Physician Work Hours and Patient Safety
Background
Long and unpredictable work hours have been a staple of medical training for centuries. In fact, the term "resident" is a relic of times when physicians in postgraduate training literally lived at the hospital. Though this system faded away several decades ago, as recently as 15 years ago, resident physicians routinely worked 90–100 hours per week, for up to 36 consecutive hours without rest, for the entire duration of residency training. These grueling hours were viewed by many as a necessary "rite of passage" and were considered essential to ensure that physicians developed their clinical acumen and would be capable of independent practice once training was completed.
Little attention was paid to the potential patient safety effects of fatigue among residents until March 1984, when 18-year-old Libby Zion died at New York Hospital due to a medication-prescribing error while under the care of residents in the midst of a 36-hour shift. The subsequent investigation into her death led to the formation of the Bell Commission, which passed regulations in 1987 mandating that residents at New York hospitals should work no more than 80 hours per week and no more than 24 consecutive hours.
Though work hours and shift duration decreased somewhat for residents over the next decade, it was not until the goals of the patient safety movement aligned with research documenting a connection between fatigue and clinical performance that stronger regulations came into place. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented new rules limiting work hours for all residents, with the key components being that residents should work no more than 80 hours per week or 24 consecutive hours on duty, should not be "on-call" more than every third night, and should have 1 day off per week. (Some fields, principally surgical specialties, received partial exemption from the regulations.) A landmark study published in 2004 found that reducing medical residents' work hours during rotations in the intensive care unit resulted in a significant reduction in medical errors, lending support to the regulations.
Effect of Resident Duty Hour Regulations
The 2003 regulations have engendered significant controversy since their implementation, and thus far, their overall effect appears to be mixed. A 2011 systematic review found that while resident well-being improved after implementation of the 2003 work hour regulations, there was no clear effect on patient safety or clinical outcomes. This may be because burnout and fatigue—known risk factors for poor job performance—remain common among residents, despite reduced duty hours. Moreover, any potentially beneficial effects of duty hour reductions may have been attenuated because of the increased number of patient handoffs, which may result in more safety hazards.
The impact of the duty hour regulations on educational variables has also been surprisingly mixed. Residents' educational experience appears to have been adversely affected by the regulations. Surveys of key clinical facultyand residents themselves have found that, although residents' quality of life has improved since 2004, their overall educational experience may have worsened, because they have less time available for teaching and to attend educational activities. A 2014 systematic review found that surgical residents had lower case volumes and scored more poorly on certification exams after implementation of duty hour restrictions.
Source: Reed DA, Levine RB, Miller RG, et al. Effect of Residency Duty-Hour Limits. Arch Intern Med. 2007;167:1487-1492. [go to PubMed]
Practicing Clinicians
Duty hour regulations for residents have also spurred interest in the issue of fatigue among practicing clinicians. A recent study found that many attending physicians, particularly surgeons, routinely work hours that would be prohibited in residency programs. To date, no study has found a definitive link between attending physician fatigue and adverse clinical or safety outcomes, although one study did find an increased risk of surgical complications when surgeons had the opportunity to sleep less than 6 hours the night before the procedure.
Current Context
The ACGME's current duty hour regulations went into effect in July 2011. The new regulations eliminated extended duration shifts (which have been linked to errors in prior studies) for first-year residents, and strengthened oversight by more senior physicians. These regulations have already caused considerable controversy, as implementation of these regulations has been costly for teaching hospitals. Early data has shown that patient outcomes have not improved, and residents themselves believe the regulations may be negatively impacting their education. In order to balance the need for clinical training with patient safety, it is likely that further changes to duty hours will increase interest in incorporating simulation training into medical student and resident education, and will continue to require additional training in handoffs and signouts. An influential 2014study demonstrated that training residents to use a formal handoff bundle could prevent adverse events in pediatric inpatients.
The 2011 ACGME regulations maintained a maximum limit of 80 work hours per week. By comparison, residents in many other countries work significantly fewer hours; the European Working Time Directive currently limits residents in Europe to no more than 48 hours per week on duty.
Long and unpredictable work hours have been a staple of medical training for centuries. In fact, the term "resident" is a relic of times when physicians in postgraduate training literally lived at the hospital. Though this system faded away several decades ago, as recently as 15 years ago, resident physicians routinely worked 90–100 hours per week, for up to 36 consecutive hours without rest, for the entire duration of residency training. These grueling hours were viewed by many as a necessary "rite of passage" and were considered essential to ensure that physicians developed their clinical acumen and would be capable of independent practice once training was completed.
Little attention was paid to the potential patient safety effects of fatigue among residents until March 1984, when 18-year-old Libby Zion died at New York Hospital due to a medication-prescribing error while under the care of residents in the midst of a 36-hour shift. The subsequent investigation into her death led to the formation of the Bell Commission, which passed regulations in 1987 mandating that residents at New York hospitals should work no more than 80 hours per week and no more than 24 consecutive hours.
Though work hours and shift duration decreased somewhat for residents over the next decade, it was not until the goals of the patient safety movement aligned with research documenting a connection between fatigue and clinical performance that stronger regulations came into place. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented new rules limiting work hours for all residents, with the key components being that residents should work no more than 80 hours per week or 24 consecutive hours on duty, should not be "on-call" more than every third night, and should have 1 day off per week. (Some fields, principally surgical specialties, received partial exemption from the regulations.) A landmark study published in 2004 found that reducing medical residents' work hours during rotations in the intensive care unit resulted in a significant reduction in medical errors, lending support to the regulations.
