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Work-hour restrictions have had unintended consequences for resident preparedness
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In July 2003, the Accreditation Council for Graduate Medical Education mandated that resident physicians at accredited medical training institutions in the United States could work no more than 80 hours per week, averaged over 4 weeks. In addition, residents were limited to no more than 24 hours of continuous duty, plus up to 6 more hours for continuity of care, one day off per every 7 days, and no more than one in-house call per every 3 nights averaged over 4 weeks. In July 2011, it was further mandated that post-graduate year 1 residents could work no more than 16 hours in a row, with a mandatory rest period of 8 hours, with 10 hours recommended, between duty periods.
The 80-hour work week mandate was established mainly out of concern for patient safety, due to the perception that residents were overworked and fatigued, resulting in poor decision-making, and ultimately, making medical errors that negatively impacted patient care. The Accreditation Council for Graduate Medical Education’s (ACGME) development of resident work-hour restrictions was the result of a variety of factors. However, a single unfortunate incident was certainly influential. In 1984, 18-year-old Libby Zion, daughter of lawyer and journalist Sidney Zion, died within 24 hours of admission to a hospital in New York City. Upon learning the physicians caring for his daughter overnight were resident physicians who were, in his opinion, overworked, Zion initiated a series of events, many through mainstream media appearances, which led to the development of resident work-hour restrictions in New York in 1989, and ultimately, the 2003 ACGME restrictions.
Contrived work-hour restrictions
During the past decade, there has been a significant increase in the number peer-reviewed published studies which have discussed the impact work-hour restrictions have had on patient safety, resident performance and confidence, the need for fellowships and the preparedness of residents to enter the “real world” after training. Resident preparedness is perhaps most critical to this discussion because once resident physicians graduate residency, they make clinical decisions, indicate patients for surgery and perform operations.
Anthony A. Romeo
When orthopedic residents become attending surgeons, they will not have contrived work-hour restrictions. Depending on the work situation, they may need to take call for 24 hours, and on their call, they may see patients and operate throughout the night. When the call shift ends the next day, the same physicians will have to proceed with normal responsibilities, which could include seeing patients in the office or performing surgical procedures. A consequence of the 80-hour work week, particularly the limitation of the hours permitted in consecutive duty, is residents who have completed training within the past 10 years may not be prepared to cope with performing surgery after being on-call the previous night.
In surgery, which emphasizes manual dexterity well beyond what is learned from academic study, it is critical trainees have ample opportunity to practice physical skills before they are responsible for surgical outcomes. As Malcolm Gladwell described in his book Outliers, it takes approximately 10,000 hours of practice to achieve mastery in a field. Gladwell’s conclusion was based on the study of successul people. Due in part to work-hour restrictions, current residents may be less likely to get the volume of needed training and may leave residency further away from the 10,000 hours needed for “expertise.” While some may advocate extending residency training to a sixth or even seventh year, this is not a feasible solution for most training programs given funding concerns. This also does not solve the problem of residents not being prepared for times where they are on-call one night and have to do elective cases the next day.
Declining operative experience
The impact of a potentially declining operative experience for residents has been evaluated in several studies, and orthopedic residents and faculty have reported an overall negative impact of work-hour restrictions on the operative experience. In 2013, Drolet and colleagues reported survey results of 1,013 residents in surgical training programs who were asked to comment on the impact of the 2011 ACGME duty hour regulations had on education, patient care and resident quality of life. Nearly two-thirds of respondents disapproved of the restrictions. The authors concluded work-hour restrictions have not led to improved education, patient care or resident quality of life, and that “It may be difficult for residents, particularly in surgical fields, to learn and care for patients under the 2011 ACGME regulations.”
Govindarajan and colleagues recently reported on the outcomes of 39,978 patients who had elective daytime procedures performed by 1,448 surgeons who treated patients from midnight to 7 a.m. the previous day, and compared their outcomes to patients who had the same procedures by the same surgeon on a day when the surgeon was not on-call the previous night. They found no differences in death, readmission, procedure duration, hospital length of stay or complication rates between the groups.
Future research
Rachel M. Frank
The 80-hour work week has significantly changed resident training, but no convincing evidence supports the position that the mandated restriction of resident duty hours has had a positive, measurable impact on the quality or safety of patient care. One sensationalized example of alleged poor judgment in the care of one patient, fueled by the media, with allegations not supported by previous or contemporary scientific analysis, has resulted in a dramatic paradigm shift in the education of physicians. The paradigm has been in place for more than a decade, which has provided the opportunity for scientific study to assess the impact of artificial work-hour limits.
For many involved in orthopedic surgeon education, the contrived limitation has resulted in unintended consequences of decreased direct patient care and less supervised practice of technical skills. Future research efforts should focus on scientifically based strategies to improve residency education and training. Future orthopedic surgeons deserve an opportunity to appropriately progress to have the potential of developing competent skills as orthopedic surgeons in the “real world” where work-hour restrictions do not apply.
- References:
- Drolet BC, et al. JAMA Surg. 2013;doi:10.1001/jamasurg.2013.169.
- Govindarajan A, et al. N Engl J Med. 2015;doi:10.1056/NEJMsa1415994.
- Immerman I, et al. Am J Orthop. 2007;Dec;36(12):E172-9; discussion E179.
- Zuckerman JD, et al. J Bone Joint Surg Am. 2005;87(4):903-908.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
- Rachel M. Frank, MD, is a fifth-year resident at Rush University Medical Center. She can be reached at 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: rmfrank3@gmail.com.
Disclosures: Romeo reports he receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed. Frank reports no relevant financial disclosures.