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Wednesday Dec 07, 2016

Time to Lift 16-Hour Limit on First-year Residents

The rules regarding residency work hours have changed significantly in recent years, and now it appears likely they will change again. The 16-hour limit placed on first-year residents, which was instituted just five years ago, could already be on its way out.

The Accreditation Council for Graduate Medical Education (ACGME) recently introduced a new Common Program Requirements proposal(www.acgme.org) that would allow residencies to expand first-year residents' work hours from 16 hours to up to 28 hours (24 hours plus four additional hours, if needed, to complete care for an individual patient). Given the importance of residency training and the work hour rules that govern this experience, it is well worth an examination of how we arrived at this point, as well as where the AAFP stands on the new rule proposal.

The term "house staff," which used to commonly apply to residents, comes from an era in the early 20th century when residents were responsible for nearly all patient care. To handle this, they essentially lived in the hospital. Of course, this was a time of less supervision but also less medical complexity. Chronic disease was far less common -- as was our expansive range of treatment options that carry a wide array of potential interactions and side effects.

No formal limits were proposed for residency work hours until 1989, when New York instituted them for all residencies in the state pursuant to recommendations from the Bell Commission. That commission had recommended such restrictions two years earlier after the death of Libby Zion, a young woman who died from serotonin syndrome after being prescribed an inappropriate combination of medications by two residents who had gone more than 30 hours without sleep and were not being supervised by an attending physician.

As time passed, more states adopted work hour limits that were later codified by the ACGME(www.acgme.org). The ACGME argued that they were needed to prevent extreme fatigue among residents and reduce the likelihood of medical errors, and it developed a system to penalize nonadherent programs. The argument for work hour limitations is supported by research that suggests sleep deprivation is associated with increased workplace accidents(www.nejm.org) and reduced productivty.

In the early 2000s, these limits were again questioned. Ongoing debate resulted in a further reduction in work hours, so that in 2011, the number of continuous hours a first-year resident could work was reduced to 16. This move was quickly met with consternation from senior residents and some faculty who, with interns working fewer hours, were forced to provide more coverage. Although intern satisfaction was shown to have risen, this coincided with a decline in senior resident and faculty satisfaction.

Yet beyond the calculus of who would provide the requisite long hours of patient coverage, another argument against shortened work hours arose: The limits that had been intended to improve patient safety were actually making patients less safe. This argument had been made in years past, with some programs noting that shortened work days for first-year residents necessitates increased handoffs. In clinical medicine, it has been shown that care transitions are more likely to precipitate medical errors because there is an increased likelihood that information from a health care professional who has taken care of a patient for some time is not fully or faithfully transmitted to the health care professional assuming that care, creating opportunities for missed care elements or unnecessary duplication of care. This was significant because it directly refuted the argument that longer working hours jeopardized patient care. The argument against shortened hours therefore became more aligned with the principle of "Primum non nocere" -- "First, do no harm."

Furthermore, the educational welfare of interns was cited as a reason for longer work hours. This argument suggested that the continuity of care provided by longer hours is a key component to the education of new physicians. The increased hours are meant to provide more clinical responsibilities and a panel of diverse patients and diseases, both of which are fundamental to clinical learning. Shorter clinical hours would compromise these benefits. Additionally, shorter intern hours put more demand on senior residents and attendings, who contend that this impedes their ability to perform their necessary supervisory roles and limits time to provide educational opportunities.

Of course, the counterargument is that sleep deprivation has been shown to be associated with reduced learning and memory formation, and shorter hours would give interns more time for self-study.

The ACGME has proposed resolving these two perspectives by again increasing hours. Between concerns for patient safety and intern satisfaction, the AAFP has given priority to the former, putting the Academy in alignment with the ACGME. Stan Kozakowski, M.D., director of the AAFP Division of Medical Education, recently told MedPage Today(www.medpagetoday.com), "The ACGME has done its homework. It has done due diligence around looking at the current literature and looking at the professional development of learners and put patient safety right up front."

Kozakowski said the ACGME proposal recognizes that duty hours -- or, as they are now being called, clinical and educational work hours -- cannot be considered in isolation, but rather with respect to the larger clinical learning environment that includes resident supervision, care transition management, fatigue recognition and mitigation, and other factors. This larger context, he said, is intended to protect patients as well as residents and improve the educational experience.

For those of us involved in medical education, this issue will significantly impact the residents we oversee -- who are our soon-to-be colleagues. I bring this to your attention because the comment period for this proposal(www.acgme.org) is open through Dec. 19. Please feel free to submit your comments before then.

Matthew Burke, M.D., is the new physician member of the AAFP Board of Directors.

Posted at 01:40PM Dec 07, 2016 by Matthew Burke, M.D.

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