Effect of Resident Duty Hour Regulations
The 2003 regulations have engendered significant controversy since their implementation, and thus far, their overall effect appears to be mixed. A 2011 systematic review found that while resident well-being improved after implementation of the 2003 work hour regulations, there was no clear effect on patient safety or clinical outcomes. This may be because burnout and fatigue—known risk factors for poor job performance—remain common among residents, despite reduced duty hours. Moreover, any potentially beneficial effects of duty hour reductions may have been attenuated because of the increased number of patient handoffs, which may result in more safety hazards.
The impact of the duty hour regulations on educational variables has also been surprisingly mixed. Residents' educational experience appears to have been adversely affected by the regulations. Surveys of key clinical facultyand residents themselves have found that, although residents' quality of life has improved since 2004, their overall educational experience may have worsened, because they have less time available for teaching and to attend educational activities. A 2014 systematic review found that surgical residents had lower case volumes and scored more poorly on certification exams after implementation of duty hour restrictions.
Source: Reed DA, Levine RB, Miller RG, et al. Effect of Residency Duty-Hour Limits. Arch Intern Med. 2007;167:1487-1492. [go to PubMed]
Practicing Clinicians
Duty hour regulations for residents have also spurred interest in the issue of fatigue among practicing clinicians. A recent study found that many attending physicians, particularly surgeons, routinely work hours that would be prohibited in residency programs. To date, no study has found a definitive link between attending physician fatigue and adverse clinical or safety outcomes, although one study did find an increased risk of surgical complications when surgeons had the opportunity to sleep less than 6 hours the night before the procedure.
Current Context
The ACGME's current duty hour regulations went into effect in July 2011. The new regulations eliminated extended duration shifts (which have been linked to errors in prior studies) for first-year residents, and strengthened oversight by more senior physicians. These regulations have already caused considerable controversy, as implementation of these regulations has been costly for teaching hospitals. Early data has shown that patient outcomes have not improved, and residents themselves believe the regulations may be negatively impacting their education. In order to balance the need for clinical training with patient safety, it is likely that further changes to duty hours will increase interest in incorporating simulation training into medical student and resident education, and will continue to require additional training in handoffs and signouts. An influential 2014study demonstrated that training residents to use a formal handoff bundle could prevent adverse events in pediatric inpatients.
The 2011 ACGME regulations maintained a maximum limit of 80 work hours per week. By comparison, residents in many other countries work significantly fewer hours; the European Working Time Directive currently limits residents in Europe to no more than 48 hours per week on duty.
What's New in Physician Work Hours and Patient Safety on AHRQ PSNet
NEWSPAPER/MAGAZINE ARTICLE
Nurses seek to reduce long hours and fatigue.
Ungar L. USA Today. February 1, 2015.
SPECIAL OR THEME ISSUE
Resident Duty Hours Across Borders: An International Perspective.
Imrie KR, Frank JR, Parshuram CS, eds. BMC Med Educ. 2014;14(suppl1):S1-S18.
STUDY
Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.
Rajaram R, Chung JW, Jones AT, et al. JAMA. 2014;312:2374-2384.
STUDY
Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.
Patel MS, Volpp KG, Small DS, et al. JAMA. 2014;312:2364-2373.
Nurses seek to reduce long hours and fatigue.
Ungar L. USA Today. February 1, 2015.
SPECIAL OR THEME ISSUE
Resident Duty Hours Across Borders: An International Perspective.
Imrie KR, Frank JR, Parshuram CS, eds. BMC Med Educ. 2014;14(suppl1):S1-S18.
Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.
Rajaram R, Chung JW, Jones AT, et al. JAMA. 2014;312:2374-2384.
Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.
Patel MS, Volpp KG, Small DS, et al. JAMA. 2014;312:2364-2373.
In Conversation with…Thomas J. Nasca, MD.
AHRQ WebM&M [serial online]. February 2010
The Role of Graduate Medical Education (GME) in Improving Patient Safety.
Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS. AHRQ WebM&M [serial online]. February 2010
In Conversation with…Christopher P. Landrigan, MD.
AHRQ WebM&M [serial online]. April 2005
AHRQ WebM&M [serial online]. February 2010
The Role of Graduate Medical Education (GME) in Improving Patient Safety.
Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS. AHRQ WebM&M [serial online]. February 2010
AHRQ WebM&M [serial online]. April 2005
JOURNAL ARTICLE
Jena AB, Schoemaker L, Bhattacharya J. Health Aff (Millwood). 2014;33:1832-1840.
A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.Ahmed N, Devitt KS, Keshet I, et al. Ann Surg. 2014;259:1041-1053.
Sen S, Kranzler HR, Didwania AK, et al. JAMA Intern Med. 2013;173:657-662.
The new recommendations on duty hours from the ACGME Task Force.Nasca TJ, Day SH, Amis ES Jr; for ACGME Duty Hours Task Force. N Engl J Med. 2010;363:e3.
Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education.Reed DA, Fletcher KE, Arora VM. Ann Intern Med. 2010;153:829-842.
Risks of complications by attending physicians after performing nighttime procedures.Rothschild JM, Keohane CA, Rogers S, et al. JAMA. 2009;302:1565-1572.
Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.Landrigan CP, Fahrenkopf AM, Lewin D, et al. Pediatrics. 2008;122:250-258.
Effect of reducing interns' work hours on serious medical errors in intensive care units.Landrigan CP, Rothschild JM, Cronin JW, et al. N Engl J Med. 2004;351:1838-1848.
Fatigue among clinicians and the safety of patients.Gaba DM, Howard SK. N Engl J Med. 2002;347:1249-1255.
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.Robins NS. New York, NY: Delacorte Press; 1995. ISBN 0385308094.
Accreditation Council for Graduate Medical Education.
Residency Training—A Decade of Duty-Hour Regulations.Weinstein DF, Arora V, Drolet B, Reynolds EE. N Engl J Med. 2013;369:e32.
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