Longer surgical resident shifts pose no risk to patients

A new study published in the New England Journal of Medicine (NEJM) says that longer shifts for surgical residents pose no safety risk to patients. 

These findings lend weight to the argument that restricting the traditionally long residency shifts of new doctors does not significantly improve patient outcomes and in fact may lead to problems with patients' continuity of care. 

The study results were announced just as the Accreditation Council for Graduate Medical Education (ACGME) rethinks its work hour restriction policies. In 2003, concerns over patient safety and risk of medical errors prompted a national push to restrict resident physicians from working back-to-back shifts of up to 30 hours and more. In 2011, the ACGME imposed additional restrictions. The reforms limit residents' work hours to 80 per week, cap shifts to 28 consecutive hours and mandate minimum time off between shifts.

To determine whether longer work hours influence patient outcomes, researchers randomly assigned 117 general surgery residency programs to two different types of policies. One group followed the current rules that limit the work week to 80 hours; those rules were waived for the other group so residents could work more than 28 hours at a time if they thought it necessary. Researchers then analyzed data from more than 138,000 patients and determined that flexible, less-restrictive work hour policies did not increase the rate of death or serious complications.

"It's counterintuitive to think it's better for doctors to work longer hours," said the study's lead author, Karl Bilimoria, M.D., the director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine, in a study announcement. "But when doctors have to hand off their patients to other doctors at dangerous, inopportune times, that creates vulnerability to the loss of critical information, a break in the doctor-patient relationship and unsafe care."

The study is the first-ever national randomized trial of resident duty-hour policies, according to the announcement. Bilimoria and the other investigators' findings coincide with those of a similar, smaller study by the American College of Surgeons (ACS) in July 2015.

"These restrictions impose obstacles for residents and their residency programs," Ravi Rajaram, M.D., of the ACS, said at the time. "Under the new policies, residents are handing off patients more often, and patient handoffs are one of the most common preventable causes of serious patient harm events."

Not everyone is convinced, however. In 2015, two groups--consumer advocacy group Public Citizen and the American Medical Students Association--demanded that the ACGME halt two trial programs in which it loosened restrictions on doctors in residencies. They argue that sleep deprivation due to excessively long work shifts increases the risk of motor vehicle accidents, needle-stick injuries and exposure to blood-borne pathogens and depression in medical residents.

And in an opinion piece for the NEJM that accompanied the latest study, John D. Birkmeyer, M.D., of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, said that instead of backtracking on the ACGME duty-hour rules, surgical leaders must develop safe systems that don't depend on overworked resident physicians.

"To many current residents and medical students, 80-hour (or even 72-hour) workweeks and 24-hour shifts probably seem long enough," he wrote. "Although few surgical residents would ever acknowledge this publicly, I'm sure that many love to hear, 'We can take care of this case without you. Go home, see your family, and come in fresh tomorrow.'"

To learn more:
- here's the study abstract
- read the announcement
- check out the commentary