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    Restricting resident duty hours- Where is the evidence

    Resident duty hour restrictions have been in place for nearly 10 years. Have these regulations improved patient safety and residency training?

    Dr. Lockwood, editor in chief, is Dean of the College of Medicine and Vice President for Health Sciences at The Ohio State University, Columbus, Ohio. Send your feedback to [email protected].

     

    Those of us who trained in the 1980s or earlier have less-than-fond memories of being on call as residents. I remember a particularly grueling series of every-other-night calls while covering a busy internal medicine intensive care step-down unit early in my internship.

    One morning, I was summoned to the office of the program director, who told me the nurses on the unit had complained that I used foul language. I was honestly shocked and indignantly denied the charge. When I spoke with the unit’s head nurse, he stunned me by saying it was true; the night nurses noticed that when they phoned my on-call room (ie, closet) after I had been asleep for an hour or 2, I would sometimes curse and, worse, not come out. They then had to knock on the door to rouse me. Apparently, I was so exhausted that I never fully awoke until they actually knocked on my door.

    That was the last time I ever had REM sleep while on call—or heard any complaints about my language. However, as tired as I might have been, I can’t recall making an error of commission or omission because of sleep deprivation, although I may have been too tired to notice. On the other hand I am confident that I delivered far more babies, applied far more forceps, managed more vaginal breech deliveries, and performed more gynecological surgeries than the average graduating ob/gyn resident does today based on published norms. So as we approach the 10th anniversary of resident duty hour restrictions, it is a good time to ask whether these regulations have improved either patient safety or residency training as intended.

    The history of duty hour regulations

    The genesis of resident duty hour restrictions began in 1989, when the State of New York mandated an 80-hour resident workweek in reaction to the now notorious 1984 Libby Zion case. The allegation by Ms. Zion’s family was that exhaustion contributed to residents missing a fatal drug interaction. In retrospect, knowledge deficits, lack of current electronic prescribing software, and a failure by the patient to fully disclose clinically relevant facts were far more relevant to the tragic outcome. Interestingly, while implementation of these requirements added more than $350 million in staffing costs to New York hospitals, the regulations did not improve patient safety.1-3

    Despite the cost of duty hour restrictions and their failure to measurably enhance patient safety, consumer and congressional pressure for national regulations mounted, and in 2003 the Accreditation Council for Graduate Medical Education (ACGME) adopted a national standard limiting duty hours.4 Elements included the limitation of duty hours to 80 hours per week averaged 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. The ACGME decision was prompted by 3 factors: 1) a perception that healthcare delivery was becoming more complex and acute; 2) research that sleep deprivation adversely impacted job performance; and 3) public attention to resident work hours.5 Of course it is hard to say which factor had the greatest impact on the ACGME’s decision.

    In 2008 the Institute of Medicine (IOM) released a report on resident duty hours recommending even stricter standards, including limiting intern shifts to 16 hours and counting moonlighting.6 In 2011 the ACGME implemented these changes as well.4 However, even as it implemented these more stringent standards, the ACGME admitted “both the IOM report and the Task Force found a relative dearth of scientific evidence in many areas important for setting standards to promote sound education and safe and effective patient care.”
    For an organization that prides itself on using evidence to dictate management, the basis for the ACGME’s decision to limit duty hours was remarkably bereft of empirical evidence that it would either improve patient safety  or benefit training. Indeed, evidence suggests it did neither.

     

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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