Charles E. Driscoll, MD Clinical Professor, Department of Family Medicine, University of Virginia, Charlottesville, and Director, Family Medicine Residency Program, Lynchburg, Va

The name Libby Zion may not be familiar to many residents today, most of whom do not realize how the events related to this 18-year-old woman changed their own medical education.¹ When Miss Zion died in the early hours one day in 1984, she was under the care of interns and residents who were showing fatigue after many hours of work. A New York grand jury that was convened for this case did not file criminal charges against the young doctors who committed some medical errors, but it did put into motion a series of regulations that, in July 1989, resulted in an overhaul of hospital rules and the New York State duty-hour legislation.¹ Fourteen years passed before these laws were adopted by the Accreditation Council for Graduate Medical Education (ACGME) to preclude federal regulation and legislation.

Since July 2003, all residents are restricted to work 80 hours per week, averaged over a 4-week period, a 10-hour duty-free period between shifts, and a maximum of 24 hours per work shift, with an additional 6 hours allowed for nondirect patient care. In addition, 1 day in 7, averaged over 4 weeks, must be free of all duties.² Four years after the initiation of these national duty-hour rules, we are beginning to examine their effects on medical education and patient care.

Good evidence supports the claim for the potential for harm to residents and their patients when duty extends beyond 24 hours. A resident who stays awake for 24 hours may experience impaired performance similar to that produced by a blood alcohol level of 0.10%.³ Interns make substantially more serious medical errors when they work frequent shifts lasting 24 hours or more in an intensive care unit.^4,5 A meta-analysis of the effects of sleep loss revealed that performance drops to 7% after 24 consecutive hours of wakefulness compared with performance in a fully rested state.⁶ When interns work extended shifts, they are at more than twice the risk for being involved in a motor vehicle crash on their way to the hospital and back.⁷ These findings underscore the importance of suggesting a change in medical education, by placing current limits on the frequency and duration of extended duty-hour shifts. Nevertheless, two axioms need to be carefully examined.

First, because medicine and education are interconnected systems and not silos of isolation, can it be shown that these systems are improved or at least unchanged by reducing work hours? A study in a large teaching institution has shown that duty-hour regulations have increased the clinical responsibility of attending faculty and decreased teaching time for the residents.⁸ Reed and colleagues have surveyed key clinical faculty (KCF) at 39 US internal medicine residency programs to assess the impact of duty-hour regulations on those who have the most contact with residents—their teachers.⁹ The KCF perceived that patient care provided by residents suffered from a loss of continuity, as well as from residents being unavailable for communicating with patients and families. Reed and colleagues also claimed that residents compromised their education by decreasing opportunities for didactics, bedside teaching, performance of procedures, and loss of autonomy, because faculty members began to take over additional tasks related to direct patient care. Although the majority of the KCF agreed that residents' well-being (fatigue and personal life) had improved, they also agreed that their professionalism (accountability, placing patient interests above self, and resident–patient relationships) was significantly worsened. In addition, they observed a significant negative effect on faculty workload and satisfaction, which could foreshadow a problem with recruitment and retention of academic physicians.¹⁰

With the loss of academic physicians will come the disenfranchisement of a large number of patients who depend on them for care, and fewer teachers imply less supervision of residents or downsizing of residency programs. Medical students' teaching will undoubtedly also suffer a decline in time and quality. It is also important to remember that the work is not diminished when the hours are. Hospitals are forced to incur additional expense for midlevel providers to fill the 20% gap in manpower as the workweek of residents diminish from an average of 100 to only 80 hours per week.⁷ It has been estimated that a reduction in adverse events of between 5% and 9% would be necessary to make duty-hour reforms cost-neutral from a societal perspective, but an even greater reduction of between 18% and 31% would be needed to make them cost-neutral for teaching hospitals.¹¹

Second, can we prove the assumption that the current duty-hour regulations will have a positive impact on patient care? Two recent studies provide preliminary data.^11,12 Trends in risk-adjusted mortality rates for Medicare patients hospitalized in short-term, acute-care US nonfederal hospitals were examined for differences between teaching-intensive versus less teaching-intensive institutions.¹² In the first two years after the institution of the ACGME regulations, neither a significant positive nor a significant negative change in mortality occurred. Potentially, some confounding variables, such as unreported noncompliance with duty-hour regulations³ or offsetting positive and negative effects that could not be teased out of the data, may account for the lack of a positive impact. When patients of the Veterans' Administration (VA) hospitals were studied, the teaching-intensive group showed significant improvement in mortality for a subset of medical patients with acute myocardial infarction; however, no significant changes occurred for surgical patients.¹³ Possible explanations for improved mortality were the greater number of residents per patient bed at VA hospitals, greater autonomy for VA residents, differing staffing models, and patient volumes.

Duty-hour regulations are not likely to disappear, even if some negative consequences were to be identified. Before we see any increase in the duty-hour limits, as has occurred in Europe, or before harsher penalties for noncompliance are enacted, more evidence-based information is needed to optimize the design of such measures and to study all their ramifications on medical education, quality of care, cost, availability of care, and physician workforce.

The ACGME is embarking on a series of pilot studies designed to gather more information about these issues. Whether temporary waivers of regulations are necessary for ensuring accurate information and results remains to be determined. All residency program directors are called upon to provide an honest report on compliance with the regulations to remove any doubt that it is confounding the results. Another productive area for study is to define the best use and function of healthcare teams. We are now impelled to find ways to optimize societal, patient, resident, and faculty experiences within the confines of these regulations.

References

1. French HW. In overhaul of hospital rules, New York slashes interns' hours. The New York Times. July 3, 1989.
2. Philibert I. Frequently-Asked Questions about the ACGME Common Duty Hour Standards (Updated April 2007). Available at www.acgme.org/acWebsite/dutyHours/dh_faqs.pdf. Accessed November 14, 2007.
3. Landrigan CP, Barger LK, Cade BE, et al. Interns' compliance with accreditation council for graduate medical education workhour limits. JAMA. 2006;296:1063-1070.
4. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838-1848.
5. Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351:1829-1837.
6. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28:1392-1402.
7. Lee CJ. Federal regulation of hospital resident work hours: enforcement with real teeth. J Health Care Law & Policy. 2006;9:162-216.
8. Harrison R, Allen E. Teaching internal medicine residents in the new era: inpatient attending with duty-hour regulations. J Gen Intern Med. 2006;21:447-452.
9. Reed DA, Levine RB, Miller RG, et al. Effect of residency dutyhour limits: views of key clinical faculty. Arch Intern Med. 2007;167:1487-1492.
10. Klingensmith ME, Winslow ER, Hamilton BH, Hall BL. Impact of resident duty-hour reform on faculty clinical productivity. Curr Surg. 2006;63:74-79.
11. Meltzer DO, Arora VM. Evaluating resident duty hour reforms: more work to do. JAMA. 2007;298:1055-1057.
12. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:975-983.
13. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:984-992.