACGME) limited first-year residents to 16-hour shifts, banned them from moonlighting, and required them to have at least 8 hours free between duty hours.

In a recent survey of more than 6,000 residents, two-thirds (65.5%) said junior-level responsibilities had been transferred to more senior residents. While most interns said their quality of life had improved (62%), half of senior residents said their quality of life has worsened.1

Residency program directors were similarly critical. In a survey of 549 program directors, 72% disapproved of the 16-hour limits on interns and less than half (48%) supported 24-hour shift limits on senior residents. About half of them felt fatigue and quality of life had improved for residents, but a larger majority said the quality of education and preparation for senior roles had declined while handoffs increased and continuity of care worsened.2

“There needs to be more flexibility and graduated responsibility,” says lead author Brian Drolet, MD, a fifth-year resident in plastic surgery at Rhode Island Hospital in Providence, which is affiliated with Brown University. “Setting a hard and fast limit of 16 hours for the intern year and having that disappear on July 1 of your second year...doesn’t make a lot of sense.”

At the Health Research Group of the advocacy organization Public Citizen, staff researcher Sammy Almashat, MD, MPH, agrees that the two-tiered system is flawed, but his solution would be much different from that suggested by Drolet. Public Citizen has unsuccessfully petitioned the U.S. Occupational Safety and Health Administration to regulate resident work hours and to limit all resident physicians to shifts of 16 hours.

“One of the central flaws in duty hour rules that were instituted in 2011 was this double standard for first-year residents and upper-level residents,” says Almashat. “[Upper-level residents] were not only required to work the same number of hours as before, but they also have to dramatically increase their workload during their shift. It created a worse situation for the majority of residents.”

Fewer hours, more handoffs

Duty hour limits stem from growing concerns about fatigue in health care and its relationship to medical errors. 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.3

Drolet asserts that resident errors do not necessarily mean patients were placed at risk. “Part of being a resident is learning and making mistakes and having those mistakes acknowledged by senior residents and attendings,” he says.

Conversely, when there are duty hour limits, patient handoffs increase — and so does the potential for inadequate communication about a patient’s needs, he says.

Those transitions of care do need to be improved, acknowledges Almashat. “One shouldn’t focus on one deficiency in the medical system to justify keeping another deficiency in place. If you really care about patient care, you’d focus on both.”

Almashat points to research that shows declining cognitive performance as people become more sleep deprived. Even attending physicians are subject to the impact of fatigue, he says. “These are biological effects of sleep deprivation for human beings. [Physicians] are not immune to it,” he says.

Under current ACGME rules, residents beyond their first year can work up to 28 consecutive hours. They must work no more than 80 hours per week, but that can be averaged throughout the month so that a single week could encompass as many as 100 hours.

Public Citizen had petitioned OSHA to regulate duty hours of interns and residents. In the denial, OSHA administrator David Michaels, PhD, MPH, noted that residents are protected by whistle-blower provisions if they raise concerns about extended work hours. He also said, “OSHA will continue to watch with interest whether the new ACGME standards result in improved working conditions for medical residents and interns.”

Drolet says he would like to see some adjustment in the limits, particularly to provide more flexibility and recognition of different educational demands for different specialties. But he acknowledges that it’s not likely to happen.

“The public perception [of the need for duty hour limits] is so strong that I’m not sure we can go back,” he says. “The pendulum has swung and it may still be swinging in the direction of more limitations rather than the opposite direction.”

References

1. Drolet BC, Christopher DA, Fischer SA. Residents’ response to duty-hour regulations – A follow-up national survey. N Eng J Med 2012;366:e35. Available at http://www.nejm.org/doi/full/10.1056/NEJMp1202848. Accessed on May 23, 2013.

2. Drolet BC, Khokhar MT, and Fischer SA. The 2011 duty-hour requirements – a survey of residency program directors. N Engl J Med 2013; 368:694-697.

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