The 16-hour day dilemma: Will shortening residents' hours work?

Coming this July, medical residents will receive a "gift" in terms of possibly getting a little more shut eye. Under new guidelines approved last year by the Accreditation Council for Graduate Medical Education, daily duty hours for resident physicians will be limited to no more than 16 consecutive hours.

A major reason for the push to limit hours was patient safety: longer hours meant more tired residents and the greater likelihood for adverse events or medical errors to occur. But it's an issue that will not sit back easily, as demonstrated by discussions in the March issue of Mayo Clinic Proceedings, as we reported earlier this week.

Results of a survey sent to directors of residency programs around the country by study co-author, Darcy Reed, MD, MPH, an internist and Mayo assistant professor or medicine, discovered that many are concerned that the upcoming duty‑hour limitations will impinge on physician education.

"Our results showed that the duty‑hour limitations may not be a quick fix to an important problem," said Reed.

Of the nearly 500 respondents from the fields of surgery, internal medicine, and pediatrics, 87 percent of program directors thought the shortened shifts could interrupt interactions between residents and hospitalized patients.

"Many survey respondents expressed concern that the limits will decrease the continuity of care," Reed said. "As residents face more handoff of responsibilities within a 24‑hour period, they have less opportunity to see and learn how patients' care progresses."

In particular, nearly 78 percent of directors felt the restricted shifts would likely result in graduates who fell short in the key competency areas identified by the ACGME. They include patient care, medical knowledge, interpersonal and communications skills, and professionalism, Reed said.

And, in surveying various fields, directors of surgery programs showed the greatest concern. "Further research is necessary to understand the particular concerns of directors of surgery programs, but it's possible some directors may feel residents will not get sufficient time in the [operating room]," Reed said.

In another study in the same Mayo journal, a group of researchers, as part of Mayo's Educational Innovations Project, piloted a project that eliminated resident shifts longer than 16 daily hours--without increasing staff or decreasing patient admissions--on two gastroenterology services during several months in 2009.

Overall, the researchers found inpatient services can be staffed with residents working shifts less than 16 hours without additional residents. However, the overall relationship of care, education quality and time off between shifts was impacted, they said.

For the survey, the residency directors appeared skeptical as well on whether the new time limits would reduce physician fatigue. Among respondents, 65 percent thought the limits would have no effect on fatigue, and 6 percent said the restrictions could increase fatigue. "Other studies have found that reducing work hours doesn't necessarily lead to people going home to sleep," Reed said.

Obviously, no easy answers arise from these studies. But it does plant some seeds for the idea of looking at whether resident time limits will help or harm the practice of providing quality medicine at the hospital level and ensuring good outcomes.

"This will probably not be the final iteration of recommendations that are set in place," Reed said. "I believe we'll continue to see these policies evolve." - Jan