The issues of fatigue in the workplace have been of concern for decades. Restrictions on duty hours for several professions have been commonplace and expected by the public, including the airline industry6 and truck drivers,9 but relatively late in coming to the healthcare arena. Like airline pilots, physicians are entrusted with the public's welfare. Unlike many jobs, medical professionals usually have no strictly defined work hours and few mandated workplace conditions focused on their own health. The landscape changed dramatically with the promulgation of duty week guidelines for housestaff by the Accreditation Council for Graduate Medical Education (ACGME),2 and attention to other groups of healthcare students and professionals are likely to follow.
I will review the nature of current duty hour guidelines for housestaff, the reasons for their development, current attitudes of residents towards these accreditation requirements, and questions raised by these new rules.
On July 1, 2003, guidelines promulgated by the ACGME went into effect for all residency training programs,2 and future accreditation will depend upon adherence to these rules. Briefly these guidelines include the following: (1) residents can work no more than 80 hours (up to 88 hours with successful appeal) per week, averaged over a 4-week period; (2) shift lengths cannot exceed 24 hours, with an additional 6 hours to transition provided no new patients are accepted; (3) a minimum of 10 hours off must be provided between shifts; (4) at least one 24-hour period off from all clinical, educational, and administrative responsibilities must be provided each week, averaged over a 4-week period; (5) in-house call responsibilities cannot occur more frequently than every third night, averaged over a 4-week period.
While these guidelines are described as voluntary, accreditation is contingent upon adherence. No funds are provided to programs to assist with compliance. These latter two points are in contrast to proposed Federal legislation that would disallow averaging over time and would provide some funding for compliance.16
There are at least three major reasons to limit activities causing housestaff fatigue: (1) Patient safety; (2) Resident well-being; (3) Resident education.
Patient Safety: In a recent report from the Institute of Medicine, it was estimated approximately 98,000 patients die each year as a result of a medical error, and fatigue of healthcare professionals plays a major role in many of these incidents.10 Many previous studies have demonstrated changes in mental function, communication, and technical skills with sleep deprivation among a wide range of workers, including physicians.8,19,21 Reports are available from as early as 1991 citing perceptions amongst 41% of residents that fatigue played a major role in committing an error.24 More recent studies demonstrate a substantial improvement in the frequency of errors made by interns in an intensive care environment with restricted hours as the variable.11,13
Resident Well-being: With chronic fatigue comes personal health disorders and risks. Several reports suggest fatigue and physically demanding work conditions among housestaff contribute to a higher rate of problem pregnancies (eg, preterm births, small for gestational age, and hypertension or eclampsia ) and infringes on mental health (eg, cognitive function and mood status).12,14 The risk of a motor vehicle accident, when leaving the hospital fatigued, is increased at least 40%.4 Lack of sleep for 24 hours produces reductions in mental abilities and technical skills (including driving) similar to a blood alcohol level of 0.1%.7
Resident Education: The effect of fatigue on education and training remains uncertain. On one hand, it is clear one's ability to learn is impaired by sleep deprivation. However, there is also the perception with the reduction in the duty week, there is less opportunity to learn by exposure to operative cases and other educational clinical experiences.
The recently imposed restriction in duty hours is foremost a response to patient safety. It is, however, a strongly intended consequence that the health and welfare of housestaff will also improve. Indeed, the effectiveness of the guidelines will ultimately be judged by the degree to which medical errors are reduced, resident health is restored, and risks of personal injuring recede. The impact of these guidelines on education must also be understood so the training environment can adjust as necessary to ensure the quality of medical education and continued competence of physicians in training.
