Are duty hour restrictions working? A discussion of two recent studies from JAMA

alex_fox_wht by Alex Fox

When discussing my status as a resident physician with the general public, two comments come up frequently. First, people want to know how long until I am a “real doctor”, and second, they love to ask about how much I work. While in general we as physicians struggle to communicate complex ideas effectively with patients, we seem to have been wildly successful in informing the public that we work ALL. THE. TIME, especially as residents. While we do work long hours, what that actually means changed in 2003 and 2011, when the ACGME implemented work hour restrictions of 80 hours per week, 16 hour shifts for interns, and 24 hour shifts for upper level residents. These new rules have become a source of irritation to some “old school” physicians, who not-so-fondly remember the rite of passage of 36+ hour work days and 100+ hour weeks. It is also a source of joy among some residents, who know that no matter how busy and chaotic things get, there is a limit to how much time they can spend in the hospital.

There were a variety of reasons cited for this work hour change. First and foremost was a concern over mistakes being made by stressed, overworked, and sleep deprived residents. Residents (and attendings for that matter) will occasionally make mistakes, and the thought was that by cutting the end off of those long shifts, residents would be mentally fresher and more in the moment, increasing the ability to correctly diagnose and treat illness.

Now that restrictions have been in place for a few years, major studies are starting to appear analyzing the change, the initial data looks pretty bleak. Recently JAMA published 2 major studies regarding patient safety in the post-restriction era. The first study reviewed 30 day mortality and readmission rates in a population of over 2.7 million Medicare patients in the pre- and post- restriction eras. This was a patient population that focused on bread-and-butter hospital admissions, including myocardial infarction, stroke, GI bleed, congestive heart failure, and a variety of surgical procedures. The result of the study? There were no significant differences in mortality or readmission between the groups treated by pre-restriction residents or post-restriction residents. The second study looked at general surgery patient outcomes and general surgery in-training, written board and oral board exams before and after the change. This study looked at a population of over 200,000 general surgery patients, with a main outcome of death or serious morbidity. The study also completed an overall review of resident exam performance. Once again, no significant changes were seen in patient outcomes, and there was no change in resident exam performance.

So what does this all mean? Based on these two studies, patients are not receiving better care, but they are not receiving worse care either. Residents are not getting dumber, but they are not getting smarter. The more things change, the more things stay the same.

Clearly patient outcomes were not the only factor that went into the decision to implement work hour restrictions. There was also the question of resident physical and mental health. Currently there is no good data to support whether restrictions have made things safer for residents, especially in the high-danger time of driving home after long shifts. Anecdotally, there are few stories from my fellow residents of falling asleep behind the wheel at stoplights or in the garage, which is a phenomenon seemingly every attending physician from the pre-restriction days has experienced. Without good pre-restriction data for events like traffic accidents or illness, we will continue to depend on resident wellness surveys to judge success in the area of resident health, which have generally shown positive change.
So what does this mean for the future of work hour restrictions? In terms of safety, my initial thought is that perhaps we have found an equilibrium where the danger of tired residents is balanced by the danger of frequent patient handoffs. This does not mean that there is nothing to be done to improve patient safety, but instead that we need to look into other, high-value arenas to make more effective changes (a nationally linked, standardized EMR comes to mind, but that is one person’s bias). For resident health, in general we are still tired, but perhaps slightly less than our predecessors. As long as patients are not getting sicker, resident’s exam scores are not dropping, and residents are feeling better about their lives, I think few residents will volunteer to return to the pre-restriction era.

Alex Fox is a second year Family Medicine Resident at the University of Utah

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