Work Hour Limitations for Residents - What Are They Good For?

I have the (dubious?) distinction of being part of the first cohort of interns who can only work 16 hours at a stretch in the context of an 80 hour work week. These new restrictions were put in place by the American Council for Graduate Medical Education (ACGME) for the purported reasons of reducing medical errors and improving education for first year residents.

These changes come on the heels of a previous set of work hour restrictions put into place in 2004. Prior to that time point residents were pulling long(er) work weeks. Some high profile cases and research into medical errors pointed to the sleepy residence who'd been up 30 hours or something as the culpable party. Hence, residency programs were mandated to have residents work no more than 80 hours on an average week (over some time frame like four weeks).

Interestingly, the data on whether these work hour restrictions produced better outcomes for patients is mixed. Some studies show positive effects on mortality and complications and some show no effect (here's a systematic review from this year covering a whole bunch of studies in the US and UK).

All of this begs two questions: Why did the original work hours restriction not give unambiguously positive effects on patient outcomes? And why the further restriction in 2011, limiting the length of shift to 16 hours?

On the first point, one theory is that compliance to the 80 hour work week was low in residency programs: there was no effect because work hours really didn't decrease. Another explanation is that work hour reductions led to increases in patient "hand-offs." Resident A can't work anymore so resident B might have to take over. If resident A does a poor job telling resident B about a complicated patient, mistakes and bad outcomes become more likely when resident B takes over the caregiving role.

Growing concerns over poor handoffs - and there is some kind of evidence base (see here for an example) now suggesting that handoffs are indeed poor - have prompted many to criticize the ACGME's latest work hour restrictions. If there original work hour restrictions didn't affect patient outcomes, why make any further changes, especially if the number of handoffs increase?

An interesting piece in the NYT a few days ago really gets at the heart of the matter, I think. The author, Darshak Sanghavi, begins deconstructing our obsession with work hour restrictions by examining the case of Libby Zion. In 1984, Zion, a college student, died in an NYC emergency department while being take care of by two residents, one of which was an intern on little sleep. Essentially, a medication error was made that led to a drug interaction that cost Zion her life. The incident became the test case for resident work hour reform, with New York State instituting such reforms first, and the ACGME following suit nationally.

Sanghavi examines this case in detail and notes that there were a multitude of different factors - fragmented outpatient care, poor electronic medical records and decision support, among others - that also could have credibly contributed to Zion's tragic demise. This deconstruction makes a powerful point - sleepy residents may indeed make more errors, but we should be wary of tunnel vision. Other factors deserve consideration. It's a great article and I encourage you to read it (hat tip to OKS for sending it to me).

That said, it may be that the latest work hour restrictions may have some positive effects on patient outcomes. It could be that the real margin of improvement is reducing a given work stretch from 30 to 16 hours, not reducing the total weekly work hours from 100+ to 80. It may also be that less lengthy shifts may reduce burnout and actually allow interns to go home and read something medical. Certainly, there will be a good deal of empirical work on these latest restrictions, and I'll be interested to see which way the axe falls.

(PS: Not sure how much time I'll have to read. One disadvantage of the new restrictions is that it looks like I'll be in the hospital more often during inpatient rotations. In the end, they get you somehow!)