On March 10, 2017, the Accreditation Council for Graduate Medical Education (ACGME) announced a controversial decision. They decided that, effective July 1, 2017, the maximum work shift for medical interns would increase from 16 to 24 hours. Work hour restriction is a decades-old debate in medicine that raises many valid arguments on both sides of the fence. Was increasing the work hour limit from 16 to 24 the right decision?
Investigations into the effects of long work hours of resident physician performance began in the 1970s. Friedman and colleagues (1971) published a study that demonstrated the relationship between performance and work hours. They had well-rested (a mean of 7.0 hours of sleep) and poorly-rested (a mean of 1.8 hours of sleep) interns read electrocardiograms. Well-rested interns made fewer mistakes than poorly-rested ones. Following this, and several similar studies, the ACGME began to implement regulations stating that “[h]ospital duties should not be so pressing or consuming that they preclude ample time for other important phases of the training program or for personal needs.” However, it is not clear that residency programs followed these recommendations. It is likely that actual work hours exceeded mandated work hours (as reported by Drolet and colleagues). The work hour issue was a ticking time bomb waiting to explode.
The explosion came in 1984, when the death of Libby Zion pushed resident physician work hours into the spotlight. Ms. Zion was an 18-year old college student, who, her father Sidney Zion argued, died under the care of overworked and tired physicians. On March 4th, 1984, Ms. Zion presented to New York Hospital with a week of fever and sore throat. She was admitted for a viral syndrome and initially appeared to be stable. Overnight she developed a fever of 107.6 degrees and had a cardiac arrest the next morning. Ms. Zion most likely died due to serotonin syndrome, secondary to the interaction of meperidine and the monoamine oxidase inhibitor phenelzine. The negative publicity prompted the formation of the Bell Commission, which was charged with making recommendations related to medical education reform. It suggested that residents be limited to an 80-hour work week, with no more than 24 consecutive work hours, and that an attending physician be present at the hospital at all times. These were implemented by New York State in 1989 in Code 405.4.
It was not until 2003 that the ACGME implemented the first nationwide and specialty-wide limitation on resident works hours based on the Bell Commission recommendations.[9,10] The regulation was eventually revised in 2011, capping interns at 16-hour workdays. However, the issue once again entered the spotlight on March 10, 2017, when the ACGME announced the return of a maximum shift length of 24 hours for interns. In order to evaluate the advisability of this change, the two most important factors to consider are patient safety and physician wellbeing.
The return to 24-hour maximum shifts was largely based on the Flexibility In Duty Hour Restrictions for Surgical Trainees (FIRST) trial. The FIRST trial compared several endpoints under ACGME-regulated work hours against non-restricted work hours in general surgical residents from 117 different programs.
Primarily, the FIRST trial compared objective patient outcomes between the two work hour groups. They found no significant difference between the two groups in 30-day postoperative death rates or serious complications.11 A follow-up study found no significant difference in length of stay for patients undergoing intra-abdominal surgeries, which they used as a surrogate for all health complications. Therefore, the authors concluded, there was evidence to support the noninferiority of longer resident work hours compared to shorter hours. It is worth mentioning that benefit from fewer patient handoffs is a commonly cited argument in favor of increasing work hours. However, the data from the FIRST trial show no objective evidence for this claim.
Secondarily, the FIRST trial addressed physician wellbeing. Physician wellbeing is important, as some studies estimate the rate of physician suicide is as high as 5.7 times that of the general population. Interestingly, the study found no significant difference between the residents’ self-reported perception of the quality of their education, or overall sense of wellbeing. The residents working longer hours reported fewer concerns about patient safety; however, they did note a negative impact on their personal activities outside of work, such as spending time with family. These data are difficult to interpret. They are self-reported measures of satisfaction, and therefore subjective. They are also subject to bias from external influences, such as the desire to display “mental toughness” to one’s residency program directors. Perhaps a more helpful measure of resident wellbeing would be based on objective and validated instruments, such as the Patient Health Questionnaire-9, which has both a sensitivity and specificity of 88% for major depressive disorder when a cutoff score of 10 is used. In fact, one recent investigation used the previously validated Maslach Burnout Inventory to measure resident wellbeing after the 2003 ACGME regulations were implemented.15 They found improved physician wellbeing associated with reduced work hours. Future research could utilize retrospective analyses of resident suicide rates to analyze the impact of work hour regulations. Also, performance on cognitive tasks could serve as a suitable surrogate for mental wellbeing.
