Resident duty hours: Does more sleep mean safer care?
■ Six years after resident work limits took effect, the impact on safety is still hotly contested. A push for more sleep is reigniting the debate.
By Kevin B. O'Reilly amednews correspondent — Posted Oct. 5, 2009
"Oh, I forgot all about that," Monal Joshi, MD, responded to a question from a senior resident during morning report. The internal medicine intern, entering the 25th hour of a 30-hour shift at Rush University Medical Center in Chicago, had overlooked a patient's test result.
The slip was quickly caught by a supervisor, and no harm was done. But was the resident's momentary lapse due to fatigue?
Dr. Joshi had at least two hours of sleep the night before -- pretty good for when she's on call.
Some other members of the five-person Rush internal medicine residency team looked worse for wear as their shifts neared the end one day last spring. Third-year medical student Shikha Wadhwani rested her hand on her head, blinking slowly and yawning widely, as the others went through their reports.
But Yoojin Kim, MD, an intern who slept from 3:30 a.m. to 6 a.m., looked bright as a fluorescent light as she sped through her patient reports.
Sleep scientists say staying awake for more than 16 hours decreases the ability to concentrate, impairs memory and hinders the ability to do tasks such as tracking test results on a monitor.
Yet sleep deprivation does not affect everyone the same way. Such is the enigma of the debate on whether resident duty-hour limits have helped patients.
Six years have passed since the Accreditation Council for Graduate Medical Education cut resident workweeks to 80 hours. The council also restricted shifts to 24 hours of call plus six hours of patient transition and educational activities.
Some health leaders said cutting back the weekend-long shifts and 120-hour workweeks that were common before the 2003 rules would yield a safety benefit -- fewer patient deaths and fewer complications. But it is hard to make a definitive, evidence-based argument that the work-hour limits have improved patient outcomes, experts said.
More adjustments could be on the way. The ACGME is examining whether to adopt a 16-hour shift or mandate a five-hour nap in each 30-hour shift. Those are among changes recommended by an Institute of Medicine panel in a report issued in December 2008. The ACGME could propose new rules next February, taking effect as early as July 2011.
The American Medical Association supports the 80-hour workweek. Its Council on Medical Education will deliver a report at the November Interim Meeting with recommendations about the IOM report.
Examining impact on safety
Kathlyn E. Fletcher, MD, has published systematic reviews of work-hour safety studies and is part of a team helping the ACGME sort through more than 5,000 articles on residency education published since the 2003 rules took effect.
"There is not much evidence to suggest mortality has gotten worse. At worst, it has not changed and, at best, maybe it has gotten better," said Dr. Fletcher, interim section chief of general internal medicine at the Clement J. Zablocki Veterans Affairs Medical Center in Wisconsin. "The studies that have looked at things like complications are more difficult to interpret. Some studies find more complications, and some find fewer complications, and some have shown no change. There's probably a finer look that needs to be taken, but at this point, it looks pretty positive."
Two of the biggest studies of clinical outcomes to date, published in the Sept. 5, 2007 Journal of the American Medical Association, highlight the equivocal nature of the evidence.
The time-series studies, done by the same research team, looked at 30-day mortality among nearly 320,000 VA patients and more than 8.5 million Medicare patients from 2000 to 2005. The duty-hour rules were associated with a significant mortality improvement for VA medical patients, but no change for VA surgical patients. In the Medicare population, mortality did not significantly improve or worsen.
Vineet Arora, MD, who is working with Dr. Fletcher on the literature review, said more sleep does not automatically mean safer care.
"Whenever you restrict hours, there will be more handoffs," said Dr. Arora, associate program director of the University of Chicago Pritzker School of Medicine's internal medicine residency program. "There are more handoffs in ... teaching hospitals now, and we know they can lead to patient harm. One of the difficult things to isolate in a complex system is what is the contribution of handoff error to patient harm?
"You have the tradeoff between having a fatigued doctor who knows the patient well and a well-rested doctor who may not know the patient. How good is the handoff that the well-rested doctor can take over very well for the fatigued doctor who signed out?"
John R. Potts III, MD, general surgery residency program director at the University of Texas Medical School at Houston, said the safety evidence does not support shorter shifts.
"The data to say that patient care has improved since the 2003 duty hours were instituted is completely lacking," Dr. Potts said. "I don't think anybody would reasonably argue that a better-rested doctor would not typically make better decisions. But the counterargument, though, is that we do have multiple levels of oversight of graduate medical education in this country.
"You can only provide 24-hour care with reduced duty hours by increasing the number of handoffs, and there is a hopefully small but still universally recognized fumble error in handoffs. So it becomes a question of the lesser of two evils."
The sleep-versus-handover tradeoff is one that residents struggle with daily.
"The 30-hour requirement made it very challenging sometimes, because I needed to be out at 1 p.m.," said Jessica Rouse, MD, who completed a family medicine residency at Fletcher Allen Health Care in Vermont this year. She now practices in Middlebury, Vt. "If I had a couple of hours in the middle of the night, I thought, 'Is it worth it to get a one- or two-hour nap in to be much more efficient in the morning rounds, or should I use that time to do paperwork?' Because when those 30 hours were up, I wanted to make sure everything was done so that I could hand off my patients all tucked in."
Many experts said the recommendation for a five-hour nap in a 30-hour shift was unrealistic, because residents might work during that time.
The IOM's recommendations were based principally on sleep science, said Maureen Bisognano, who served on the panel and is executive vice president and chief operating officer of the Institute for Healthcare Improvement in Massachusetts. The measured effect of the 2003 work-hour rules on patient outcomes was less clear, she said.
"It was a difficult thing to get our hands on in the six years since the new rules took effect, because I don't think the science points us in one clear direction or the other," Bisognano said. Testimony and data from the aviation and trucking industries showed that learning would not be impaired, "but patients would be safer because they would not be in the hands of fatigued providers."
Safety hard to measure
Bisognano argued that reducing medical-resident fatigue alone might not be sufficient to improve patient safety in teaching hospitals. "It's a system of safety, and it all needs attention," she said. "Unless we get to that point where we are looking at the whole system, then incremental change in one piece or another won't give us the kind of change we need and that we owe our patients."
Robert Wachter, MD, chief of the medical service at the University of California, San Francisco, Medical Center, said it is no surprise that the purported advantages of better-rested residents have not shown up strongly when studied.
"One of the challenges in the safety field is that it's pretty hard to measure safety," said Dr. Wachter, a leading patient safety researcher. "It's possible [the ACGME work-hour rules] had some good effects in terms of safety, and it's just not a signal we've been able to detect so far."
Dr. Wachter opposes moving to a 16-hour shift, because it would shorten the handoff process, interrupt continuity of care and worsen residents' learning experiences. "Too much additional regulation may harm as much as help."
Even if moving to a 16-hour shift and giving residents more time off would improve patient safety, some residents prefer the current work schedule. "If you're doing 16-hour shifts, maybe you go home to your own bed at like 11 p.m.," said Dr. Kim, now a senior resident at Rush. "You're dead tired, and you have to come back the next day at 7 a.m., and maybe you get five hours' sleep.
"I feel like on my post-call days, I get to go home and I don't have to think about anything for the rest of the day. I get home by 1 or 2, then I sleep for 14 hours straight -- and I love it."