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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 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. 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 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, "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 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.

Comments:

AAFP needs to support medical student, resident, and physician sanity and best personal and practice function. There is no support for best function with irregular or prolonged work hours - none.

Learning takes a lifetime and should not take a life - including the life of a resident.

There is no evidence for improved quality and outcomes before or after changes to work hours - because the outcomes are about the patient and other factors not related to resident care.

Posted by Robert C. Bowman, M.D. on December 08, 2016 at 01:29 AM CST #

There are quite a few studies out now about the ACGME work hours restrictions. They all say the same thing- there was no quantifiable impact on patient care, the attendings subjectively thought that the work hour restrictions were bad because back in the day when they were residents they didn't have them, and the residents generally were happier with the restrictions. Burnout is a major issue amongst all physicians, but especially residents, so why NOT keep something that improves their overall poor quality of life?

I call it "work hours restrictions" because let's not lie- residents are used as better-than-free labor to help to prop up a hospital's bottom line, particularly interns. Spending many thousands of hours in a hospital inpatient ward, OR, or labor and delivery floor is not very educational in the best of circumstances for nearly all family physicians, as the vast majority of family physicians practice ambulatory medicine in a clinic setting today. But yet interns spend a mere 3 to 6 hours a week seeing patients in a clinic compared to 80+ hours per week working in the hospital.

Posted by MO Family Doc on December 08, 2016 at 12:32 PM CST #

16 in-hospital hours is more than enough for an intern.
The AAFP must consider the silent existence of programs that routinely promote the violation and under-reporting of duty hours (including punishing/blacklisting the resident if he/she were indeed to report the correct amount). Another frequently occurring problem is that both residents and attendings often have no choice but to continue their charting at home, making the 16 hours workday closer to 20 hours/day. While seniors overall have less charting to do, increasing interns' duty hours would only further add to the problem, as the work compounds and takes away any consistency in the daily schedule.
The answer to inadequate patient handoffs is better patient handoffs...but this is closely related to patient workload and having a standard sign off routine. It is inextricably tied to having an adequate amount of residents and faculty per program, and limitations to adjunct obligations/contracts. Small residency programs especially, are stretched very thin, making it quite difficult to meet requirements in the breadth of family medicine. Hospitals push for increased productivity, non-aligned additional requirements, while decreasing cost, overhead and resources. This ultimately unloads onto the residents and the focus is taken out of education and delivered onto profit. Less precepting, less knowledge, scarce time for self study and personal well-being, means higher risk in mental fatigue, burnout, apathy, and ultimately, a fall-out in caring about patients and about medicine. A preventative measure, the 16 hour rule becomes a potential buffer zone for an intern: where the primary workload and hardest learning curve lies.

Posted by Anonymous on December 08, 2016 at 01:06 PM CST #

The comments posted to date are excellent.
I would simply encourage we practice evidenced based medicine, in policies, as well as practice.
The decision of residency hours affects many, and should not be decided by a few.
At the least at survey of family physicians not directly associated with a residency program should be considered as an inquiry into this issue.

Posted by Ron Greco, MD on December 08, 2016 at 03:33 PM CST #

The traditional educational model many of us trained under --that we will learn more by working 120 hours or more a week-- is fallacious, flawed, and dangerous. Such a practice places the patients under our care in harm's way. Just as pilots have a mandated "crew rest" allotment, so, too, should our physicians-in-training (and attendings, for that matter) have adequate time to recharge and recuperate between demanding stints of patient care. We do not learn more by becoming exhausted, apathetic, and cynical (as often happens to resident docs.) No, we learn more by engaging with our colleagues, listening to our patients, and relaxing with our families. Meaningful clinical experiences rather than marathon work sessions will create the empathic, caring, well-adjusted family physicians our country needs.

Posted by Brad Meyers, MD, FAAFP on December 08, 2016 at 04:08 PM CST #

It is just common sense that people should not work more than 16 hours straight!

Posted by Larry Kipe on December 08, 2016 at 04:40 PM CST #

Having been 30 years in practice 26 as residency/university faculty and 20 as a residency director, this is a difficult issue to broach. It is not OK to work 120 hours a week like ,myself and contemporaries did, but I cannot help but notice that graduates are not as well prepared for practice, particularly in rural and full-scope (outpatient/inpatient rural ICU and OB) as they were even 15 years ago.

My specialist colleagues all would agree, and we hire many graduates for a 280 physician multi-specialty medical group/year. We have "graduates" of OB/GYN residences that have done maybe 1 or 2 hysterectomies in training- I did more in my internship.

What used to be learned in residency is no longer available to any trainees- and frankly, when you are a rural FP, 36 hours is often the expected length of a shift- sometime that extends to a 72 hour weekend . There is a paucity of literature that defends a 16 hour day as being good for patient care, but a growing body of research (and plenty of anecdotal support) that fragmented care is harmful. There is a lot to be said for the independence that is fostered looking after patients (with available back up) while on call.

