Do physicians in training take better care of patients or perform better on their exams when their work hours are restricted? Two recent studies in the Journal of the American Medical Association suggest that the answer is no. In one, patients of surgery residents showed no difference in morality or postoperative outcomes after duty hour restrictions were implemented. Their test scores did not improve either. In the other, hospitalized Medicare patients being cared for by physicians working shorter hours experienced no improvement in mortality or readmission rates.
US resident duty hour restrictions were born in 2003, when the ACGME, the organization that accredits medical residency programs, capped the work week at 80 hours. It also mandated that residents have 10 hours off between duty periods and a 24 hour limit on continuous duty, with 1 day in 7 free from patient care. In 2011, the organization revised its policy, further restricting the total number of continuous duty hours for physicians in the first year of training to 16.
How could well-intentioned attempts to ensure that hardworking young physicians get sufficient rest fail to benefit patients? To begin with, simply restricting duty hours does not guarantee that residents will use their extra off-duty time to sleep. They might, for example, use it to study, exercise, or socialize. It is also possible that the outcomes being assessed by these studies are influenced by so many factors that merely changing duty hours is insufficient to cause a change. Yet if such changes do not benefit patients, how strong is the case for their implementation?
Some educators worry that duty hours restrictions are undermining the quality of medical education. For example, a survey of surgery program directors published last year showed that 21% believe that residency graduates are unprepared for the operating room, 30% believe they cannot independently remove a gallbladder, and 68% believe they cannot perform a major procedure unsupervised for more than 30 minutes. Another survey showed that 38% of residents themselves lack confidence in their preparation even after 5 years of training.
Part of the problem may lie in the fact that the duty hours restrictions have reduced the number of cases such residents are able to learn from. For example, one study of the caseloads of surgery residents found that the implementation of duty hour restrictions was associated with a 26% reduction in cases per resident. Moreover, the complexity of operating room cases in which residents participated declined even more, 32%. To compensate for such reductions, some critics have argued that if duty hours restrictions remain in place, the length of surgery residency will need to be increased from the current 5 to 6 or even 7 years.
But the problems with attempts to reduce duty hours go deeper still. When residents spend less time in the hospital, the number of patient “handoffs” that need to occur between residents increases. A resident who might once have cared for a patient for 24 consecutive hours now needs to hand the patient off to a colleague at 16 hours. It is well documented that every time a patient’s care is transferred from one health professional to another, errors in communication tend to occur. Studies suggest that such error rates can be reduced, but not eliminated.
An associated problem is the fact that residents operating under duty hours restrictions have less time to get to know their patients. In addition to creating opportunities for error, this also has negative implications for the quality of relationships that young physicians develop with their patients. Confidence and trust are built in part on familiarity, which the duty hours restrictions tend to reduce. As a result, many young physicians may expect less from relationships with patients, and these diminished expectations may remain with them throughout their careers.
The intent behind duty hours restrictions is a noble one. As sleeplessness increases, it takes a toll on mental performance, including reaction time and the ability to memorize new information. But sleeplessness is but one factor in the performance equation, and it may be counterbalanced by other equally or even more important factors, such as the importance of the task at hand. When a patient’s health or even life is on the line, it is possible that many young physicians are able to compensate for lack of rest.
Another drawback of the duty hours restrictions is psychological, perhaps even cultural. A whole generation of physicians in training is being told, directly or indirectly, that their education is not as rigorous as their teachers’. They do work as hard and are not being tested to the same degree as those who trained before them. As a result, many complete their training questioning whether they have given less of themselves than they needed to.
Without doubt, the culture of hard work and sacrifice can be taken too far. A colleague recently shared with me this story. When he was an intern, he was taking call every third night, admitting at least 8 patients each call shift, and getting too little sleep. One morning while on rounds with his chief resident he stopped and said, “I don’t think I can keep doing this. It is dangerous for the patients.” The chief showed absolutely no sympathy, instead responded dismissively, “Just suck it up and carry on.”
Duty hours restrictions represent an attempt to deal with a genuine problem, a dominant culture in medicine that says, “If you can’t do this, you are weak.” Yet they are problematic because they represent a one-size-fits-all solution. In many cases, a more tailor-made approach is called for. It makes no more sense to treat all residents in all medical fields identically than it would to treat all patients as if they were cut from the same mold.
Before we impose blanket restrictions on duty hours for every training program and resident in the country, we should turn our attention to more pressing matters. First, we should try to foster a culture in which young physicians can admit they need help without fear of reprisal. Second, we should ensure that the work residents are being asked to do is truly educational and important. And third, we should put more trust in the ability of program directors and their residents to discern for themselves the amount of work they are able to handle.
I would be curious to see the outcomes of more than just two studies. Would the conclusions still look the same? While I agree that not everyone works under the same mold, it generally holds true that those who are sleep deprived and overworked tend to make more mistakes and not retain information.
While spending more time with a patient can increase physician-patient trust, the attitude of the physician also impacts that trust. From a patient’s perspective, I would be more inclined to trust a physician that I can tell is well rested, alert, and has a good bedside manner. I know that errors can occur in handoffs, but if both physicians are well rested, there is a possibility that less mistakes would be made in the transfer of care.
True that the studies evaluating the new work-hour restrictions showed that patient outcomes and re-admissions were not better…but they also showed that they outcomes were not worse. In other words, physicians who were working longer hours were not better doctors as a result of being abused and exhausted. Physicians trained in the older system forever harp on the syllogism 1) They are great doctors 2) They were abused as residents, therefor 3) Abuse makes great doctors. The two studies prove, if anything, that the sleep deprivation did nothing to improve care. The US Military has known this for decades after conducting proper sleep/performance studies and implementing appropriate restrictions on their aviators with resulting dramatic decreases in aircraft mishaps and deaths. Here’s a syllogism that is proven by scientifically valid studies: 1) Sleep deprivation decreases learning and increases mistakes in humans 2) Physicians are human, therefor 3) Physicians who are sleep deprived learn less and make more mistakes.
One thing pilots know that doctors don’t (and aviators train just as hard as physicians, incidentally) is that when they make mistakes, they (and their crew) might die. If Attendings’ lives were put in the hands of overtired residents, I think they would think differently about extended work hours.
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This issue is emblematic of a deeper problem in graduate medical education; that resident responsibilities and experiences are continually being watered-down under the guise of “quality”, “safety”, “patient-centeredness”, etc which are used for cover of economic, political or plainly naive motivations.
Opportunities to be hands-on, exercise judgement, make a mistake, and *gasp* actually learn something valuable in residency are quickly being replaced with mindless standardization and protocol-compliance.
At a bare minimum we must acknowledge the short-term and the long-term are not independent. 4 years-worth of making mistakes, pissing off patients, and providing inefficient care is much better than an entire career-worth
Handoffs and EHRs are synergistically dangerous. Killers, actually.
Reducing (a) may make doctors more patient friendly.
Great example of trade-off.
a) Tired doctors make mistakes.
b) Doctors disrupted in continuity of care make mistakes.
Reducing (a) increases (b).
Doctors are so tough that they can prove a negative. Do they still teach that in residency?