Doctor of Medicine: the career respected throughout the world and contended for by thousands of students in the U.S. every year, just got easier to endure. After a tough four years of undergraduate studies and an even more grueling medical school education, students are finally exposed to the real medical world under the guidance of other physicians during their residency. In 2011, the residency hour requirements shifted from intensive 30-hour shift limits to more agreeable 16-hour shifts.
Unfortunately, the reduced shift hours seem to be affecting more than just the resident’s sleep schedule. In fact, according to a new Hopkins study published on March 25, the resident’s increased comfort may come at the expense of patient health. Is the trade-off worth it when the most important aspect of a doctor’s job — the patient’s well-being — is put at risk?
A couple of years ago, a 120-hour work schedule was considered acceptable in the typical resident’s seven day week. Residents would work despite exhaustion, forced to make life-changing decisions while sleep-deprived. The Accreditation Council for Graduate Medical Education (ACGME) realized this might be endangering patients’ quality of life and decided to take action to amend standards set in 2003.
The implemented ACGME measures allow for night calls only once every three days, and a maximum of 80 work hours and one day of rest a week amongst others. Controversy arose soon after the release of these requirements as hospitals fought to accommodate residents and patients alike.
Sanjay Virendra Desai, the director of the residency program for internal medicine at Hopkins Hospital, investigated the effects of the ACGME rules on patient well-being.
“I think the need to study this was that the policies affect the core of US healthcare — the safety of patients and training of our physicians,” Desai wrote in an email to The News-Letter. “There was little data for these new restrictions and, given the importance, we felt the need to fill that gap. The goal was to build an evidence base to inform policy.”
Among other variables, Desai and her team explored handoff times, sleep/error correlation and resident education.
With the new regulations, hospitals changed resident shifts to last around 16 hours, a great decrease from the approximate 30 hours previously allotted. The average number of residents each patient would see went from three to five, an increase of about 33 to 67 percent. This raised the likelihood of both hand-off miscommunication and greater patient discomfort.
“We demonstrated that while these changes led to some (albeit small) changes in sleep around the time of call, there were negative effects in the domains of education, perceived quality of care and substantial increases in transitions of care from one provider to another,” Desai wrote. “Patient safety is always the priority, and it is intrinsically tied to well-being of trainees.”
The amount of sleep the residents gained from the changes was found to be minimal. Residents working 16-hour shifts procured an average of three additional hours of sleep per 48-hour period.
But how much did this enhance the resident’s performance? Are these three hours really as consequential as previously thought?
The researchers sought opinions on this issue from nurses who interact closely with both residents and patients. The nurses recognized that interns with longer hours showed more continuity in their work, learned more and overall afforded better patient satisfaction.
With decreased work hours, the amount of time allocated to resident education is often reduced as well. Each intern admits fewer patients into the hospital, has time to attend less medical conferences and, most importantly, spends less time on rounds.
Although patient care is of utmost importance, the researchers acknowledged the intentions of the ACGME restrictions and the importance of a balance between trainee work hours and patient well-being.
“Patient safety is a highly complex science,” Desai wrote. “Any manipulation of one variable, in this case duty hours, will necessarily affect other relevant variables. Ultimately, we are optimistic the ACGME will consider these data as we move forward. In the end, the goals of the ACGME and of training programs are exactly the same — to enhance patient safety and trainee well-being.”
