Restricted resident duty hours and unintended consequences

June 1, 2013

Is there evidence that patient care has improved since the work limits took effect?

 

Two years have passed since the Accreditation Council for Graduate Medical Education (ACGME) restricted to 16 the number of duty hours medical interns may work in one day. The consequences this restriction has had on young doctors’ workloads and well-being are discussed by Pauline W. Chen, MD, in a recent article on the New York Times Web site titled “The impossible workload for doctors in training.” Chen asserts that the mandate has led to overworked interns and understaffed departments as fewer doctors scramble to care for more patients. She writes, “there has been no significant improvement in the quality of care since the work limits took effect."

Restrictions on duty hours have increased over the past 10 years. In 2003 the ACGME limited duty hours to 80 hours per week over a 4-week period; 1 day off in 7; and a maximum shift of 24 hours with 6 additional hours for education and handoffs. In 2011 the 16-hour mandate concerning interns took effect.

Contemporary OB/GYN Editor in Chief Charles J. Lockwood, MD, MHCM, addressed the issue of duty hour restrictions in a January 2013 editorial, writing, “at best, duty hour restrictions may not have adversely impacted patient safety, but they also have not improved it.” He asserted, “Studies should be performed to assess the impact of duty hour restrictions on the proficiency of graduates of ob/gyn and other surgical discipline residency programs. I think we have gone too far with duty hour limits, but I have learned not to base my management on hunches-I would like to see the evidence!”

This evidence is now being revealed. Studies on the mandate’s repercussions are now being published, Chen writes, and they have found negative effects on interns’ health, education, and work performance. In one randomized trial, “Effect of the 2011 vs 2003 duty hour regulation–compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff,” published on the JAMA Internal Medicine Web site on March 25, 2013, researchers found that although two 2011 duty hour regulation–compliant models were associated with increased sleep for interns, the models were also associated with “deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.”

Another study, “Effects of the 2011 duty hour reforms on interns and their patients,” also published on the JAMA Internal Medicine Web site on March 25, 2013, found that the decrease in duty hours “has not been accompanied by an increase in hours of sleep or an improvement in [residents’] depressive symptoms or well-being.” In addition, the decrease in hours “has been accompanied by an unanticipated increase in self-reported medical errors,” the researchers noted in their conclusion.

While the ACGME restrictions were undoubtedly intended to ease residents’ burdens and improve patient care, these studies are showing that the restrictions have had unintended negative consequences on both doctors and their patients. In an invited commentary accompanying the above studies in JAMA Internal Medicine, Lara Goitein, MD, and Kenneth M. Ludmerer, MD, write, “Work hour limitations, by restricting the length of hospital shifts and spacing them, smooth out the peaks and valleys of work and ensure more regular sleep periods. But they do not change the total amount of work by residents in our teaching hospitals; they simply redistribute it.”

Chen PW. The impossible workload for doctors in training. April 18, 2013. http://well.blogs.nytimes.com/2013/04/18/doing-the-math-on-resident-work-hours/?ref=health. Accessed May 16, 2013.

Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation–compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff. JAMA Intern Med. 2013;173(8):649-655.

Lockwood CJ. Restricting resident duty hours: Where is the evidence? Contemporary OB/GYN. 2013;58(1):8-10.

Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients. JAMA Intern Med. 2013;173(8):657-662.