University of Michigan-led study of 2,300 first-year residents questions impact of 2011 duty rules. At hospitals in the U.S., young doctors fresh out of medical
school help care for patients of all kinds - and work intense, long
hours as part of their residency training.
Traditionally, residents were allowed to work more than 24 hours without a break. In 2011, new rules cut back the number of hours they can work consecutively to 16, in the name of protecting patients from errors by sleepy physicians.
But a new study of more than 2,300 doctors in their first year of
residency at over a dozen hospital systems across the country raises
questions about how well the rules are protecting both patients and new
doctors.
While work hours went down after new rules took effect in 2011, sleep
hours didn't go up significantly and risk of depression symptoms in the
doctors stayed the same, according to a new paper published online in JAMA Internal Medicine by a team led by University of Michigan Medical School researchers.
Most concerning: the percentage of residents reporting that they had
committed medical errors that harmed patients went up after the new
rules took effect.
The results, especially the increase in errors, surprised Srijan Sen,
M.D., Ph.D., the U-M psychiatrist who is the report's first author.
"In the year before the new duty hour rules took effect, 19.9 percent
of the interns reported committing an error that harmed a patient, but
this percentage went up to 23.3 percent after the new rules went into
effect," he says. "That's a 15 to 20 percent increase in errors - a
pretty dramatic uptick, especially when you consider that part of the
reason these work-hour rules were put into place was to reduce errors."
The findings echo anecdotal reports about the impact of the 2011 duty hour rules.
Co-author Sudha Amarnath, M.D., a resident in the radiation oncology
program at the University of Washington, says, "Many interns entering
after the new work hour restrictions took effect felt that they were
expected to do the same amount of work as in previous years, but in a
more limited amount of time, leading to more harried and tiring work
schedules despite working fewer hours. Overall, they felt that there was
less 'down time' during the work day compared to pre-2011 work
schedules, which may partially explain some of the unexpected findings."
Breck Nichols, M.D., MPH, the program director of the combined
Internal Medicine and Pediatrics residency program at the University of
Southern California, and another co-author on the paper, concurs.
"In 2000 a typical call day lasted 36 hours. We have very
specifically reduced that for interns from 36 hours to 30 hours in 2003,
and now with the latest 2011 work hours change it has been reduced even
further to 16 hours," he says. "For most programs the significant
reduction in work hours has not been accompanied by any increase in
funding to offload the work. As a result, though many programs have made
some attempts to account for this lost work in other ways, the end
result is that current interns have about 20 less hours each week to
complete the same or only slightly less work. If we know that timed
tests result in more errors than untimed ones, we should not be
surprised that giving interns less time to complete the same amount of
work would increase their errors as well."
All the interns assessed in this study were working under the duty
hour restrictions that went into effect in 2003 - limiting residents to
no more than 80 hours of work in a week, and other restrictions. Some
studies have suggested that these rule changes, recommended by the
Accreditation Council for Graduate Medical Education, did result in
better safety for patients cared for by residents. But in an effort to
achieve even greater safety, the ACGME recommended further changes that
were implemented in 2011.
Each year, Sen and colleagues send out surveys to students entering
residency programs around the U.S. The research team then surveys these
interns every three months throughout that first year, asking questions
that gauge mental health, overall well-being, sleep habits, work hours
and performance on the job.
By comparing the interns serving before the new ACGME rules (called the 2009 and 2010 cohorts) with the interns serving after the new rules were implemented (the 2011 cohort), the research team assessed the effects of the new duty hour rules.
In addition to the increase in self-reported medical errors, 20 percent of the residents screened positive for depression.
Sen was an intern in 2006, and in the years since has studied
depression among medical students and residents, said he had been in
favor of the adjusting duty hour rules in principle. "It was obvious
that after working for 24 hours, we were not functioning at our best,
and this was not optimal for us or the patients we were treating," he
explains. But in practice, he says, the new rules may have had
unintended consequences that ran counter to the goals of new guidelines.
In addition to "work compression," he says, residents now hand off
responsibility for a long list of patients more frequently than in the
past. Communication between the intern who is ending a shift, and the
one beginning a shift, may not cover all patients in detail, he
suggests, and this gap in communication may not become apparent until an
urgent situation arises with one of the patients.
He also said the increase in errors may come back down with time.
"The 2011 changes were a pretty radical shift," he notes. "Doctors have
worked 30-hour shifts for decades, and it may just take time for all
parts of the health care system to get used to the new rules and
adjust."
But, he cautions, the new data don't definitively support any one of
these theories as the culprit in the rise in error rates or the lack of
progress in sleep hours and well-being among young doctors. Further
study is needed to assess what's happening - and determine how to
better support young doctors in during their stressful training and keep
the patients that they treat as safe as possible.
The Intern Health Study, from which the new results are drawn, is
funded by the National Institutes of Health (grants UL1RR024986,
MH095109 and AA013736) with additional support from the American
Foundation for Suicide Prevention. In addition to Sen, Amarnath and
Nichols, the paper's authors include Joseph Kolars, M.D., senior
associate dean for education and global at the U-M Medical School,
Gregory Dalack, M.D., chair of the U-M Department of Psychiatry, Henry
R. Kranzler, M.D., from the University of Pennsylvania; Aashish K.
Didwania, M.D., from Northwestern University; Ann C. Schwartz, M.D.,
from Emory University; and Constance Guille, M.D. from the Medical
University of South Carolina.
Journal Reference: JAMA Internal Medicine, doi:10.1001/jamainternmed.2013.351