In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established national duty hour restrictions for all residency and fellowship programs they accredit. These included limiting work hours for residents to 80 hours per week averaged over a 4-week period, with a maximum work shift length of 24 hours and at least 10 hours off between shifts. These changes were intended to promote safe care and high-quality learning at teaching institutions.1 The restrictions came about as a result of many years of debate on the effects of physician sleep deprivation on patient safety2 and have been a source of much controversy. However, some reports suggested that the 2003 rules did not reduce resident fatigue.3,4 More importantly, studies were unable to show an improvement in patient care.5,6 Effective July 1, 2011, the ACGME implemented further restrictions, which included limiting intern shift length to 16 hours and limiting night float to no more than six consecutive nights1 (Table 1).
National Orthopaedics Survey
With the 2011 rules having now been in effect, we believed it was an opportune time to comprehensively assess existing literature on work hour rules as well as the various perspectives of the orthopaedic community. We thus conducted a national survey of US orthopaedic residents and residency program directors regarding the 2003 and 2011 ACGME duty hour regulations. Our aim was to assess opinions of the 2003 and 2011 rule changes and perceptions of their impact on three areas: resident education, quality of life, and patient care.
A 41-item Likert-scale survey created through SurveyMonkey was approved by the American Orthopaedic Association and distributed via email link to membership as well as to all residency program directors and program coordinators for whom email addresses could be obtained and forwarded to residents. Responses were collected from April to July 2012. In all, 26.2% of residents (914) and 48.7% of residency directors (75) completed the survey (Table 2).
Statistical analysis was performed with the SPSS Statistics software. We used the standard error of proportions to calculate two-sided confidence levels (CIs) with an α level of 0.05 (Table 3). Responses were collapsed into three categories to better portray the overall level of disagreement, neutrality, or agreement. We then performed difference of proportions tests to investigate differences of opinion between residency directors versus residents (Table 4). Finally, the mean responses of residency directors, senior residents, junior residents, and interns were calculated to assess opinions across the various levels of training (Figures 1 and 2).
Much of the impetus for rule changes stems from the debate regarding the effects of physician sleep deprivation on performance. One study found that post-call performance on simulated driving tasks during a heavy call rotation is comparable to impairment associated with a 0.04% to 0.05% blood alcohol concentration during a light call rotation and raised concerns that residents may not be able to judge their level of impairment.2 At one institution, fatigue was prevalent and pervasive among studied orthopaedic residents.7 Residents were impaired (correlating with a blood alcohol level of 0.08%) during 27% of their time awake. However, another study found that sleep-deprived residents were able to learn new surgical tasks proficiently despite an increase in sleepiness.8
Impact of Work-hour Rules on Fatigue
Although there may be negative consequences to fatigue, reports suggest the ACGME rules have not successfully reduced resident fatigue. One study reported in Pediatrics in 2008 found that total hours of work and sleep did not change after implementation of the 2003 duty hour standards.3 A look at factors contributing to fatigue concluded that simply decreasing the number of duty hours may not appreciably reduce intern fatigue.4 With respect to the new 2011 rules, our recent orthopaedic survey results show that while 52.6% of all respondents thought that the new 2011 rules improve resident quality of life, only 34.8% of respondents felt that residents are more rested (Table 3). One possible explanation could be that the 16-hour limit has decreased time off between shifts, as was found to occur in a pre-implementation pilot study.9 Alternatively, incomplete compliance may play a role. Although our subjective survey study was limited in its ability to ascertain compliance, more than a third of responding orthopaedic interns (35.4% [95% CI, 28.3% to 42.6%]) knowingly underreported work hours within 1 month before survey completion to comply with regulations (Table 5).
Unfortunately, it has not been shown that work hour rules have had a positive impact on the quality and safety of patient care. A pre-implementation study showed that interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts.10 Observational studies since implementation of regulations show no significant relative changes in mortality6 and no difference in mortality among surgical patients.5
Existing evidence suggests that reduced resident shift length does not improve surgical outcomes.11 Our respondents strongly felt the new rule changes in 2011 have not improved the surgical experience (71.9% [95% CI, 69.1% to 74.7%]). Although existing observational studies are limited, researchers have begun planning the prospective randomized iCOMPARE trial, which will investigate new models of care to mitigate intern fatigue.12
Views of the Orthopaedic Community
The views of the orthopaedic community regarding duty hour standards have been previously studied. A national orthopaedics survey conducted in early 2011, before implementation of the new 2011 rules, found that residents and program directors agreed that the further reductions in duty hours may be detrimental to resident education and patient care.13 This sentiment was shared by residents in all medical specialties in 201014 and persisted in 2012 after the new limits had been put into effect.15
Recent Survey Results
New 2011 Rules
Overall, only 19.7% of all respondents (both residency directors and residents) were satisfied with the new 2011 duty hour regulations (Table 3). Just 8.4% believed limiting interns to 16 hours per day is an improvement, whereas most (51.1%) considered limiting night duty to be an improvement. Only 10.8% thought that the new 2011 rules improve resident education, and 17.0% thought the new rules improve patient care. Most respondents (65.5%) felt resident supervision has been adequate. Although 80.1% believed their program consistently adheres to the new rule limiting interns to 16 hours per day, 29.6% of residents said they knowingly underreported actual work hours during the previous month to comply with the new 2011 rules (Table 5). Opinions of the new 2011 rules were further subdivided into the groups interns, junior residents, senior residents, and residency directors with mean responses displayed graphically (Figure 1), which reveals a trend of younger trainees viewing the new rules more favorably.