It is important to remember that these regulation changes only apply to interns. Second-year and older residents’ work hours remain unchanged.
In light of these data, there may not be sufficient evidence to warrant the increase in resident work hours. In terms of patient safety, the noninferiority of longer work hours has been adequately supported. However, the impact of the policy on residents’ mental health may not yet be adequately investigated. Perhaps the results of more objective studies would support the FIRST trial’s findings. But given the prevalence of physician suicide, any increases in physician work hours should be done with great care.
Simon Rodier is a 2nd year medical student at NYU School of Medicine
Peer reviewed by Barron Lerner, MD, internal medicine, department of population health, NYU Langone Health
Image courtesy of Wikimedia Commons
1. Accreditation Council for Graduate Medical Education. Common program requirements section VI. Summary and impact of major requirement revisions. ACGME website. Available at: https://www.acgme.org. Accessed March 16, 2017.
2. Friedman RC, Bigger JT, Kornfeld DS. The intern and sleep loss. N Engl J Med. 1971;285(4):201-203. doi:10.1056/NEJM197107222850405. https://www.ncbi.nlm.nih.gov/pubmed/5087723
3. Liston SE, Fetgatter GL. The general essentials of accredited residencies in graduate medical education. JAMA J Am Med Assoc. 1982;247(21):3002-3003. doi:10.1001/jama.1982.03320460096040. https://www.ncbi.nlm.nih.gov/pubmed/7045413
4. Drolet BC, Schwede M, Bishop KD, Fischer SA. Compliance and falsification of duty hours: reports from residents and program directors. J Grad Med Educ. 2013;5(3):368-373. doi:10.4300/JGME-D-12-00375.1. http://www.jgme.org/doi/abs/10.4300/JGME-D-12-00375.1?code=gmed-site
5. Spritz N. Oversight of physicians’ conduct by state licensing agencies. Lessons from New York’s Libby Zion case. Ann Intern Med. 1991;115(3):219-222. Available at: http://www.ncbi.nlm.nih.gov/pubmed/2058876. Accessed March 16, 2017.
6. ACGME Task Force on Quality Care and Professionalism. The ACGME 2011 duty hour standards: enhancing quality of care, supervision, and resident professional development. In: Accreditation Council for Graduate Medical Education; 2011:5-11. Available at: https://www.acgme.org/Portals/0/PDFs/jgme-monograph.pdf. Published 2011. Accessed March 16, 2017.
7. Bell BM. Evolutionary imperatives, quiet revolutions: changing working conditions and supervision of house officers [see comments]. Pharos Alpha Omega Alpha Honor Med Soc. 1989;52(2):16-19. Available at: https://repository.library.georgetown.edu/handle/10822/830617. Accessed March 16, 2017.
8. New York Department of State, Division of Administrative Rules. New York Laws, Rules and Regulations; 1998.
9. Nasca TJ, Day SH, Amis ES Jr; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800.
10. Resident duty hours in the learning and working environment: comparison of 2003 and 2011 standards. Accreditation Council for Graduate Medical Education. Available at: https://www.acgme.org/Portals/0/PDFs/dh-Comparison Table2003v2011.pdf. Published 2011. Accessed March 16, 2017.
11. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016;374(8):713-727. doi:10.1056/NEJMoa1515724.
12. Stulberg JJ, Pavey ES, Cohen ME, Ko CY, Hoyt DB, Bilimoria KY. Effect of flexible duty hour policies on length of stay for complex intra-abdominal operations: a flexibility in duty hour requirements for surgical trainees (FIRST) trial analysis. J Am Coll Surg. 2017;224(2):143-148.e1. doi:10.1016/j.jamcollsurg.2016.10.040.
13. Lindeman S, Laara E, Hakko H, Lonnqvist J. A systematic review on gender-specific suicide mortality in medical doctors. Br J Psychiatry. 1996;168(3):274-279. doi:10.1192/BJP.168.3.274.
14. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.
15. Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165(22):2595-2600. doi:10.1001/archinte.165.22.2595.