ARTICLE: Resident Duty Hours and Medical Education Policy — Raising the Evidence Bar
AUTHORS: David A. Asch, Karl Y. Bilimoria and Sanjay V. Desai
JOURNAL: N Engl J Med. 2017 Apr 5. doi: 10.1056/NEJMp1703690. [Epub ahead of print]
On March 10, 2017, the Accreditation Council for Graduate Medical Education (ACGME) issued revised common program requirements for residents that go into effect this July. The revisions emphasize the importance of teamwork, flexibility, and physician welfare during training, but all the attention has been (and will no doubt remain) focused on the changes in duty hours. The new rules maintain an 80-hour-per-week cap on residents’ work, averaged over 4 weeks, but extend the permissible work shifts for first-year residents from 16 hours to 24 — limits already in place for residents in year 2 and beyond — and permit more within-shift flexibility as long as weekly duty-hour limits are met. What makes this policy change so important is that it seems to reverse direction on the basis of a new approach to developing and using evidence to inform education policy.
For a public largely used to 8-hour workdays and 40-hour workweeks, the old rules seemed stressful enough. Public interest in the topic has been strong since 1984, when an 18-year-old college freshman named Libby Zion died at New York Hospital, ostensibly because she was cared for by overworked and undersupervised residents.1 A New York State grand jury investigating the case looked beyond the involved physicians and hospital and essentially indicted U.S. graduate medical education for its long hours and lax supervision. Resident duty hours became a focus of the ACGME, and duty-hour policies were introduced, shaped, and reshaped over the subsequent three decades, at first on the basis of opinion, and later supplemented by bits and pieces of evidence.
At the heart of this debate is the concern that residents working longer hours might get less sleep and that sleep-deprived residents might make errors that hurt patients or themselves. Competing concerns are that shorter work hours mean more patient hand-offs, which are themselves dangerous, and might also mean less education, or socialization into a kind of “shift mentality” that reduces professionalism — either of which might result in less competent and less committed doctors for patients in the future.
The debate has been colored by concerns that academic medicine is holding on to tired and abusive traditions akin to the hazing of cadets, or that what is really at stake is money, since resident physicians are such a captive and elastic source of cheap labor. Critics of restrictive rules have countered that one can regulate work hours but not sleep, and that resident fatigue may be caused more by the compression of a large volume of clinical work, which may be exacerbated by duty-hour limits. At times, the debate has seemed like a shouting contest, rooted in opinion rather than evidence.
But science has had a place, including a National Academy of Medicine report.2 A large literature reveals that sleep deprivation causes errors, and physicians are just as susceptible to these effects as anyone else. Alertness and performance vary with the point in one’s circadian rhythm. Observational studies reveal that changes in resident duty-hour rules have not been associated with changes in patient mortality or other clinical outcomes.3 Varying call schedules or providing protected nap times affects the amount of sleep on a given day but not sleep time averaged over a few days. There has been no consistently observed relationship between duty hours and education, socialization, or physician burnout or well-being.
For a link to the full article, visit: http://www.nejm.org/doi/full/10.1056/NEJMp1703690?query=TOC