Fewer Hours, Fewer Errors?

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The ACGME's restrictions on residents' work hours were designed to decrease errors by overworked young physicians. But are the restrictions really working?

On July 1, 2003, the Chicago-based Accreditation Council for Graduate Medical Education imposed an 80-hour maximum workweek for medical residents and implemented other duty-hour restrictions in the hope of reducing fatigue-related medical errors.

Five years later, nobody knows if those restrictions are working.

In August, Pediatrics magazine published a study that reviewed the work habits of 220 residents in three large pediatric training programs in Boston, California, and Washington, DC. The study found no change in residents' total work hours or sleep hours, no change in the overall rate of medication errors, and a slight increase in the rate of resident physician ordering errors. In addition, rates of motor vehicle crashes, occupational exposures, depression, and self-reported medical errors and overall ratings of work and educational experiences among residents did not change, the study determined.

The report found its way into the mainstream media, where USA Today reported that residents weren't helped by the duty-hours cap. The negative attention has rankled Ingrid Philibert, senior vice president for field activities at ACGME, who says the study relies on data collected when residency programs were still adjusting to the new rules. "These headlines fail to note that this is data from 2004," Philibert says. "Given the heavy reliance on residents in some areas of clinical service, you aren't going to see this huge shift from June 30 of the year we didn't have standards to July 1 of the year we do have standards. Hours have continued to go down, which is what we find when we do our surveys. Each year, programs are able to adapt a little better to the standards."

Philibert concedes, however, that it is difficult to determine whether reducing residents' duty hours has helped in the overall reduction of medical errors.

"If you look at patient safety outcome data, what is mixed in there is probably some small improvement in the reduction in technical errors because residents are more rested, offset by some small set of errors coming from a new source of errors, which is inadequate exchange of information at hand off," she says. "You now have more frequent disconnections in care because of shorter shifts. Somebody else takes over and you forget to tell them something."

Sandeep Jauhar, MD, director of the Heart Failure Program at Long Island Jewish Medical Center and the author of Intern: A Doctor's Initiation, a memoir of his years as a resident, says reducing the hours that young physicians work creates its own set of problems. "Interns probably do still work too hard, but there is only so much more you can take away from their hours and still ensure that they see enough medical pathology to become competent physicians," Jauhar says. "It's a balancing act. Eighty hours a week seems like a reasonable limit. More than that and you are going to create the potential for more mistakes. Significantly less than that and the young doctors won't have enough experience."

So far, Philibert says, determining when fatigue or bad patient hand-offs are to blame for errors has been difficult. She says multisite studies using similar procedures might be able to determine some cause-and-effect relationships. "The one thing we definitely have to do is get a whole lot better at hand-offs," she says. "It's another complex issue. What is essential is for the resident to have a good clinical understanding so they can construct a patient's story from a small snippet of information, from what can be conveyed in a 15-minute conversation that covers 12 patients."

Philibert predicts improved data systems in the coming years will improve information transfers at the hand-off. "We just aren't there yet," she says.

Beth Israel Deaconess Medical Center in Boston was recently threatened with a sanction by ACGME because several young surgeons at the hospital reported they were either working in excess of 80 hours per week, working more than 30 hours consecutively, or did not have at least one day off per month. Richard Schwartzstein, MD, vice president for education at 621-licensed-bed Beth Israel Deaconess, says the excess hours involved only a small number of residents in a surgery program. "Sometimes when you see that there are duty-hour violations, it isn't because the program or the hospital hasn't been sending the message. It's that the resident has something they want to be in the hospital for," says Schwartzstein, who is also associate dean for medical education at Harvard University Medical School.

Schwartzstein says a growing emphasis on "competency-based training" for residents could help alleviate the issue of excessive hours. "You're deemed ready to move on to the next level of training not because you served time but because you can show competence. In the long run, that is a healthier way to look at it."

—John Commins

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