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:
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
"One size does not fit all for training," said Ahmed, director of
the University of Toronto's general surgery residency training
"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
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
"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
Annals of Surgery, online March 21, 2014.
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