Dr. Joseph Esherick Monthly Blog – September 2011
National resident work hour restrictions were first implemented by the ACGME in 2003. The debate started initially after the unfortunate death of Libby Zion in 1984 which prompted the state of New York to restrict resident duty hours. The assumption was that resident fatigue caused the death of Libby Zion. Among other restrictions, the 2003 regulations restricted resident shifts longer than 30 hours. The regulations also stipulated that resident physicians must have at least one day in seven off and must have a 10 hour break between work shifts.
In 2008, the Institute of Medicine (IOM) declared that resident duty hour restrictions must be tighter to reduce medical errors and improve resident education. The IOM proclaimed that resident shifts should not exceed 16 hours unless they are interrupted by a five-hour uninterrupted nap, no shift should exceed 30 hours, and moonlighting hours are counted as a part of the 80-hour weekly maximum. Based on these recommendations, the ACGME has imposed new 2010 regulations that prohibit first-year residents from working shifts longer than 16 hours, senior residents must work shifts no longer than 24 hours, and shifts must be separated by a 10 hour break. The assumption that has been made is that these duty hour restrictions will decrease resident fatigue and therefore lead to improved patient safety and improved resident education, which will eventually lead to better graduating physicians.
The reality, however, is these residency duty hour restrictions have led to neither improved patient outcomes nor improved resident education. The data suggest that the IOMs assumptions are wrong... A massive study in 2009 involving 14 million veterans and Medicare patients showed no improvement in patient safety after the 2003 ACGME restrictions. A recent systematic review published this year examined the impact of work hour reduction on patient outcomes and medical education. The study found that the work hour restrictions neither improved patient outcomes nor improved postgraduate medical education. In order to implement these mandated changes, hospitals have had to hire additional attending physicians and support staff to compensate for the lower resident workload. This has cost the country an additional $1.6 billion dollars and leads to increased physician hand-offs, which has been consistently cited as a major risk factor for medical errors.
In the end, though, what is the goal of medical residency? As the IOM writes in its 2008 recommendations, “The principal aim of medical residency in the United States is to prepare recent medical school graduates to practice medicine independently.” I would add that residents should also be prepared for medical practice in “the real world.” These new duty hour restrictions are creating a breed of resident physicians who are used to shift work and have less of an attachment or sense of ownership for their patients. The vast majority of the residency directors of internal medicine, family medicine, pediatrics, and general surgery programs in the United States oppose these new restrictions. , The vast majority of these program directors believe that these changes would lead to the following: patient safety would not be improved; resident education would suffer; residents would develop a “shift worker mentality”; residents would be less able to competently practice independently after graduation; graduating doctors would take less “ownership” for the care of their patients; residents would be less prepared for the work hour demands of their future practices; and residents will be less able to provide continuous care for patients, coordinate patient care, and will have worse communication skills.
So again, are these resident duty hour restrictions better for graduate medical education, patient safety, the development of our future physicians, or society as a whole given the extra $1.6 billion expenditure needed to implement these changes? My answer is no. The ACGME and IOM blew it on this one.