Resident Duty Hour Regulations May Have Unintended Harms

Laurie Barclay, MD

March 25, 2013

House staff duty hour restrictions may reduce patient care continuity, intern and nurse perceptions of care quality, and educational opportunities, according to 2 studies reported in online March 25 in JAMA Internal Medicine.

"On July 1, 2011, the Accreditation Council for Graduate Medical Education [ACGME] implemented further restrictions of its 2003 regulations on duty hours and supervision," write Sanjay V. Desai, MD, and colleagues from John Hopkins University in Baltimore, Maryland. "It remains unclear if the 2003 regulations improved trainee well-being or patient safety."

Using a 3-month crossover design, the investigators randomly assigned 43 interns either to a 2003-compliant schedule of every fourth night overnight call (control) with 30-hour duty limits or to 1 of 2 2011-compliant schedules with 16-hour duty limits. These were every fifth night overnight call (Q5) or a night float schedule (NF).

During 560 control, 420 Q5, and 140 NF days that interns worked, there were 834 hospital admissions. Actigraphy showed that compared with controls, interns on NF slept longer during the on-call period (mean, 5.1 vs 8.3 hours; P = .003), and interns on Q5 slept longer during the postcall period (mean, 7.5 vs 10.2 hours; P = .05).

Compared with control schedules, the Q5 and NF schedules showed increased handoffs, reduced availability for teaching conferences, and reduced intern presence during daytime shifts. With Q5 and NF schedules, residents and nurses perceived reduced quality of care, resulting in early termination of NF.

Study limitations included possible lack of generalizability, possibly an insufficient number of patient encounters to identify small differences in operation outcomes, and the inability to account for intern unfamiliarity with or prejudice against the new schedules.

Prospective Study

A longitudinal, multi-institutional cohort study embedded in the Intern Health Study compared interns serving before implementation of the new duty hour requirements (2009-2010) with interns serving thereafter (2011).

"[W]e found that during the 2011-2012 academic year, interns reported working fewer hours but more frequently reported concerns about committing medical errors than interns serving before the ACGME duty hour reforms were implemented," write Srijan Sen, MD, PhD, from the University of Michigan, Ann Arbor, and colleagues. "'Furthermore, we found that the reforms were not associated with any reported changes in interns' sleep duration or their symptoms of depression."

At 51 residency programs of 14 university and community-based GME institutions, 2323 medical interns (58% of those invited) self-reported duty hours, sleep hours, depressive symptoms, well-being, and medical errors at 3, 6, 9, and 12 months of the internship year.

Average reported duty hours decreased from 67.0 hours/week in 2009-2010 to 64.3 hours/week in 2011 (P < .001). Despite this reduction, hours slept, depressive symptoms, and well-being did not change significantly, and the percentage of interns concerned about making a serious medical error increased from 19.9% to 23.3% (P = .007).

"Different strategies for improving resident education and patient care may be necessary to achieve the desired impact of ACGME reforms," the study authors write.

Reliance on self-report is the most important limitation of this study.

Alternative Strategies

An Editor's Note by Patrick G. O'Malley, MD, MPH, calls for "innovative models of care and teaching that optimize learning, minimize transitions of care, and maximize the safety and quality of care, while also tending to the lifestyle and educational needs of trainees."

In an accompanying editorial, Lara Goitein, MD, and Kenneth M. Ludmerer, MD, note that work hour limitations do not reduce the total amount of work by residents; they merely redistribute it and reduce flexibility in accomplishing tasks. They suggest that alternative strategies are costly and difficult to implement but could ultimately be cost-effective.

"First, resident positions should be increased to reduce resident work intensity, which would simultaneously address the perceived national shortage of physicians," they write. "Second, administrators of teaching hospitals should shift service burden from residents to nonresident providers in settings of high work intensity....Vigorous and targeted advocacy, as well as public education by the ACGME and other professional organizations and leaders, is essential."

Dr. Desai and colleagues, Dr. Goitein, and Dr. Ludmerer report no relevant financial relationships. The American Foundation for Suicide Prevention, the National Center for Research Resources, the National Institute for Mental Health, and the National Institute on Alcohol Abuse and Alcoholism supported Dr. Sen's study. One of the authors of that study (Dr. Krantzler) reports various financial relationships with Alkermes, Lilly, Lundbeck, Pfizer, Roche, and Abbott.

JAMA Intern Med. Published online March 25, 2013. Abstract, Abstract, Commentary, Editorial