August 9th, 2019
Duty Hours: Can We Lay This Debate To Rest?
Cassandra Fritz, MD
Cassandra Fritz, MD, is a Chief Resident at Barnes-Jewish Hospital and Washington University Medical School in St. Louis, MO
Duty hours have been the focus of a lot of research recently. If you are just joining this discussion, the iCOMPARE trial randomized 63 internal medicine residency programs to either flexible (interns could work more than 16 hours) or standard (interns had to work within the 16-hour limit) work hours. The results so far have shown no significant difference in the time interns spend on patient care (NEJM JW Gen Med May 1 2018 and N Engl J Med 2018; 378:1494) or hours of sleep (N Engl J Med 2019; 380:905). Most importantly, patient outcomes and 30-day mortality are not adversely affected by flexible duty hours (NEJM JW Gen Med Apr 1 2019 and N Engl J Med 380:915).
With no significant differences in the studied outcomes, we can likely lay the standard vs. flexible duty hour debate to rest. Flexible hours allow programs and program directors to make decisions based on the needs of their patients, hospitals, and trainees. However, duty hours should continue to remain in the spotlight, but for a different reason. I will argue that our next question should be whether current duty hour restrictions are preparing trainees for the world in which they will practice.
ARE DUTY HOURS LIKE THE REAL WORLD?
Like many academic institutions, we are constantly discussing innovative ways to improve the balance between resident wellness, patient continuity, and duty hour compliance. I think these discussions are important, but I do wonder if we are preparing residents for a world that doesn’t currently exist?
Training programs have built residency systems where residents can call in because they are exhausted or can cite “duty hours” when the maximum number of hours is reached. Personally, I think these are good things when used appropriately. Yet the ability to wave the white flag disappears quickly after training. We foster an illusion that, once you are in independent practice, you no longer suffer from exhaustion or an ever-increasing workload. Although people can choose what type of practice model they join after training, many of us will be in clinic the day before and after covering the ICU, delivering a baby, or completing procedures/surgeries during the night. Attendings don’t have an option to shout “duty hours” when they’re exhausted.
With this in mind, I am thankful that I trained in a rigorous system with flexibility. A program that pushed me to my limits but provided a safety net. I learned valuable lessons about understanding my limits, when to ask for help, and when waving the white flag is not only what is best for my health but also for my patients.
SHOULD DUTY HOURS BE THE “REAL WORLD?”
As we rise in the ranks, our task load continues to increase, whereas the ability to take time off during a call cycle if necessary, seemingly disappears. I understand the need for random time off might be less common in independent practice, but the risk for exhaustion is still there. Therefore, I think our conversation about work hours needs to continue with the following considerations:
- Should we develop policies that afford attendings some of the same benefits we provide residents in relation to exhaustion?
- Should we consider how task load contributes to exhaustion? Does this, in turn, affect physician performance? If so, are there other skills that we should be cultivating during residency?
- Should our systems provide an environment that works toward mitigating task load to improve physician satisfaction?
- Finally, will all of the above lead to happier more efficient doctors? Will this move the needle on patient satisfaction?
I think the discussion surrounding work hour limitations and restrictions needs to continue but should include the physician workforce as a whole. We might not need sweeping regulations from a national agency, but we should continue to discuss optimal task load in relation to exhaustion, physician satisfaction, patient satisfaction, and overall efficiency for providing care.
NEXT STEPS?
My argument is neither to make training “harder” nor to make attending work “easier.” I just think we should contemplate whether our training environment is reflecting the realities of the task load and work hours that are required to be successful in independent practice. My hope is that we can all work together to continue to have discussions about what’s best for not only our patients and residents but for physicians at ALL levels.
4 Responses to “Duty Hours: Can We Lay This Debate To Rest?”
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The question of hours on duty has been present for decades. In recent years, the term ‘burnout’ has come to the fore and some equate it to “overwork”. I am now 84
Your evaluation of iCompare does not include the very real between group differences that were seen in perceived wellness and health. If there is no difference in outcomes, why do we make people work a 28 hour shift. This if not physiologic, and I argue is at the detriment of the health of our residents. We know from studies that women in residency have intrauterine growth restriction and see other negative effects of work stress on pregnancy. There are very real consequences to forcing (none of this is chosen by a resident (16 v. 28 hours shifts) residents to work these hours for 3 to 7 years of their lives.
No this discussion should not be laid to rest. We are the only high risk profession where we are still discussing whether working too many hours might adversely affect outcomes. My sister trained before duty hour restrictions and can tell the stories of how she not only got in to a car accident after a 36 hour shift (which almost killed her), but of how she was adversely affected psychologically and in terms of her performance by the inhuman hours she worked. We should focus on changing the system and to why attending physicians are working so many hours, and not at reducing safety measures like duty hour restrictions.
HI Dr. Fritz,
Thank you for this post. I too felt similarly about the artificial restriction of 80hrs not translating to attending life until one of my attendings placed the current rules into perspective. The 80 hour restriction of duty hours during residency, translates to opportunity costs as an attending. Specifically spending time with our significant other, friends & family and participating in wellness-building activities. Theoretically, if we use the hard cap during residency to train ourselves to achieve maximum efficiency as residents, hopefully this can translate to benefits down the line. While this may seem overly simplistic, there may be some truth in this. We’ll see…