Restrictions on Resident Hours Harming Education

Allison Gandey

September 13, 2011

September 13, 2011 — New rules overhauling resident work hours are having a negative effect, a new study suggests. Residents report familiarity with patients, continuity of care, and patient hand-offs have all been negatively affected by the changes.

Institute of Medicine recommendations are altering residency programs by limiting work hours and encouraging regular opportunities for sleep. The institute has also called on the Accreditation Council for Graduate Medical Education to improve monitoring of duty hour limits and guidelines for patient caseloads.

However, investigators, led by Lori Schuh, MD, from Henry Ford Hospital in Detroit, Michigan, have found that the recommendations may be having unintended consequences, apparently without solving the problems they were meant to address.

The results of the study were published online July 27 and in the August 30 issue of Neurology.

Faculty, Residents Less Satisfied

The team evaluated 3 residency programs and looked at resident sleepiness, personal study hours, and quality of life during a control and intervention month.

Resident participation in both schedules was mandatory, but resident and faculty participation in the outcome measures was voluntary. A total of 34 residents were involved.

Investigators found resident duty hours, study hours, sleep hours, and sleepiness remained constant from the first month to the second. Residents said they are not getting any more sleep, and are no less tired than before.

However, resident and faculty ratings of continuity of care, hand-off communication, and resident familiarity with the details of their patients' medical circumstances declined significantly in the second month.

Faculty ratings of the safety and quality of patient care that the residents provided also declined under the new recommendations. There was also a significant decline in faculty members' ratings of how completely the residents were performing their clinical duties, as opposed to leaving tasks for the faculty members themselves to complete.

"Although neurology educators must work toward an educational environment that improves patient safety, our data indicate that adoption of the Institute of Medicine recommendations will not reduce resident fatigue and may have negative effects on resident education in neurology," the authors note. "Further study in neurology residency programs should be required."

Several groups including Public Citizen and the American Medical Student Association petitioned the Occupational Safety and Health Administration to adopt the recommendations and offer oversight.

Do Benefits Outweigh Costs?

In an accompanying editorial, Douglas Gelb, MD, from the University of Michigan Neurology Department, said that when it comes to adopting further restrictions on resident duty hours, "Let's look before we leap."

He points out the new mandate to limit resident duty hours was not accompanied by a proportional increase in the number of residents, so other physicians and medical professionals were compelled to pick up the slack.

"Briefer shifts meant more 'hand-offs' and greater potential for miscommunication and other errors. In short, duty hour restrictions have negative consequences as well as positive ones, and it is legitimate to ask whether the benefits outweigh the costs," he writes.

Medical education policy makers appear to have a penchant for imposing sweeping mandates based on good intentions and plausible arguments but little or no empiric evidence.

The Institute of Medicine committee provided justifications for many of these recommendations based on literature regarding the effects of sleep deprivation and the time required to recover, Dr. Gelb points out, but did not attempt any pilot programs or other studies to determine how the proposed policies would affect residents or patients in practice. He suggests this new study achieves this despite its limitations.

However, he notes, "If experience is any guide, this call for caution may go unheeded. Medical education policy makers appear to have a penchant for imposing sweeping mandates based on good intentions and plausible arguments but little or no empiric evidence, and subsequent studies that raise concerns about those mandates seem to have little effect."

Dr. Schuh is a member of the Accreditation Council for Graduate Medical Education Neurology Review Committee. A coauthor has disclosed receiving research support from Myriad Genetics and Novartis. The other authors have disclosed no relevant financial relationships. Editorialist Dr. Gelb reports receiving honoraria from the American Academy of Neurology for writing multiple-choice questions for Continuum.

Neurology. 2011;77:883-887. Abstract