by Adrianna McIntyre –
Since the most recent restrictions on medical resident shift limits went into effect, their medical errors have increased by about 15%. Nope, not an April Fool’s joke.
Last week, JAMA published a few pieces on the effects of “duty hour requirements” for US medical residents. The Accreditation Council for Graduate Medical Education (ACGME) phased in new requirements in July 2011, following 2003 changes that seemed to improve resident well-being and patient safety. The 2011 measures included a 16-hour limit on shift lengths for first-year residents, based on evidence that long hours harm both patients and the residents themselves.
To examine the effect of the recent requirements, University of Michigan investigators surveyed 2323 medical interns from 51 residency programs (gated). Their main conclusion may surprise you:
Although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being but has been accompanied by an unanticipated increase in self-reported medical errors.
Say what? The researchers offer several explanations for their findings.
To start, the requirement was largely designed to promote more sleep—except residents didn’t start sleeping more, leading to these suggestions from the investigators: try to adapt shifts to circadian rhythms or train residents in better sleep practices.
Another factor that might be at play is “work compression”—hospitals reduced residents’ hours, but didn’t hire additional clinical staff to fill the ensuing labor gap; the new ACGME requirements didn’t come with any kind of funding accommodation to offset duty restrictions. Consequently, residents may have been expected to do the same amount of work as their predecessors, just in fewer hours. Work compression is associated with decreased clinical performance and decreased resident satisfaction.
Increased patient handoffs may also be significantly contributing to increases in medical errors. With shorter shifts, patients are shuffled more frequently between residents, which can cause problems in continuity of care.
There’s a commentary (unfortunately also gated) offering strategies to address these problems. One suggestion is to increase schedule flexibility, potentially allowing for longer work shifts, but limiting weekly average hours and call frequency. Additionally, we could reduce work intensity (the compression issue) by increasing the number of resident slots. This—according to the authors—does the double-duty of addressing the perceived physician shortage. I’d like to caveat that we have a primary care provider shortage and provider distribution issues (geographically, doctors aren’t going where we need them most), not necessarily a broader physician shortage. These are important nuances if we’re going to talk about expanding the number of residencies available.
I’m not a medical student, but I know that a number of our readers are. Thoughts? Discuss!