Here’s a common joke I heard during my residency.
“What’s the problem with every other night call?”
“You miss half the cases.”
The gist was that the more you saw, the more you did, and the more you learned.
Because it was believed that patient safety suffered in the wake of such extensive hours, the Accreditation Council for Graduate Medical Education (ACGME) restricted the amount of hours residents could work.
In 2003, the ACGME limited the work weeks of all residents to 80 hours, averaged over 4 weeks, and on-site duty, including in-house call, to shifts of no more than 30 hours. These 30 hours consisted of a maximum 24 straight hours of duty and up to 6 additional hours, designed to give residents time for patient handoffs, outpatient clinics, and didactic activities, among other things.
In 2011, the ACGME restricted first-year residents to shifts of 16 hours, and other residents to 24 hours. For the latter group, “strategic napping…is strongly suggested,” especially after 16 hours of continuous duty and between 10 pm and 8 am. Residents beyond their first year also can be asked to stay after their shift if need be, but not beyond 4 hours.
In 2009, the Institute of Medicine suggested that studies should be performed to see if the change in hours impacted patient safety.
One study just wrapped up and the data is being analyzed. It was called FIRST. Flexibility in Duty Hour Requirements for Surgical Trainees. That study included ~160 hospitals across the country. General surgery residents were randomly assigned to one of two arms. The first was the status quo – embracing the long standing ACGME restrictions. The experimental arm was free to ignore all ACGME restrictions except three: Residents still could not work more than 80 hours a week on average nor take in-house calls more frequently than every third night, and they had to have at least 1 free day per week on average. So, it was possible to have a 30-36 hour shift.
The primary outcome measure is patient death within 30 days. Secondary outcome was serious morbidity.
The second trial is called iCOMPARE. Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education. This study will address internal medicine residents at 63 hospitals. The experimental group will mirror that of the surgeons in the FIRST study.
The chief investigator of the surgeon study, Dr. Bilimoria, stated “There’s a balance. Sleepy residents may commit errors, but breaks in continuity of care can make for worse patient care.”
Asked whether the experimental study embraced informed consent, Dr. Bilimoria replied that if residents strongly disagreed with the prospect of longer hours, “they could choose to work elsewhere.”
Dr Bilimoria said he has not heard of any complaints from residents in FIRST about extended shifts. Instead, “the enthusiasm among residents and faculty has been high,” because duty-hour flexibility improves patient care, particularly by reducing patient handoffs.
It is undisputed that the more hours you spend in a hospital during a residency the more you will see. And it is presumed you will learn more. The question is whether the benefits outweigh the risks. We’re about to find out.