Poll Says 86% of Public Favor 16-Hour Cap on Resident Hours

Marcia Frellick

September 14, 2016

Results released Tuesday from a poll commissioned by the watchdog Public Citizen's Health Research Group indicate that 86% of likely voters oppose a move to lift the current 16-hour cap on first-year medical residents' shifts.

Celinda Lake, president of Lake Research Partners, which polled 500 likely voters nationwide by telephone in a random, representative sample from July 20-24, said that 77% of those polled strongly opposed lifting the cap and that "there is near unanimity in every demographic and political group.

"After people hear arguments both in favor and against eliminating the 16-hour shift limit, voters' opposition holds firm at 86%, 79% strongly opposed," she said. "Eight in 10 would support decreasing the shift limits for second-year residents from 28 hours to 16 hours as well."

The poll results, released in a telephone press conference, come as the Accreditation Council for Graduate Medical Education (ACGME) is facing pressure from some physicians, educators, and hospitals to lift its current 16-hour shift cap for first-year medical residents, imposed in 2011, and allow them to work 28 hours consecutively, as is permitted for more experienced residents.

Critics have argued that shorter shifts mean more hand-offs, which result in higher risk for medical error and interruption in care that they say lowers quality of care. They also say it allows less time for resident education.

Supporters of lifting the ban also point to studies such as the FIRST trial, published in the New England Journal of Medicine in February, which concludes, "Flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality."

The study found no significant differences between those residents whose hours were capped and those whose hours were flexible with respect to resident-reported perception of the effect of fatigue on personal or patient safety.

Karl Y. Bilimoria, MD, director of the Surgical Outcomes and Quality Improvement Center and vice chair for quality in the Department of Surgery at the Feinberg School of Medicine at Northwestern University in Chicago, Illinois, is the lead investigator on the trial, which included more than 4000 residents.

He told Medscape Medical News that it is important to note that all the residents, even in the flexibility arm of the trial, had to adhere to the 80-hour work week, but they could work more than 16 hours a day.

Referring to the study, Dr Bilimoria said, "Introducing flexibility in duty-hour policies for surgical trainees is safe with respect to patient outcomes and offers certain benefits for resident education and well-being.".

On Tuesday, Public Citizen sent Northwestern University a letter asking Northwestern, as the coordinating site, to terminate the study, calling it unethical because it did not require the consent of residents and patients in the flexible arm.

Dr Bilimoria said the group has repeatedly called for the end of the study during the past 2 years and notes that their complaint before the Office for Human Resource Protections has not received a response.

"There have not been complaints from other groups or organizations, and, importantly, during the entire conduct of the surgical trial, there has never been a complaint from our residents or...any of the oversight agencies," Dr Bilimoria said.

Panelists List Reasons to Keep Cap in Place

After poll results were announced in the press conference, panelists spoke of the reasons they support keeping the 16-hour ban.

Among them were Charles Czeisler, PhD, chief of the Division of Sleep and Circadian Disorders from the Departments of Medicine and Neurology, Brigham and Women's Hospital, who is also Baldino Professor of Sleep Medicine at Harvard Medical School in Boston, Massachusetts.

"We know that when an individual is awake for more than 24 hours, their performance is impaired by an amount that is equivalent to being legally drunk. And that bears out in the statistics we have collected. We have found that resident physicians working in intensive care units make 36% more medical errors on the patients that they are treating."

In addition, the residents are at risk for making serious diagnostic mistakes "that is 460% higher when they are working extended-duration shifts," Dr Czeisler said.

He also said the extended shifts put physicians at considerable risk.

"There's a 73% increased risk of stabbing themselves with a needle or having other percutaneous injury with a scalpel when working for more than 20 consecutive hours," he said. "When driving home from these marathon shifts, they have a 168% increased risk of a motor vehicle crash and a 460% increased risk of near-crash events."

Pamela Wible, MD, founder, Ideal Medical Care Movement and author of the book Physician Suicide Letters—Answered, said the extent of negative effects on residents is largely unknown because suicides and abuse often go unreported.

"The majority of resident suicides remain covered up, unreported by medical institutions, and, surprisingly, no organizations tracks these suicides," she said.

When residents do speak up about lack of sleep and abuses, they are often labeled as unprofessional, she said. "Urgent action is required to address the sleep deprivation and unsafe working conditions."

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