What are the Cost(s) of Duty Hour Limits?
Once again, duty hour limits are making headlines in the national media and the medical literature, as noted in the June 2009 issue of the AMA's GME e-Letter.
A study in the New England Journal of Medicine estimated that it would cost $1.6 billion per year to implement the Institute of Medicine's recommendations in its December report. Further, the authors state that the patient safety implications are unknown.
Following are the responses received from e-Letter readers. In the interest of confidentiality, each respondent's identifying information has been removed.
The recent news regarding resident duty hours once again highlights the dilemma between clinical service by residents and educating residents.
The various news reports dwell on the cost of limiting residents' hours rather than on the quality of the educational experience. For example, the reports noted that limiting residents' shifts to 16 hours would cost about $1.6 billion, and distributing the clinical service provided by residents to other hospital workers could cost as much as $2.5 billion.
Is the issue education or is it cost? For decades residents have performed clinical services that others prefer not to perform or that others do not perform because there has been no payer, governmental or other, for the clinical services. The 80-hour work week was implemented supposedly to eliminate the specter of residents too tired to learn and too tired to provide safe care. But, as noted in the news reports, where is the evidence? And what evidence does one seek?
At the same time, is the number of hours worked per week really the issue? Perhaps the issue really is not an 80-hour week but rather how many consecutive hours residents can work before they become too tired to learn and too tired to provide quality, safe clinical care. Another issue is when will health care payers and providers accept that residents are learners and other providers may need to take on certain care duties now provided by residents?
An 80-hour work week still enables a resident to work 24- to 30-hour shifts. That number of consecutive hours does not make for a rested resident who is able to learn and able to provide safe, quality clinical service. Rather, a restriction to working a maximum of 14 hours per 24-hour day with a minimum of 36 consecutive hours free each week would help residents be rested learners and care providers. Furthermore, the number of hours available for learning would not be affected.
The war stories about residents needing to learn how it will be to work long hours in "real life" is not a reasonable excuse. In "real life" does anyone want to fly with a pilot who has been on duty 30 consecutive hours or have surgery performed by a surgeon who has been working 30 consecutive hours?
I believe there has been a decline in the quality of resident education in internal medicine because of the duty hours requirement. We all understand the probable or definite impact of sleep deprivation; the current solution, however, is a poor one.
I believe each institution and every specialty within an institution should establish unique guidelines with periodic internal evaluations from residents, medical students, attending physicians, and faculty teachers. Once each year an institution's DIO should write a short document relating problems and solutions and--most importantly--state that the institution is continually evaluating the status of requisite duty hours. No inspections, just a simple certification mailed to the ACGME.
As a program administrator, I do agree that duty hour limitations do somewhat interfere with residents' learning experiences, especially when they cannot see a case through because they have to leave or can’t come to important lectures. At the same time, it does prevent residents being abused, as noted by several of my faculty when recalling their own training. And let’s face it, anyone would be fatigued after doing a 24-hour call—I know I would be.
My concern, however, is not about residents’ work hours, at this point, but faculty work hours. I know a lot of faculty who have to work a lot of hours due to duty hour limits and difficulties recruiting faculty and CRNAs at academic institutions. To tell you the truth, I wouldn’t want an attending (any more than a resident) giving me anesthesia after working 36 or more hours. And attendings supervise residents, so I think that, ultimately, the responsibility for errors due to fatigue lies with the attending and not solely with the resident. I think that residents are frequently scapegoats. It is much easier to blame a resident in training for an error than it is to blame a faculty person who has been practicing for years.
We have not had any incidents or problems in our program, but I’ve heard of this issue from several other program coordinators in various specialties, and I can see it potentially becoming a problem at some point. I think that more concern should be given to this issue, and I am truly surprised that in all of these publications nothing has been mentioned about faculty/attending fatigue and that the focus has been solely on the residents who are, let’s face it, "in training."
I fail to understand why the medical profession has a double standard. We are the ones who advise the general public about the importance of adequate rest in the form of daily sleep. When it comes to members of our own profession, however, we do not want residents to sleep at all. Talking about compromised training standards, especially in surgery, is plain BS. It all depends on how the whole training is designed. So wake up to the needs of members of your own fraternity and do justice. We already have damaged ourselves by letting others dictate rules to us simply because we don’t care for our own.
I just read with keen interest the article/review on neurological surgery training programs and the consideration to further reduce residents’ weekly work hours. As a nonphysician, but someone who has spoken with numerous neurosurgeons during my career as a physician recruiter, I believe the authors make several excellent and obvious points—not the least of which is how reduced hours would affect the experience these budding surgeons receive. I certainly appreciate balancing training hours and the potential fatigue a physician can experience from extended shifts; my opinion, however, is that further reductions would have adverse ramifications for the training these surgeons receive and thus the expertise they bring to the operating table as independent neurosurgeons beyond residency. Let’s be candid, choosing to be a physician is demanding and probably to a greater degree for a neurosurgeon. I think the ACGME’s implementation of an 80-hour week in 2003 was sufficient. To further reduce the hours and shifts (as suggested in the British standard) would be detrimental to the quality of surgeon being produced in US training programs.
I’m sure many other points raised in the article will be argued, but for me, this is the most important to consider . . . one that directly affects patient safety and quality of care. This addresses neurosurgery specifically; however, my hunch is that the same principle applies to other residency programs as well.
I would like to voice a very strong opposition to the proposed changes to ACGME duty hours. There is rumor that additional duty hour restrictions are coming, and I think it is an absurd idea. While I support the current restrictions, limiting total duty hours to 80 hours a week and the 24+6 rule for maximum duration of shift, we have yet to prove that these restrictions actually improve care.
The proposed restrictions to further limit duty hours to no more than 16 in a row fail to acknowledge some fundamental realities of caring for patients. While we are on duty, not in medicine but in subspecialty residencies, we may accept as many as seven to eight patients and get another seven to eight consults. This work simply cannot be accomplished in 16 hours. Further, to pass the work on to the next person leads to development of a "shift work" attitude in physicians, who are not and should not ever be shift workers.
It additionally puts patients at risk by increasing handoffs, a weakness in the system that has already been established. Further, working for 24 hours is not difficult. I am 37 years old, and can say that while pulling an "all-nighter" may seem difficult for those who do not do it on a regular basis, one gets quickly used to it and not even age alters this perception. People have been doing it for ages, and will continue to do so. Finally, to be gone from the hospital, with such limited access, simply reduces the opportunity for education. This is not time people will spend reading about their patients or sleeping, but relaxing and watching more television, on the whole.
For economic reasons, physicians will resist the idea of lengthening the duration of residencies to counter the loss of time spent learning in the hospitals, so these changes would result in less well-educated physicians in a culture of less dedication to the patient's interests-a change that can already be appreciated even by current residents working under the existing regulations.
I strongly disagree with further limiting duty hours, and I encourage prolonged deliberation after more research on the current restrictions, with greater disclosure about evidence and the rationale supporting these changes.