There are 2 clear choices here, based on hours of experience, and competency of graduated trainees: either lengthen residencies of all types by up to 2 years, or go back to a compromise between 120 hours a week and 80- I thought the 80 hours/week rule worked well- providing it was adhered to.

Many residents in my rural FP program begged to stay to get experience- and this should be allowed rather than forcing an arbitrary work "shift" onto willing, able, awake and non -coherced learners.

Reality is in many situations, you will never have the luxury of calling in "back up" when you are in rural America- because you are the OB, the ED and the hospitalist-and there is no pipeline of primary care doctors in the future that are coming to take these jobs- because there is no cogent policy for attracting FP's to training or keeping them in practice.

Professionals are dedicated to their patients, and care less for policy and out of control regulatory interference than for self regulation and help when necessary- and there is no scientific evidence except in other unrelated work, that any policy or rule is superior.

Posted by Robert Ross on December 08, 2016 at 08:11 PM CST #

I spent two years in a surgical residency program working 120+ hour weeks for several months at a time before changing to family medicine. I burned out, and I can't say that I've ever recovered. One of my surgery co-residents committed suicide. Studies show remarkably high levels of depression in medical students, and a recent study showed that 70% of residents meet criteria for burnout.

It is remarkable that a cocaine addict (Dr. Halstead) normalized living in the hospital and we still use this model. This is inflammatory to say, but it must be said: the push for more hours comes nearly exclusively from residency program directors and faculty who themselves have the _least clinically demanding_ schedules in our profession. There is a real moral hazard here and our young colleagues are burning out and killing themselves. I've spent most of my career working in a developing country with a dire shortage of physicians and am incensed by the casual association made between working long hours in training vs long hours as a seasoned physician.

I would certainly support increasing the number of years of training if it will ensure a humane work schedule. I am willing to provide testimony in any malpractice case where excessive duty hours is argued to be contributory. I would suggest naming AAFP as a co-defendant in such cases secondary to AAFP's support of the regressive policy. I probably will not renew my AAFP membership.

This is not an abusive post. The evidence shows that we are failing to protect our younger colleagues. We need to provide systemic changes to meet current challenges. We should not regress.

Posted by Anonymous on December 09, 2016 at 02:25 AM CST #

I am astonished that the AAFP & ACGME are considering this, especially given the epidemic of physician burnout we are currently experiencing. We need to be better role models for the incoming new physicians in terms of self care as well as patient care. After my year of internship with 36 hour shifts, I was ready to quit, and was very thankful for a psych rotation to start my 2nd year which allowed me to recharge and remember why I wanted to go into medicine. Patient safety is certainly important, but time for quality handoffs should be factored into the resident's shift. The bigger question is the shortage of physicians, especially in primary care, but we won't be able to improve that by "slave labor" of trainees, nor their trainors. We should rather focus on what we can do to change the economics of Health Care such that there is more money spent on training & income of physicians, espeically PCPs, allowing them time for quality of life, and less profits by the other health care industries (health care systems, insurance & pharmaceutical companies, etc.). I doubt any other professional organization would expect that primary work force to even consider these kinds of hours, especially any that are dealing with life-death decisions that impact all their patients.

Posted by Arlis Adolf, M.D. on December 09, 2016 at 11:15 AM CST #

I was in residency during the change from allowing 28-30 hour shifts for interns to limiting them to 16 hours. The result was creating rotating teams of interns. Now I am in rural practice and take 24 hour call shifts before a day at clinic just like doctors in most of the rural US. I feel those long shifts in residency helped prepare me for practice. I feel I have great work/life balance in practice. I also felt like I had decent balance in residency, because after a 28 hour shift, I had the next day off to sleep and then do whatever I wanted. The post-call days were great. The rotating shifts for interns did not allow them enough off time to do anything fun. Now, I do not think long term sleep deprivation is a good idea. However, it depends on the program how they make the schedule. But the reality is that doctors need to learn how to do 24 hour shifts, because there are not enough doctors in the rural US for 12-16 hour shifts.

Posted by Andrew Ellsworth, MD on December 09, 2016 at 01:56 PM CST #

I have never forgotten the morning 23 years ago during my OB rotation in a FP residency, where I had been awake for 24 hours and was doing morning rounds. I literally stood with an opened chart and a pen in my hand unable to write down the words I had in my brain but was so exhausted my hand would not cooperate. I knew at that point how crazy and dangerous it was to push people, even Type A super achievers, to their point of exhaustion. There was no way I, or many of my fellow interns, was safe to be making life and death decisions for patients after such episodes of sleep deprivation. I have never agreed with the old boy network of "I had to do it, so they can do it, too." We are in a severe shortage of primary care doctors and this is certainly not going to entice young people to join our ranks. I have been a member of AAFP since residency and supporting these new extended hours IS NOT SOMETHING I AGREE WITH. I would suggest AAFP take a poll of their members before supporting such a measure.