Regarding the old rules, most (58.9%) believed the 80-hour work week standard, averaged over 4 weeks, is appropriate. A total of 39.2% felt that the 80-hour week lessens the educational experience, whereas 35.7% felt it did not. More respondents (38.8%) felt that the 80-hour week improves patient safety, with 27.3% disagreeing. A total of 77.5% say their program consistently adheres to the 80-hour rule.
Continuity of Care
One potential explanation to reconcile the lack of data showing improved patient outcomes after work-hour restrictions is that continuity of care may have suffered. Most respondents thought that the resultant increased patient handoffs are detrimental to patient safety (75.5% [95% CI, 72.9% to 78.2%]) and that continuity of care has been negatively impacted (70.1% [95% CI, 67.2% to 72.9%]). It will be important to see if these concerns are borne out in future outcome studies.
The large majority (81.3% [95% CI, 72.3% to 90.4%]) of residency director respondents to our survey do not feel the new 2011 rules improve resident education, and most residents (65.1% [95% CI, 62.0% to 68.2%]) agree. Perceptions toward the limitation of night float to 6 consecutive nights are more favorable. Most respondents (52.8% ([95% CI, 49.7% to 55.9%]) thought that this improves resident education, and more thought it improves patient safety (43.7% ([95% CI, 40.6% to 46.8%]) than did not (17.0% ([95% CI, 14.6% to 19.3%]). This may be partially explained by the recent finding that night-float residents were more impaired, with an increased risk of medical error.7 Night float might also be less educationally beneficial than time spent in the hospital during the day. General surgery ABSITE (American Board of Surgery In-Training Examination) scores improved significantly after the reform, whereas surgical experience and overall surgical case volume were unaffected.16-18
In addition to the aforementioned changes, the new 2011 ACGME rules also emphasized improved resident supervision and faculty oversight. Now first-year residents must have immediate access to in-house supervision.1 Of those surveyed 65.5% (95% CI, 62.6% to 68.5%) felt the level of resident supervision in their program has been adequate since the rule changes, with just 7.1% (95% CI, 5.5% to 8.7%) in disagreement. A recent survey of all specialties showed most thought supervision has not changed since the new 2011 rules were implemented.15
Differences of Opinion
An additional goal of our survey was to assess views on the 80-hour average work week and to determine if differences of opinion exist between individuals at different levels of training. Whereas there was general agreement in opposition to the new 2011 rules, attitudes toward the 80-hour work week differed significantly. A total of 60.9% (95% CI, 57.8% to 64.1%) of residents but just 33.3% (95% CI, 22.4% to 44.3%) of program directors think the 80-hour work week is appropriate (P < 0.001). This dichotomy of opinion with residents viewing the 80-hour week more favorably is consistent with the findings of past orthopaedic surveys.13,19 Interestingly, only 4% (95% CI, zero to 8.5%) of program directors and 27% (95% CI, 24.1% to 29.9%) of residents believe an 80-hour week will prepare residents for life as an attending in practice. When asked what is a reasonable amount of hours each week for residents to work, 88.3% of responses were >71 hours per week and 44.4% were >81 hours per week.
Although the work-hour discussions often focus on the more immediate impact on patient safety and resident training, much of the concern lies in the potential long-term consequences of current policies. In their comments, many program directors worry that the regulations promote a shift-worker mentality rather than engendering a sense of altruistic responsibility and patient ownership. A total of 70.3% (95% CI, 59.6% to 80.9%) of program directors felt that the resident work ethic has deteriorated. Although generational differences may exist, resistance to the rules was not limited to directors. In their comments, many residents lamented facing the decision to leave a sick patient or forego an educational case to avoid a work-rules violation. This concern had been previously expressed by the ACGME1 and by US orthopaedic surgeons.13
Comments regarding the new 2011 rule limiting interns to 16 hours are generally consistent with the results of the survey. Although 29.7% of residency directors reported that they are currently working >80 hours per week on average as an attending, they noted that they cannot routinely “hand off” patients or pass on responsibility. Comments emphasized the importance of learning to work safely through fatigue when necessary. They noted the dangers of delayed preparedness for roles as a senior resident and the potential shock of the increased personal responsibility as an attending. This may help explain why the attitudes of senior residents more closely resemble that of attendings and why most think preparedness for life as an attending is suffering. Comments also echoed sentiments that a one-size-fits-all approach for all specialties may not be appropriate.17
Ultimately, decreased competency of orthopaedic surgeons because of reduced work-hours need not necessarily become a reality. Many commented that 80 hours per week should in theory provide ample time to educate capable residents, but the current hospital system often relies on residents to perform valuable tasks that are of minimal educational value. Hiring additional help to cover these lower-yield learning activities can increase the efficiency of work-hours, but at substantial cost.20,21
There are important inherent limitations to such a survey study that deserve acknowledgment. There is the potential for sampling bias with response rates of 26.2% of residents and 48.7% of directors, which can skew results and make extrapolations regarding the entire orthopaedic population inaccurate. Another limitation is the inability to definitively investigate outcomes. Additional studies are needed to determine whether the expressed opinions regarding the impact of work-hour regulations reflect actual outcomes.
