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Sleep over Safety?

[OP/Note] Should graduate medical education focus on understanding the difference between 2 eras in duty hour restrictions?

Dr. Atul Grover, the Chief Public Policy Officer of the AAMC, alerted me to the fact that Public Citizen and the American Medical Student Association were up in arms over the current study deliberating between the 2003 and 2011 ACGME duty hour rules.


While I am no expert in the subject, as a product of the 80-hour workweek (I trained between 2006 and 2010) my firm belief is that the 2011 duty hour restrictions go too far. And while I hated being on call for 30-hours, driving home “sleep-drunk”, catching a few zzz’s on my post-call day, and then returning right back to work the next, I do believe I knew my patients better when I met them in the emergency department and carried them through their entire admission. Something about picking a patient up the next day from the night float team just didn’t provide the same amount of continuity and investment that today’s physicians need to learn during their formative years.

So reading the objections, I went to find what the evidence would say about the subject.

Source: Pubmed

Source: Pubmed

Recalling a study in JAMA Internal Medicine from 2013, it’s clear that the 2011 duty hours restrictions (which essentially eliminated overnight call for interns) lead to decreased work hours, without any significant change in sleeping habits or well-being for residents. All of this occurred while leading trainees to dramatically feel that patient errors were more commonplace (by over 15%).

We all know it is much easier to adjust internal medicine schedules to accommodate the 2011 ACGME duty hours, however the surgical experience has been much more difficult.

I found a systematic review from the Annals of Surgery that indicated that most studies addressing this issue show that patient safety and resident education suffered as a result of the 2011 duty hours, while the 2003 duty hours were safer for patients and residents.

“There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented.”

Source: Pubmed Central

Source: Pubmed Central

Again, I am no expert at this particular issue, but from what I do know – and from the available evidence – it seems to me that we ought to at least study the issue if not go back to the 2003 regulations that limit duty hours to 80-hours per week and 30-hour overnight call. Otherwise, you can have a well-rested resident caring for you now at a teaching hospital, but a poorly trained community hospital attending with a shoddy work ethic in 10 to 20 years.

 

Cedric Dark, MD, MPH, FACEP
About Cedric Dark, MD, MPH, FACEP

Cedric Dark, MD, MPH, FACEP is Founder and Executive Editor of Policy Prescriptions®. A summa cum laude graduate of Morehouse College, Dr. Dark earned his medical degree from New York University School of Medicine. He holds a master’s degree from the Mailman School of Public Health at Columbia University. He completed his residency training at George Washington University. Currently, Dr. Dark is an Assistant Professor in the Department of Emergency Medicine and a Health Policy Scholar in the Center for Medical Ethics & Health Policy at Baylor College of Medicine. He produces a health policy podcast for the American Academy of Emergency Medicine. Dr. Dark’s commentary and opinions on this website are his own and do not represent the views of Baylor College of Medicine or the American Academy of Emergency Medicine. Contact: Website | Facebook | Twitter | Google+ | YouTube | More Posts