It would be difficult to discuss duty hour restrictions without acknowledgement and review of the Libby Zion case. This unfortunate 18-year old woman died within hours of admission to a hospital in New York City in 1984.23 The details of her illness, the cause of her death and the appropriateness of the specific drugs and restraints used in her care are not the focus of this discussion. The results of a Grand Jury investigation and, subsequently, an appointed Commission review are germane. The Grand Jury found no basis for criminal negligence on the part of any physicians or the hospital, but cited the overworked condition of the housestaff and a lack of attending supervision. However, a subsequent jury trial ending in 1995 for civil charges did find evidence of medical negligence. The jury's additional finding that Ms. Zion was 50% percent responsible for her own death was set aside by the trial judge.25
Partly in response to that trial, in 1987 an ad hoc advisory committee chaired by Dr. Bertrand Bell made a series of recommendations to the New York State Commissioner of Health after review of the Grand Jury's findings.18 These findings were adopted as changes in the Health Code and became mandates for all training programs in the State of New York.15 In brief, the duty week for housestaff was limited to 80 hours, shifts of no more than 24 continuous hours, and at least 1 day (24 hours) off of all responsibilities each week. Whether the cause or contribution to Ms. Zion's death, the notion of an overworked, fatigued housestaff was established in this case.
The American Academy or Orthopaedic Surgeons (AAOS) has conducted surveys of orthopaedic residents before and after the implementation of the 80-hour duty week.1 Housestaff were sent the survey by a combination of mail, facsimile, and email reflecting available preferred contact information. Other groups have also developed similar information, focusing on orthopaedics17,26 and other specialties.3,5,22 The recent timing of these changes and the modest response rates render these surveys preliminary in nature. A summary of a portion of the data collected by the AAOS will be presented here, and this information is being prepared for publication in more detail.
Preimplementation Survey of Residents
In July 2003, as the new rules were being introduced (other than New York, where similar rules had been in effect since 1987), 1742 orthopaedic residents (all for whom contact information was available) were surveyed by the AAOS, with a response rate of 22% (385). Seventy percent of respondents were at the physician graduate year (PGY)-3 level or above and were in training programs averaging 23 individuals overall.
Forty-nine percent of responding house staff reported working 80 to 100 hours per week, and 40% worked 60 to 80 hours on a weekly basis before the new rules. Maximum time per shift was between 30 and 36 hours for 54%, and more than 36 hours for 22% of respondents. About half the residents indicated they had 10 to 12 hours off between shifts, with most of the rest reporting fewer hours. This set of circumstances formed the baseline duty schedule before the implementation of the new guidelines.
At the same time, 72% of residents did not feel they should be required to go home immediately after in-house call, especially if it meant missing an operative case. The same number of residents felt they were not adversely affected in their work performance by being on call for 24 hours straight.
Despite 48% feeling the new rules would have a negative influence on their education, 68% felt duty hours should be regulated. Their major concerns were a reduction in surgical case experience and loss of continuity in patient care.
Postimplementation Resident Survey
One year after implementation of the ACGME guidelines 4419 orthopaedic surgery residents were surveyed by the AAOS with responses from 554 (13%). Sixty percent were in the PGY-4 or PGY-5 of training in programs averaging 24 residents.
Only 13% were on duty more than 80 hours on average per week, compared with approximately half on duty for this length of time before the guidelines. Importantly, 33% reported they worked, at times, more than 80 hours per week, but intentionally under-reported their hours. The most frequent reasons for failing to report hours in violation of the rules were concern for the program being cited or penalized (29%), fear of personally being cited or penalized (14%), uncertainty of the importance of such reporting (14%), and peer pressure (13%).
Virtually all programs used some form of self-reporting for duty hours, some written and others electronically based. Trauma was the rotation with the most problems complying with the duty hour restrictions. Changes in programs used to address compliance most frequently included use of a night float rotation (84%), an increase in call from home (81%), and employing physician extenders (79%).
More than half the responding residents reported improvement in their satisfaction (58%) and were getting more sleep (57%), while 37% indicated their learning experience decreased and a similar number indicated it was difficult to complete their work assignments in the time provided. Sixteen percent of respondents expressed concern for continuity of care.
Unanswered Questions About the Impact of the 80-hour Duty Week
At this point, questions abound despite the fact duty hour restrictions have been the rule in New York for more than 15 years and have been commonplace by requirement or tradition in many other countries for years.20
Compliance in the United States with these new guidelines appears substantial but not yet universal. The question of how this approach is impacting the frequency of medical errors and the general health of housestaff remains uncertain and of fundamental importance. The impact of restricted duty hours on education and competence is also unknown at this point. These are, however, issues that can be clarified over time.
