Resident duty-hour limits linked to safety, education concerns

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[April 04, 2014]  By Ronnie Cohen

NEW YORK (Reuters Health) Restrictions on work hours for surgeons-in-training may have backfired, according to a new review that found doctors performed worse on certification tests and believed patient safety declined after the rule change.

Long shifts and lack of sleep among medical residents led the Accreditation Council for Graduate Medical Education (ACGME) to restrict work hours in 2003 and again in 2011.

The original regulation stemmed from the case of Libby Zion, a college freshman who died in a New York hospital in 1984 after being treated by a resident working a 36-hour shift.

That rule limited resident time on-duty to 80 hours per week. The subsequent regulation said first-year residents, called interns, could not work more than 16 hours in a row.

For the new review, researchers examined 135 prior studies and found that while limiting surgery trainees to 80-hour workweeks may improve their well-being, capping their work shifts at 16 hours might degrade patient care and resident education.

"The study reinforces something that most surgeons already know or at least feel  strict duty-hours regulations don't have the beneficial effects that many people hoped they'd have, and they may have a detrimental effect," Dr. Brian Drolet told Reuters Health.


Drolet is a fifth-year surgical resident at Rhode Island Hospital in Providence and was not involved in the new research. He led a previous study that found most surgery residents dislike rules restricting their work hours and sometimes lie to skirt the limitations (see Reuters Health story of May 17, 2013, here: http://reut.rs/1pEAIn3).

In the new analysis, just two studies examined rates of patient complications and deaths after the 16-hour limit was imposed; one found no change, the other had inconclusive results. Among 14 surveys of residents, 11 found a strong impression that patient safety had suffered.

Of 15 largely survey-based studies that looked at education and training after 16-hour maximum shifts were imposed, 12 found residents and program directors thought training had deteriorated and three showed no change, according to the results published in Annals of Surgery.

At the same time, surgical boards have reported increasing failure rates on the oral component of their exams, the study says. Over the past decade, the number of candidates who failed the thoracic surgery test has nearly tripled, and the failure rate for general surgery has nearly doubled.

Dr. Najma Ahmed, the lead author of the current study, told Reuters Health she believes the 16-hour rule may work in some specialties but not in surgery, where it hinders surgeon training and fails to protect patients.

"One size does not fit all for training," said Ahmed, director of the University of Toronto's general surgery residency training program.

"Training in dermatology or psychiatry would be different than training in neurosurgery," she said.

After the U.S. restricted first-year residents to 16-hour shifts, all medical residents in the Canadian province of Quebec were limited to 16-hour work periods when a provincial arbitrator ruled that longer shifts endangered residents' health.


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No one studied the effect of 80-hour workweeks or 16-hour shifts before imposing the regulations, Drolet said.

He said doctors are reluctant to leave their hospitalized patients to the care of other doctors. "Most of us signed up for the job to take care of people," he said. "So if someone is sick, you're going to take care of them."

He called the work schedule resulting from a 16-hour shift limit "miserable." The only way to work a weekly 80 hours, which hospitals expect from medical residents, in no more than 16-hour shifts is to put in six 13-hour days, he said.

Surgery residents working under the 16-hour limit "feel jet-lagged all the time," Ahmed said.

One prior study, also based on surveys, suggested such shift limits might increase the number of hospital errors and leave trainees spending less time in the hospital during the day, when they have the most opportunity to learn from attending doctors (see Reuters Health story of March 25, 2013 here: reut.rs/WRLaLj).

Drolet said he believes no study has yet to adequately address the impact of 16-hour shift limitations on resident fatigue. Two large, recently announced U.S. trials are expected to tackle the issue.

A five-year randomized trial will compare internal medicine residents working 16-hour shifts to those working 28-hour shifts, which include four hours of uninterrupted sleep. A two-year study of surgery residents will examine how increasing flexibility of duty-hour requirements influences patient care and surgical outcomes.


"My fear is that some of these changes are political in nature and not based in evidence," Ahmed said.

Part of the solution will be devising a way to protect doctors-in-training from interruptions between 1 a.m. and sunrise except in emergencies, she said.

"We all agree that sleep deprivation is not a great thing," she said. "There needs to be some flexibility built into these programs."

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Source: http://bit.ly/QkOwqC
Annals of Surgery, online March 21, 2014.

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