A year ago, the Accreditation Council for Graduate Medical Education implemented new duty hours governing the schedules of medical residents such as myself. The new work hours were intended to curb resident fatigue, which the Institute of Medicine had previously concluded was contributing to medical errors and accidents.
Instead of improving this problem, the ACGME’s new duty hours have actually exacerbated fatigue while jeopardizing resident education and endangering patient care at our nation’s teaching hospitals.
Mandates Fail in Practice
Until the current guidelines took effect in July 2011, medical residents could work up to eighty hours per week and thirty hours continuously. The new duty hours, while maintaining the eighty hour schedule, have limited the maximum shift for first year residents (PGY-1) to 16 hours. Senior residents can still work 28 hours straight.
Recent research reported in the New England Journal of Medicine shows these new mandates have failed to achieve their intended consequences. The authors of the study contacted every sponsoring institution of an ACGME-accredited residency program in the country, and ultimately 6,202 residents at 123 different institutions completed a twelve-question survey about the new work hours.
Of those surveyed, 43 percent indicated the resident work schedule had actually worsened, and 49.7 percent said the quality of life for senior residents had deteriorated, compared to 30.1 and 13.9 percent, respectively, that noted improvement.
A total of 40.8 percent of residents in the survey said they believed the new guidelines have worsened their education, whereas only 16.3 percent say the changes have benefited resident learning.
The survey also indicated some residents were concerned that patient care was suffering. Overall, 48.4 percent of residents disapproved of the changes, and only 22.9 percent approved.
Responsibilities Passed to Others
At first blush these findings may seem counterintuitive, but upon closer inspection they make perfect sense. As a result of the changes, residency programs now have the same number of workers with the same collective responsibilities, but the PGY-1 residents must work less. This paradigm can only be sustained by passing more and more of the clinical responsibilities onto other residents. Consequently, second-year residents and above are working significantly harder during their shifts for essentially the same number of hours and working schedules with more calls and night shifts.
Historically speaking, the first year of residency was very physically demanding and then as residents entered senior roles and took on more responsibility, the physical burden subsided in exchange for the intellectual challenge of managing sick, complicated patients. This would grant the senior house staff time to think, read, and learn from their patients, allowing the resident to grow as a physician and guarantee patients received the best care.
Most Responsibility, Most Fatigue
The new duty hours have turned this commonsense approach to residency on its head. Now the residents with the most clinical responsibility are also the most physically taxed and fatigued.
As a result of the new work hour mandates, senior residents are substantially more fatigued than ever and have significantly less time and energy to read and learn from their patients. This does not just hurt the quality of resident training, it’s actually potentially dangerous.
The ACGME may have had the best of intentions with these new duty hours; however, without coupling them with either systemic changes that reduce the resident workload or a steep increase in residency funding and slots, the organization is essentially just rearranging the lawn chairs on the Titanic.
The goal of these new regulations was to improve patient care, education, and quality of life for residents. As a resident working under this new regimen, there is no question that it has substantially missed the mark in all three parameters.
Time to Reexamine Guidelines
Medical residents currently care for the sickest and poorest patients. These mandates are impeding their ability to offer the best care. In addition, by compromising the education and training of young doctors, these duty hours could jeopardize the quality of medical treatments provided to all patients in the country.
The ACGME ought to reexamine these new guidelines and stop their implementation. The organization should temporarily revert to the old work-hour structure until a more practical and sustainable solution can be reached. If it fails to take the initiative to do this, then Congress and the Department of Health and Human Services may consider taking a closer look at this important issue with grave ramifications on patient care. Yet a private sector solution would be vastly more preferable, and hopefully government intervention can be avoided.
While efforts must be made to combat resident fatigue and protect patients from tired, overworked residents, this new round of duty hours regulations is a cure that’s worse than the disease.
Jason D. Fodeman, M.D., ([email protected]) is an internal medicine resident and a senior fellow in health care studies at the Pacific Research Institute.
“Residents’ Response to Duty-Hour Regulations—A Follow-up National Survey,” by Brian C. Drolet, M.D., Derrick A. Christopher, M.D., M.B.A., and Staci A. Fischer, M.D., New England Journal of Medicine, June 2012: http://www.nejm.org/doi/full/10.1056/NEJMp1202848