Collateral to these questions are the uncertainty of whether 80 hours per week, 24 to 30 hours per shift, or other aspects of the duty week guidelines are optimal for their intended purposes. Particularly, how do we define meaningful fatigue and how can we recognize it? Certainly, all healthcare workers do not experience fatigue at the same point in the duty week.
The new guidelines, by reducing duty hours, may have many other unintended or poorly characterized consequences requiring our collective attention. Two particularly important questions include the financial costs of these changes and how the guidelines impact other aspects of the healthcare system.
If, for example, residents are working fewer hours, then either someone else is providing some of their previously rendered services or aspects of their prior activities are not getting done or there exists some combination of these circumstances. There is an economic cost, whether the workload is shifted to attending physicians or to allied healthcare providers. There is also a potential cost to society if some services to the uninsured, who depend in many areas on housestaff for their primary care, are no longer available. Some of these costs may be associated with health deterioration in a population no longer able to obtain preventive care or timely attention to illness. The extent of these costs, human and monetary, and those who pays the price are questions that must be raised and weighed in examining the benefits ands risks associated with the current changes in duty hours for residents. Additional consideration must be given to the projected size of the physician workforce as restrictions on duty hours become more pervasive.
Another associated question pertains to which other segments of the healthcare delivery team should or will become regulated in terms of duty hours in the future. If the goal remains public safety, then isolating the issue of fatigue to housestaff will fail to realize its full potential. Again, this will come with a price, including a change in the nature of the healthcare work environment and, potentially, the nature of people attracted to the profession. Whether these changes are of benefit to the patient, the healthcare professional or both remains to be demonstrated by the collection of scientifically rigorous information and its analysis. Indeed, how will restrictions in duty hours at the housestaff level translate into changes in professionalism during training and thereafter? We will be challenged as physicians to insure transitions in care, such as “hand offs,” designed to address the issue of our fatigue are accomplished in a manner that doesn't detract from the overall quality of patient care. The balance, if not the conflict, between eliminating meaningful fatigue of physicians and the benefits sought in terms of patient safety must be closely monitored as the new paradigm for duty hours continues to evolve.
New guidelines are in place that define and restrict the duty hours of all medical and surgical housestaff in the United States. The primary reasons for these limitations in time spent in training (clinical care and education) are the improvement of patient care and the well-being of the housestaff. Both of these issues focus on the dangers of fatigue, and each concern warrants action leading to meaningful gains. Recognizing and preventing fatigue in the healthcare arena remains a work in progress and an important goal. The educational, financial, and social costs of these changes are unclear and, therefore, the optimum form of regulation is currently unresolved.
Several broad questions seem particularly important to address as the impact of the new 80-hour duty rules are being considered. At what point is an individual healthcare professional fatigued to the degree this impacts the quality of services rendered, endangers personal health, or interferes with ones ability to learn . . . and how can that point be recognized by the individual and those responsible for housestaff training? Similar issues exist in other vocational settings, including the airline and transportation industries, and talented and creative behavioral psychologists, neuro-scientists, and physicians are focused on these important factors.
Society's primary concern is the extent to which fatigue contributes to significant medical errors and whether controlling fatigue through duty-hour restrictions will actually improve this experience. This and related questions will require the ongoing vigilance and analyses of federally and state mandated reporting of medical errors on one hand, and the targeted, rigorous investigator-initiated research programs now increasingly pursued at academic medical centers.
While perhaps less visible to society, the health hazards already identified among fatigued housestaff, including risks of motor vehicle accidents, must continue to be recognized and mitigated. In part, this will require ongoing education of residents concerning the nature and causes of these personal dangers and the oversight of hospitals and their training programs to recognize and react to fatigue and mental and physical health disorders demonstrated by their trainees.
