Medical residents work less… but err more?

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.

Changes in key variables before and after 2011 ACGME reformsTo 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!

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Adrianna is a graduate student in public policy and public health at the University of Michigan.
Follow her on Twitter @onceuponA or subscribe to the blog.

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2 thoughts on “Medical residents work less… but err more?

  1. Cedric Dark says:

    As a clinician trained in the first iteration of the 80-hour work week era (i.e. still subject to 30 hours shifts as an intern), these findings were no surprise to me. While certainly more mistakes get made the more tired an individual is, even more are prone to happen with the unnecessary number of hand-offs and the lack of continuity inherent among today’s medical interns.
    I seriously doubt that work will be reduced by adding residency slots. Hospitals will use those slots in ways that are most advantageous to them. Thus, expect hospitals and teaching programs to use new residency positions to fill high revenue positions like cardiology or orthopedics (who are just as overworked) before allocating it to general internal medicine.

  2. Al says:

    When I was an intern in 1970 the working hours in the busy ER with little rest and almost no sleep was 16hr. on 16hr. off 16 hr. on 24hr. off

    As you can imagine many of the hospitals suits came from the ER that was manned mostly by interns with a resident in charge. I was told by the record and “suit” department that the hours in earlier years were 24hr. on 24hr. off. They stated that the majority of suits occurred after 16hrs. and thus the schedule was changed.

    The ER did not have any continuous care patients so that got rid of the problem of handing patients from one doctor to another. When one intern became ill there was no extra staff available so our hours went to 24hr. on 16 hr. off for a number of days. One can feel the difference.

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