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September 27th, 2013

Duty Hour Reform Revisited

Akhil Narang, M.D.

physicians' time Discussions of resident duty hour reforms reached the point of ad nauseam a few years ago.  Everyone had their say – Program Directors (“In 2003 we instituted an 80-hour work week, in 2011 we switched to 16 hour shifts, what’s next – online residencies!?”), senior residents (“What? I have to write H&Ps again? I don’t even know my computer password!”), interns (“I thought I was done with cross-covering after this year”), graduating medical students (“I get to sleep in MY bed most of next year!”), and various supervising bodies (“This is what the public wants. Of course there is evidence that these reforms will work.”). Now it’s my turn: part of the last class to have experienced 30-hour call cycles as interns – the way it should/shouldn’t be (depending on your bias).

While lamenting to my Program Director during residency on how my class not only had a difficult intern year but also had to assume “intern responsibilities” during my junior and senior years, he gently reminded me of his experience as an intern. It was routine for him to care for more than 20 patients on the general medicine service. Moreover, the ICU was “open” and any of his patients transferred to the unit continued to be under his care. Generously assuming 1 day off in 7, he worked more 100-hour work weeks than he’d care to remember.

As a junior resident, I was on service with my Chair of Medicine and he repeated many of the same stories of busy services and how the word housestaff came to be – the residents’ de facto house was the hospital. Was this dangerous? The unfortunate case of Libby Zion (and others) would suggest yes. Did my attendings became outstanding physicians, in part because of the rigorous training? Unequivocally.

Fast forward a few decades: for numerous reasons, including public pressure, an 80-hour work weeks with a maximum of 30 consecutive hours in-house (for a resident) and 16 consecutive hours (for an intern) is the new standard. In a matter of 16 hours, only so much can be accomplished. The work-up, diagnosis, and response to treatment is hardly appreciated in this short time span. The resident, who is permitted to stay in-house for 30 hours, often completes what the intern didn’t have time to do and benefits from observing in real-time the clinical course of the patient. Is this a disservice to the intern? Many would argue “yes.”

Interns now leave work after a maximum of 16 hours. The time away from the hospital is supposed to allow for a better-work life balance, enable restorative sleep, and prevent medical mistakes. A study by Kranzler and colleagues showed that this wasn’t the case. Interns did not report an increase in well-being, a decrease in depressive symptoms, more sleep, or fewer mistakes than previously.

What about patient care/outcomes? While early data from the 16-hour work day is still forthcoming, we do have recent data from the 2003 rule that capped the work week at a maximum of 80 hours. In a study published in August 2013, Volpp and colleagues examined mortality pre- and post-80-hour work weeks. More than 13 million Medicare patients (admitted to short-term, acute-care hospitals) who had primary medical diagnoses of acute MI, CHF, or GI bleed, or surgical diagnosis in general, orthopaedic, or vascular surgery were included in the study. The authors concluded that no mortality benefit was present in the early years after the 80-hour work week was implemented and a just a trend toward improved mortality was observed in years 4-5. We will start to see mortality data from the 16-hour rule in a few years, but I suspect that no significant improvements will occur in patient outcomes. In fact, medical knowledge and hands-on experience for interns might suffer.

Completing internship used to be a rite of passage, akin to pledging a fraternity. The duty hour changes have allowed for interns to spend more time away from the hospital so that, theoretically, they are less tired and make fewer mistakes at work. In practice, this might not be the case. Unquestionably, the brutal hours that generations of past trainees faced was suboptimal. but it appears as if the current duty hour rules also might be less than ideal from a learning perspective. Hopefully, in the coming years, the ACGME will reevaluate its policies in light of the data they will see.

One Response to “Duty Hour Reform Revisited”

  1. Donald Turken, MD says:

    Dr Narang-Well I remember Libby Zion, too. While internship was very demanding, as it should be, there has been an erosion of clinical skills, using our senses and brain when meeting and learning about patients. We used to call it a baptism under fire. Difficult, yes, yet so much was learned. We had students with no responsibilities who would hit the hay by 2300h. They were rested, and they learned little. When the chain of command is functioning well, other juniors as well as senior residents are available as well as attendings on call. As for Libby Zion, the breakdown was unconscionable and should not have happened. I was witness to other cases where senior and chief residents did not want to be bothered and denied they had been called and consulted with a ‘well, do the best you can’. Those tough old days you and I experienced should be brought back; it is a sacrifice for learning and for clinical skills and sense. It is a finited limited one year only. We have witnessed a weakening and softening of the profession. Thank you.

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