Work-hour limits reduce resident fatigue and confidence

Restrictions on the number of hours in a week that resident physicians can work have helped decrease fatigue among young physicians but may make them less prepared to practice medicine, according to an Annals of Surgery study published online Oct. 12.

Researchers surveyed 216 orthopedic residents before and after the implementation of work-hour rules by the Accreditation Council for Graduate Medical Education in 2003. Residents reported feeling less fatigued as a result of the changes, although the amount of sleep they received did not change significantly. Residents surveyed slept an average of 34.6 hours per week in 2003, compared with 33.7 from 2004 to 2009, the study said (link).

“This really challenges one of the primary assumptions about duty-hour standards — that if you let obviously-tired residents go home earlier more often, that they would sleep more. But they’re not sleeping more,” said Debra Weinstein, MD, senior study author and vice president for graduate medical education with Partners Healthcare in Boston.

The results suggest that residents’ perceptions of fatigue are related to other factors, she said. “It’s not just about sleep. There may be other ways that fatigue is impacted. It may be that more leisure time is more important.”

All physicians in the study participated in the Harvard Orthopaedics Combined Residency Program. Implementation of the ACGME rules reduced the number of hours per week residents spent performing major procedures, from an average of 31 in 2003 to 25.4 in 2004-09.

Residents surveyed after 2003 also cited significantly less confidence in their preparedness to make clinical decisions under stress and lower satisfaction with their educational experience. The number of hours the average resident worked decreased from 74.5 hours per week to 66.2 in 2009, the study said.

The 2003 rules limited resident workweeks to 80 hours, with a goal of improving patient safety and ending the 120-hour workweeks that had become common during training. They also placed new requirements on the supervision of residents and their workloads.

In July 2011, the ACGME implemented revised rules. Changes included increasing resident supervision, limiting first-year residents to 16-hour shifts, educating residents and faculty about sleep deprivation, and ensuring effective transfers of patient care.

At that time, council officials called for more studies to monitor the impact of work-hour standards and guide future revisions.

ACGME Chief Executive Officer Thomas J. Nasca, MD, said the Annals study contributes to that growing body of research. “This is a well-constructed study that adds to the mosaic of research studies on the impact of resident work-hours standards implemented by the ACGME in 2003,” he said.

Dr. Weinstein said more research is needed. “I don’t think anyone sees the current requirements as the final stop in this evolution. This is an evolving issue where we are continuing to learn the impact of work-hour limits,” she said.