Resident work-hour restrictions implemented by the ACGME continue to be a prevalent and controversial topic of debate in the medical community. Although evidence suggests that fatigue negatively impacts performance, it is unclear whether existing reforms have decreased resident fatigue. Studies have suggested that the resident surgical experience has not diminished and that the rules positively impact resident education, yet fail to definitely show that the 2003 and 2011 rules have improved patient outcomes.
The general opinion of the surveyed US orthopaedic surgery community is that the new duty hour rules implemented in July 2011 do not succeed in their stated goals of improving education or patient care. Most are not satisfied with the new 2011 regulations. Most residents think that the 80-hour resident work week standard, averaged over 4 weeks, is appropriate, but program directors generally do not. These results will assist leaders representing the orthopaedic surgery community in working with the ACGME and will inform decisions related to curriculum planning and changing residency education in the future.
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 10 is a level I study. References 2, 3, 7, and 8 are level II studies. References 4-6, 9, 11, and 13-20 are level III studies.
References printed in bold type are those published within the past 5 years.
1. Nasca TJ, Day SH, Amis ES Jr; ACGME Duty Hour Task Force: The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010;363(2):e3.
2. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA: Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA 2005;294(9):1025–1033.
3. Landrigan CP, Fahrenkopf AM, Lewin D, et al.: Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics 2008;122(2):250–258.
4. Friesen LD, Vidyarthi AR, Baron RB, Katz PP: Factors associated with intern fatigue. J Gen Intern Med 2008;23(12):1981–1986.
5. Volpp KG, Rosen AK, Rosenbaum PR, et al.: Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA 2007;298(9):984–992.
6. Volpp KG, Rosen AK, Rosenbaum PR, et al.: Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA 2007;298(9):975–983.
7. McCormick F, Kadzielski J, Landrigan CP, Evans B, Herndon JH, Rubash HE: Surgeon fatigue: A prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents. Arch Surg 2012;147(5):430–435.
8. Tomasko JM, Pauli EM, Kunselman AR, Haluck RS: Sleep deprivation increases cognitive workload during simulated surgical tasks. Am J Surg 2012;203(1):37–43.
9. McCoy CP, Halvorsen AJ, Loftus CG, McDonald FS, Oxentenko AS: Effect of 16-hour duty periods on patient care and resident education. Mayo Clin Proc 2011;86(3):192–196.
10. Landrigan CP, Rothschild JM, Cronin JW, et al.: Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004;351(18):1838–1848.
11. Yaghoubian A, Kaji AH, Ishaque B, et al.: Acute care surgery performed by sleep deprived residents: are outcomes affected? J Surg Res 2010;163(2):192–196.
13. Mir HR, Cannada LK, Murray JN, Black KP, Wolf JM: Orthopaedic resident and program director opinions of resident duty hours: a national survey. J Bone Joint Surg Am 2011;93(23):e1421–e1429.
14. Drolet BC, Spalluto LB, Fischer SA: Residents’ perspectives on ACGME regulation of supervision and duty hours: A national survey. N Engl J Med 2010;363(23):e34.
15. Drolet BC, Christopher DA, Fischer SA: Residents’ response to duty-hour regulations: A follow-up national survey. N Engl J Med 2012;366(24):e35.
16. Durkin ET, McDonald R, Munoz A, Mahvi D: The impact of work hour restrictions on surgical resident education. J Surg Educ 2008;65(1):54–60.
17. Baskies MA, Ruchelsman DE, Capeci CM, Zuckerman JD, Egol KA: Operative experience in an orthopaedic surgery residency program: The effect of work-hour restrictions. J Bone Joint Surg Am 2008;90(4):924–927.
18. Pappas AJ, Teague DC: The impact of the accreditation council for graduate medical education work-hour regulations on the surgical experience of orthopaedic surgery residents. J Bone Joint Surg Am 2007;89(4):904–909.
19. Immerman I, Kubiak EN, Zuckerman JD: Resident work-hour rules: a survey of residents’ and program directors’ opinions and attitudes. Am J Orthop (Belle Mead NJ) 2007;36(12):E172–E179.
20. Kamath AF, Baldwin K, Meade LK, Powell AC, Mehta S: The increased financial burden of further proposed orthopaedic resident work-hour reductions. J Bone Joint Surg Am 2011;93(7):e31.
21. Nuckols TK, Escarce JJ: Cost implications of ACGME’s 2011 changes to resident duty hours and the training environment. J Gen Intern Med 2012;27(2):241–249.