ARTICLE IN BRIEF
Two new studies reported that for internal medicine residents, duty-hour restrictions did not improve quality of life or patient care. Neurology residency directors and residents weigh in — generally agreeing with these findings.
Have the 2011 duty-hour regulations from the Accreditation Council for Graduate Medical Education improved patient care as well as the quality of life and education for medical residents? Not necessarily, according to a small, randomized trial at Johns Hopkins University Hospital in Baltimore, and a second longitudinal survey of first-year residents at 51 programs comparing pre- and post-2011 work duty rules — both published online Mar. 25 in the Journal of the American Medical Association (JAMA) Internal Medicine.
Both studies reported evidence of a decline in quality of care. The randomized trial at Johns Hopkins by Sanjay V. Desai, MD, and colleagues found an increase in “handoffs” among other measures of diminished quality, while the paper by Srijan Sen, MD, PhD, and colleagues reported that more interns expressed concerns about making a serious medical error after implementation of the 2011 rules. [For more detailed data from both reports, see “Reports on Residency Duty-Hour Limits.”]
The 2011 rules by the Accreditation Council for Graduate Medical Education (ACGME) require resident work hours to be limited to 80 hours a week averaged over four weeks and that first-year residents work no more than 16 hours a day, with 10 hours free of duty required between scheduled periods.
A SIMILAR THEME FOR NEUROLOGY
Brandy R. Matthews, MD, director of the neurology residency program at Indiana University School of Medicine, told Neurology Today the two studies are consistent with a 2011 paper in Neurology involving neurology residents reported by Lori A. Schuh, MD, and colleagues. In that paper, neurology residents also reported declines in the quality of life and education with issues related to continuity of care, patient hand-offs, and knowledge of their patients. Faculty satisfaction also declined during the intervention.
“Even with a longer period for data collection and a cross-over design, similar themes emerge that demand attention,” Dr. Matthews said of the new JAMA Internal Medicine studies. “In general, duty-hour restrictions implemented in 2011 have not improved patient safety, resident sleep time, or resident satisfaction. The quantifiable loss of patient-care hours and access to active teaching resulting from the 2011 duty-hours implementation has, to my knowledge, not yet been captured with a medical knowledge metric in neurology trainees. Likewise, the issue of faculty satisfaction and investment in the current model is generally neglected, but critically important, in our apprenticeship model of graduate medical education.”
Other reviewers emphasized that at least as important as adherence to work-hour limits is how the work shifts are arranged. “Not only does the duration of one's work shift affect morale, but also the specific hours of one's shift,” Justin Jordan, MD, a chief resident in adult neurology at University of Texas Southwestern Medical Center in Dallas, told Neurology Today. “It is important for me to have some daylight hours in the hospital, to overlap a few hours with the rest of my team, and to interact with attending physicians on a daily basis,” said Dr. Jordan, chair of the AAN Consortium of Neurology Residents and Fellows. “At our own institution, we've informally looked at two different night-float shifts — one starting at 9PM and one starting at 4PM — and found that overall residents much prefer the earlier shift, at least in part because of more interaction with the team.”
“Another important factor in morale is number of consecutive months on service,” he said. “Certainly after two or three months of call, the overarching feeling may be one of fatigue and listlessness. Also, switching from sleeping nights one month to days the next can be very difficult. Even though you may have adequate number of hours to rest, the quality of the rest may be poor due to difficulties with circadian rhythm.”
Andrew Spector, MD, a fellow in sleep medicine at Boston Medical Center, concurred. “If you are going to use a night-float system, you have to do it long enough to flip the circadian rhythm and actually make your interns nocturnal for a while,” he said. “Ideally, night float would be followed by a two week vacation block so the intern could flip the circadian rhythm back to stay awake during the day.”
Regarding the problem of hand-offs cited in the study by Dr. Desai and colleagues, Dr. Jordan suggested that this is a universal problem, not confined to academic hospitals. “I'm not aware of any systematic study of medical error related to handoffs, but I would imagine the number might be surprising,” he said. “In our own institution, we have initiated a quality improvement program using a standardized format for handoffs on a secure, electronic database. By mandating the time, location, and information in these handoffs, the general consensus is that less information is being missed and physicians are more comfortable when caring for their patients.”
Dr. Spector was more roundly critical of the two studies emphasizing that what they measured were the effect of institutional implementation of the 2011 rules — not the rules themselves. “There are a near-infinite number of ways a program could comply with the 2011 rules,” he told Neurology Today. “In the Desai study, they weren't testing the 2011 rules; they were testing their specific application of the 2011 rules. Their night float was only six nights long per intern. From a circadian perspective, this is very difficult. It takes 12 days to shift 12 hours, so all six of those nights would have been completely contrary to the interns' circadian rhythms.”
Dr. Spector noted that Dr. Sen and colleagues used data from multiple programs with multiple schedules that all implement the 2011 rules differently. “By compiling this data into averages, you lose the ability to detect the one program that might have come up with an effective schedule,” he said.
It would seem that the 2011 work-duty rules are at best an imperfect attempt to balance patient care, quality of life, and educational imperatives. And the direction of emerging data on the effects of the new rules would seem to point ultimately toward the need to address workload and manpower.
“If you don't reduce the workload alongside the work hours, it is inevitable that satisfaction will decrease,” Dr. Spector said. “The biggest problem with the eight-hour rule is that I've never heard of a program with a mechanism to accommodate this. I remember being told as a resident not to come in the next morning if I stayed at work too late the night before. But if I didn't, who would do the work?”
REPORTS ON RESIDENCY DUTY-HOUR LIMITS
In the trial at Johns Hopkins, Sanjay V. Desai, MD, and colleagues randomly assigned four medical house staff teams with 43 interns to either a control group that abided by a 2003-compliant model of every fourth night overnight call with 30-hour duty limits or to one of two “intervention” groups that abided by 2011-models of every fifth night overnight call (Q5) or a night-float schedule, both with 16-hour duty limits. They measured sleep and used admission volumes, educational opportunities, the number of handoffs, and satisfaction surveys to assess trainee education, continuity of patient care, and perceived quality of care.
They found that, compared with controls, interns on night float slept longer during the on-call period and interns on Q5 slept longer during the post-call period. But both models increased handoffs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with night float that it was terminated early, the author stated.
In the second report, as part of the Intern Health Study, Srijan Sen, MD, PhD, and colleagues conducted a longitudinal cohort study comparing interns serving before 2009 and 2010 and interns serving after 2011, when new duty-hour requirements were implemented. A total of 2,323 interns in 51 residency programs at 14 university and community-based GME institutions participated.
They measured self-reported duty hours, hours of sleep, depressive symptoms, well-being, and medical errors at three, six, nine, and 12 months of the internship year. This report found that, despite a decrease in duty hours, there were no significant changes in hours slept, depressive symptoms, or well-being score reported by interns. And with the new duty-hour rules, the percentage of interns who reported concern about making a serious medical error increased from 19.9 percent to 23.3 percent.