In her role overseeing residency training programs at UMass Medical School, Deborah DeMarco, MD, is not surprised by a recent study that shows no great benefit from a reduction in continuous work hours for first-year residents that was instituted in 2011.
“Many in the graduate medical education community feel that the more restrictive hours have not produced the desired effect—or at least we have not seen any proof of this—which is more rested residents and safer patient care. We also have not seen a corresponding increase in board scores, a proxy for medical knowledge,” said Dr. DeMarco, who is associate dean for graduate medical education and senior associate dean for clinical affairs.
The study, published online in the current issue of JAMA Internal Medicine, was conducted by researchers at Johns Hopkins. It looked at the unintended consequences of the 2011 Accreditation Council for Graduate Medical Education (ACGME) restrictions that reduced the continuous-duty working hours of first year interns from 30 to 16. According to a report, limiting the number of hours medical trainees can work continuously failed to increase the amount of sleep they got per week and dramatically increased the number of potentially dangerous handoffs of patients from one trainee to another. They also found that reduced working hours led to reduced training time.
“I agree that we need rigorous studies to determine if the duty hours are changing the environment for patients,” said DeMarco. “The trade-off for potentially better-rested residents is a marked increase in hand-offs, which is the most vulnerable time for medical errors.”
The ACGME first imposed national regulations of work hours for residents in 2003; the 2011 changes require rest periods between work periods, increased supervision for junior trainees and a 16-hour limit on continuous duty hours for first-year residents.
“We are very concerned about the shortened hours for interns particularly and how residents in general are going to learn everything they need to know,” she added. “They no longer follow patients they admit over time to see the progression of acute disease. In part this is due to shortened length of hospital stay as well as duty hours limits. There are particular concerns in surgical specialties that residents are not performing the cases they need to become competent, although we very strictly monitor case logs. We are also not really training residents for the rigors of being attending physicians.”
“On the other hand, the new 16-hour restriction for interns makes sense in many ways because prior to this, we had our least experienced trainees in the hospital at night without direct supervision. The new duty hours attempt to link graded responsibility to level of training.”
DeMarco concluded by saying, “We need data to prove that the duty hours regulations are in fact adequately addressing the issues they were put in place for. There is some sentiment for lengthening residency training—but no one is willing to pay for it.”