Making sure that the young doctor who’s treating you gets enough sleep might seem obvious. Having medical residents work fewer hours should translate into less fatigued doctors and fewer errors.
But some studies examining new restrictions on first-year intern work hours find that dialing down the length of shifts doesn’t necessarily translate into better care.
In 2003, the Accreditation Council for Graduate Medical Education recommended cutting back the maximum time that newly minted doctors could work without a break from 24 hours to 16. The rule went into effect in July 2011.
In a paper published Monday in JAMA Internal Medicine, a team led by University of Michigan Medical School scientists compared the performance of more than 2,300 first-year medical residents who served at 51 residency programs before and after the new duty hour requirements went into effect. Interns reported their hours worked, sleeping habits, depressive symptoms, sense of well-being and concerns about making medical errors on duty.
They found that while the interns’ average hours per week decreased from 67 to just over 64 after the new work restrictions were set in place, there were no significant changes in hours slept, depressive symptoms or sense of well-being. But the number of interns concerned that they had made a serious medical error on duty rose from 19.9 percent of subjects to 23.3 percent after the new duty hour rules were implemented.
"That's a 15 to 20 percent increase in errors -- a pretty dramatic uptick, especially when you consider that part of the reason these work-hour rules were put into place was to reduce errors,” lead author and University of Michigan psychiatrist Srijan Sen said in a statement Monday.
The problem may be that interns’ workloads have not been curtailed to match the new, shorter hours.
"Many interns entering after the new work hour restrictions took effect felt that they were expected to do the same amount of work as in previous years, but in a more limited amount of time, leading to more harried and tiring work schedules despite working fewer hours,” co-author and University of Washington medical resident Sudha Amarnath said in a statement. “Overall, they felt that there was less 'down time' during the work day compared to pre-2011 work schedules, which may partially explain some of the unexpected findings."
In another study published in JAMA Internal Medicine on Monday, researchers led by Johns Hopkins University physician Sanjay Desai conducted a trial comparing the old duty-hour regime with 2011-compliant schedules, and came to similar conclusions.
In that study, researchers randomly assigned four teams of interns to either a 2003 schedule, with interns on call every fourth night with a 30-hour duty limit, or to one of two 2011-compliant models with 16-hour duty limits – either being on call every fifth night, or a night float schedule, which is basically working from early evening to the early morning.
“Compared with a 2003-compliant model, two 2011 duty hour regulation-compliant models were associated with increased sleep duration during the on-call period and with deteriorations in educational opportunities, continuity of patient care and perceived quality of care,” the authors wrote.
In fact, the 2011-compliant night float model was deemed so bad for quality of care that it was terminated early, according to the authors.
"Dramatic policy changes, such as the move to 16 hours, without a better understanding of their implications are concerning," Desai said in a statement. "Training for the next generation of physicians is at risk."
One source of the perceived increase in medical errors on the shorter work schedule may stem from the phenomenon of “handoffs.” Patients now have to be passed between residents more, sometimes resulting in dropped information. One study published in June 2012 in the British Medical Journal’s Quality and Safety imprint suggested that the introduction of standardized web applications can help with the transition.