A particularly interesting circumstance, beyond intuitive resolution, is the question of whether resident education will improve or prove insufficient under the duty-hour restrictions. Will better-rested housestaff learn more effectively than fatigued residents, whether in a didactic or Socratic circumstance? With advances in standardized learning experiences (eg, patients and realistic simulators), we are in a position to answer these questions with confidence and recreate teaching models of greater efficiency and predictability. The rush to judge the newly restricted educational time with a call for longer periods of training seems premature.
Questions and opportunities do not stop with these few issues. How do the changes in the restricted duty week affect access to health care for the woefully underinsured, and how do we document and compensate for any loss of services …and who will pay for the solutions? Will some aspect of work effort formally accomplished by residents be reassigned to attending physicians? If the health care improvements realized from control of fatigue are documented at the house staff level, should similar approaches (limitations) apply to graduate attending physicians? If so, are more mid-level health care professions needed …and who will pay for them? Will professionalism become a casualty of changes implicit in the duty week restrictions?
The answers to virtually all these questions will require funding for research and funding for solutions. Therein lies the greatest challenge of all!
The survey data for housestaff was abstracted from a larger project of the Committee on Academic Advocacy, Council on Academic Affairs of the American Academy of Orthopaedic Surgeons. The efforts of these volunteer physicians and the very capable professional staff of the Academy are gratefully acknowledged, and the complete reporting of this information is the subject of another publication.
3. Barden CD, Specht MC, McCarter MD, Daly JM, Fahey TJ3rd
. Effects of limited work hours on surgical training. J Am Coll Surg
4. Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, Czeisler CA. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med
5. Chung R, Ahmed N, Chen P. Meeting the 80-hour work week requirement: what did we cut? Curr Surg
6. Crewmember Flight Time and Duty Period Limitations and Rest Requirements
. Sections 135.261 to 135.269. Washington, DC; Federal Aviation Administration; January 7, 2006.
7. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature
8. Hawkins MR, Vichick DA, Silsby HD, Kruzich DJ, Butler R. Sleep and nutritional deprivation and performance of house officers. J Med Edu
9. Hours of Service of Drivers
. Washington, DC: Dept of Transportation; October 1, 2003.
10. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System
. Washington, DC: National Academy Press; 1999.
11. Landrigan CP, Rothschild JM, Dronin JW, Kaushal R, Burdick E, Katz JT, Lilly DM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med
12. Lingenfelser T, Kaschel R, Weber A, Zaiser-Kaschel H, Jakober B, Kuper J. Young hospital doctors after night duty: their task-specific cognitive status and emotional condition. Med Edu
. 1994;28: 566-572.
13. Lockley SW, Dronin JW, Evans EE, Cade BE, Lee DJ, Landrigan CP, Rothschild JM, Katz JT, Lilly CM, Stone PH, Aeschbach D, Czeisler CA. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med
14. Mozurkewich EL, Luke B, Avni M, Wolf FM. Working conditions and adverse pregnancy outcome: a meta-analysis. Obstet Gynecol
15. New York State Department of Public Health Codes R. & Regs. Section 405.4(b)(6), 1989.
16. Patient and Physician Safety and Protection Act of 2005 (HR1228 and S1297), Introduced to the 109th
United States Congress. Available at: http://thomas.loc.gov/cgi-bin/thomas
. Accessed January 7, 2006.
17. Pellegrini VD Jr, Peabody T, Dinges DF, Moody J, Fabri PJ. Resident work-hour guidelines: A sentence or an opportunity for orthopaedic education? J Bone Joint Surg Am
18. Report of the New York State Ad Hoc Advisory Committee on Emergency Services. Supervision and Residents' Working Conditions
. New York, NY: New York State Department of Health; October 7, 1987.
19. Robbins J, Gottlieb F. Sleep deprivation and cognitive testing in internal medicine house staff. West J Med
20. Steinbrook R. The debate over residents' work hours. N Engl J Med
21. Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA
22. Whang EE, Mello MM, Ashley SW, Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg
24. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA
26. Zuckerman JD, Kubiak EN, Immerman I, DiCesare P. The early effects of the Code 405 Work Rules on attitudes of orthopaedic residents and attending surgeons. J Bone Joint Surg Am
. 2005;87: 903-908.