Posted by Rebecca Hammond , MD on December 09, 2016 at 08:47 PM CST #

Dear AAFP--you don't get to talk about physician burnout/medical student depression/suicide rates in residents AND promote interns working > 16 hour shifts. Healthcare is broken, and if you don't see how asking BRAND NEW DOCTORS--full of anxiety and insecurity--to be in charge of life and death decisions for more than 16 hours at a clip is unhealthy for everyone involved, you are part of the problem, and not part of the solution. Don't worry, they still get to put in 80 hours a week and have the post intern years of 24+ shifts. I'm disappointed if this stance is supposed to represent me as a Family Physician in Primary Care.

Posted by Jennifer Lipka on December 10, 2016 at 04:15 AM CST #

Nicely summarized from the Cost of Sleep Deprivation: "A lack of sleep among the U.S. working population is costing the economy up to $411 billion a year, which is 2.28 percent of the country's GDP, a new report finds. According to researchers at the not-for-profit research organisation RAND Europe, part of the RAND Corporation, sleep deprivation leads to a higher mortality risk and lower productivity levels among the workforce, putting a significant damper on a nation's economy.

Effects of sleep deprivation.
Credit: Mikael Häggström & Wikipedia

A person who sleeps on average less than six hours a night has a 13 percent higher mortality risk than someone sleeping between seven and nine hours, researchers found, while those sleeping between six and seven hours a day have a 7 percent higher mortality risk. Sleeping between seven and nine hours per night is described as the "healthy daily sleep range".

In total, the U.S. loses just over 1.2 million working days a year due to sleep deprivation among its working population. Productivity losses at work occur through a combination of absenteeism, employees not being at work, and presenteeism, where employees are at work but working at a sub-optimal level." end of quote from http://www.medicalnewsobserver.com/2016/11/sleep-deprivation-cost.html

Presenteeism is what happens when residents in training cannot or will not take days off? What happens to productivity, learning, and higher functions such as empathy, coordination, collegiality, and service orientation?

What are the impacts upon morbidity, mortality, and mental health of residents, students, and other team members?

And what happens when residents have life changes outside of medicine and a job that does not allow them to make these adjustments? How does that impact relationships, children, other family members?

What happens when traumatic events happen such as the death of critically ill patients or trauma victims or those close to you such as colleagues and you cannot or do not take time off? Then there are the numerous victims that we care for and those who turn to us for support when legal, social support, and other systems break down (more and more).

We are in the midst of justifying poor health and poor outcomes specific to the residents in training. We must stop this.

Medical associations charged with improving health are supporting poor sleep and poor health for the residents in training. As noted previously, there are numerous short and long term consequences of sleep deprivation. There is also a risk that sleep disturbances will become chronic.

Across health care and especially in residency training we need functioning teams with adequate staffing and support - enough support to allow appropriate adjustments with normal personal events and abnormal critical incidents.

AAFP needs to do much the same to support family physicians by working ceaselessly for substantially more support without having more hoops to address. We need enough support for the appropriate adjustments to normal personal events and abnormal critical incidents that impact us and our team members - which will be increasing as our nation ages and changes.

The solution for burnout, turnover, declining productivity, primary care woes, and mental health deficits is dependable and increasing support with declining regulation and other costly impediments to delivery and morale.

Posted by Robert C. Bowman, M.D. on December 10, 2016 at 02:12 PM CST #

I find it really disheartening that the AAFP is backing generally poor quality, retrospective trials regarding this issue. There are major problems with patient care, particularly centered around hand-offs, but I believe that many, if not all of these issues, are due to poor, rushed, and ineffective communication. Minimizing the need to communicate with others rather than teaching good communication and hand-off skills and maximizing system processes is not an appropriate solution. We will continue to see major problems in healthcare if we undervalue concise, complete, and effective communication. As a resident, I object less to the idea of working more hours and more to the idea that the AAFP, a group which I was proud to have joined, is bending to the mainstream rather than supporting the core values of family medicine.

Posted by Rachel on December 11, 2016 at 03:32 PM CST #

Dr. Lipka: I think the AAFP has made it more than clear that they don't give a hoot about burnout in either residents or practicing physicians. They are committed to advancing the interests of CMS, insurers, large hospitals, and the EMR industry - the physical, emotional, and spiritual destruction caused by the policies they push is considered completely acceptable wastage.

Posted by R Stuart on December 12, 2016 at 03:44 PM CST #

I disagree with the AAFP's support of what I see as a regressive policy. I have practiced in an outpatient setting for the past 15 years. I do not feel that the really long inpatient work hours during my residency helped me become a better physician. I am concerned about resident burnout and their physical, mental, emotional, and spiritual wellbeing. As far as an increase in hand offs, they are an inevitable reality. I think we all need to work on how to make these better, rather than avoiding them.

Posted by Anonymous on December 13, 2016 at 09:39 AM CST #

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