In 2003, the Accreditation Council for Graduate Medical Education limited residents to an 80-hour workweek (averaged over four weeks). A 2008 Institute of Medicine report called for further restrictions, and the ACGME instituted some in 2010 when it approved new rules that called for more rest between shifts and decreased the length of work shifts for first-year residents to 16 hours from 30. Those rules went into effect in July 2011.
Restrictions on resident duty hours are traced back to the efforts of the late Sidney Zion. Zion, a journalist, prosecutor and novelist, campaigned for more rest and supervision of residents after his 18-year-old daughter, Libby, died a few hours after entering New York Hospital on March 4, 1984.
In the first study, a total of 2,323 residents from 51 residency programs at 14 institutions were surveyed. The respondents included 837 physicians who began their training after the 16-hour restriction went in effect in 2011, as well as 714 who began in 2009 and 772 in 2010. Among the new interns, 22.3% reported committing a serious medical error compared with 19.1% of the residents in the pre-implementation cohort.
The researchers noted that other reports have linked the new restrictions to an increase in handoffs, which has been linked to more errors, and this could be the reason for the higher percentage of interns reporting harmful medical mistakes. In the Johns Hopkins study, the minimal number of patient handoffs increased from three under the 30-hour shift limit to as high as nine under the 16-hour limit; and the minimal number of interns seeing a patient during a three-day stay went from three to as high as five.
Conducted during two four-week periods in 2011 before the 16-hour limit went in effect in July, the interns in the Johns Hopkins study were divided into three groups, including a “2003-compliant” group which included a 30-hour limit on works shifts and two different 2011-compliant groups.
One 2011-compliant group worked a night shift, which decreased their availability for traditional residency education programs such as noontime conferences and morning rounds.
“Programs have expanded curricula to include evening teaching by attending physicians, but there will be inherent limitations in the content delivered during these hours because of faculty availability and patient convenience,” the authors wrote. “Finally, faculty often face increased clinical duties to compensate for the work previously done by residents, reducing their time to teach. This, coupled with pressures to 'get the resident out on time,' will further reduce teaching opportunities even during daytime hours.”
While public focus remains on the duty-hour aspect of physician training, new changes are going into effect this July that will focus on outcomes and whether residents are meeting educational milestones in patient care, medical knowledge, communication, professionalism and other elements aimed enhance physician preparation for practice.
Professionalism has become a focus of graduate medical education as many experts, including ACGME CEO Dr. Thomas Nasca, have expressed concern about duty-hour restrictions creating a “shift-work mentality” among young physicians where they see the role of physicians “devolving” from being a professional to being a technician.
