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Safety data support resident work-hour limits

Patients may be safer, but the debate over the best way to reform resident training continues.

By Myrle Croasdale, amednews staff. June 25, 2007.

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Roughly 10,000 lives are being saved a year because residents are more alert, researchers said in what may be one of the first national looks at the impact of resident work-hour restrictions on patient outcomes.

In the July 17 Annals of Internal Medicine, researchers examined the outcomes of 1.2 million internal medicine patients at teaching hospitals in 2001 and 2004, before and after work-hour limits were imposed in July 2003. They compared the data with patient outcomes at nonteaching hospitals and found the mortality rate for internal medicine patients fell 0.25%.

Charles A. Czeisler, MD, PhD, director of sleep medicine at Harvard Medical School and Brigham and Women's Hospital in Boston, an advocate for more limitations on trainees' hours, called the results impressive.

"The fact that even a slight reduction in work hours results in a significant reduction in mortality reveals the hazards of forcing interns and residents to work schedules that require acute and chronic sleep deprivation," he said. "Moreover, these results reveal that major gains in patient safety could be obtained if meaningful reform of work hours were implemented [such as limiting overnight call]."

The researchers gathered mortality data on 20 medical and 15 surgical diagnoses and compared the results at teaching hospitals with nonteaching hospitals. The assumption was that patients at teaching hospitals were treated by residents, while patients at nonteaching hospitals were not. Some patients may have been misclassified as being cared for by a resident when they were cared for by an attending; however, researchers tested for misclassification errors and found they were not statistically significant.

In this comparison, mortality rates for medical patients fell, but those for surgical patients stayed the same.

Kanaka Shetty, MD, lead author of the study, said the difference might be due in part to the smaller number of surgical patients in the study, slightly less than 250,000. Also, he said, the reduced hours made the biggest difference for first-year and junior residents, who handle the bulk of overnight call. Senior surgical residents may not have seen their schedules change much. If their level of fatigue was unchanged, there would be little reason to expect their patient outcomes to change.

But as evidence mounts that reducing resident fatigue is improving patient outcomes, the medical community is still debating how best to reform resident training and improve patient safety.

"The short-term effect appears to be that residents are less tired and are making fewer errors. But you have to wonder if this limit on resident education may have long-term consequences in terms of residents' experience," Dr. Shetty said.

Deborah DeMarco, MD, president of the Assn. of Program Directors in Internal Medicine, said while she had not seen this particular study, she is concerned about the trade-offs with work-hour reforms.

"I worry whether we've created a shift mentality and that residents have developed a lack of ownership for patients," she said. "It's a push-pull, a tug of war between patient safety and resident education."

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