Carol L. Chen, MD
Director, Cardiac Intermediate Care Unit
Memorial Sloan- Kettering Cancer Center
New York, NY
A: The primary goal of residency training is to transform medical students into independent, capable physicians in their chosen field within a reasonable training period. A notion made popular by Malcolm Gladwell’s bestseller, Outliers, is that 10,000 hours of practice is integral to becoming expert at any particular endeavor.1 Based on the current ACGME guidelines of an 80-hour workweek limit in a 48-week year, residents would log in a maximum 3,840 hours per year. Over 3 years (the minimal residency), a house officer would log in more than 10,000 hours, certainly sufficient hours. However, the 2011 duty-hour regulations go beyond limiting resident work hours. The crossover study by Desai et al of The Johns Hopkins Medical School’s internal medicine residency program sheds light on the possible unintended consequences of the stricter 2011 regulations.2
Many studies have confirmed that duty-hour limitations have decreased house staff fatigue and increased sleep, but a commensurate decrease in medical errors has not clearly been demonstrated.3-5 The effect of the ACGME rules on the quality of resident education has been studied by many groups by using surrogate markers such as patient volume, examination scores, board exams, and surveys, with mixed conclusions. A big difference between the 2003 and 2011 duty hours regulation is the 16-hour limit on continuous duty hours for interns. Not all hours are equal in teaching value. However, to comply with this rule, many training programs have instituted a night-float system and later start times for on-call days. As a consequence, these residents have less contact with attendings in a teaching environment, and they care for fewer patients. Thus, they may lose opportunities for discussion and timely feedback about their clinical decisions. This is a real, but difficult-toquantify, loss.
Desai’s study demonstrated that more patients were admitted and primarily cared for by the interns in the control group (compliant with the 2003 duty hours regulations) compared with both experimental groups (compliant with 2011 guidelines).2 The study also showed a 25% decrease in attendance at educational conferences by the house staff in the experimental groups. Training programs should continue to innovate schedules and formats to promote didactic sessions. The Mayo Clinic piloted a small but significant change in the time and format of the daily medical intensive care didactic session in order to comply with work-hour regulations, with good outcomes.6
Desai’s study also showed that the number of handoffs increased by 130% to 200% in the 2011 on-call models compared with the 2003 model. This consequence cannot be understated. Even prior to 2011, several studies demonstrated serious issues associated with house staff communication in passing responsibility after the 2003 regulations took place. In 1 small study utilizing house staff interviews regarding real-time handoffs, although the house staff rated their colleagues’ communication quality as high, in 60% of cases the most important piece of clinical information about a patient was not successfully communicated.7 A prospective study using recordings of 2 weeks of house staff sign-out at Yale demonstrated 7.5 sign-out-related problems per 100 patient-days, which resulted in near misses, medical errors, and delay in treatment.8 The authors acknowledged that this was likely an underestimation. The relationship and trust with the patient and family is very difficult to build as physicians hand off from one another and often appear not to communicate well.
Desai and colleagues were able to complete their study comparing different on-call models because it was done before the new rules took effect (July 1, 2011). Any further studies of this sort are no longer possible. The Next Accreditation System (NAS) as proposed by the ACGME9 has many lofty goals that emphasize innovation to improve education; however, changes will be restricted by the limited permutations within a rigid duty-hour grid with a finite number of workers. Hospitals have coped with many of these regulations by hiring more physician extenders to take the place of house staff. In the current economic climate of cutbacks, this may not be a viable option for many hospitals. Resident duty hours should be limited to avoid overwork; however, I agree strongly with Rosenbaum and Lamas’s proposal that the ACGME should allow exemptions for further research in this field in order to truly understand this complex matter.10
1. Gladwell M. Outliers: the story of success. New York, NY: Little, Brown and Co; 2008.
2. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013:1-7.
3. 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.
4. Fletcher KE, Reed DA, Arora VM. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules. J Gen Intern Med. 2011;26:907-919.
5. Howard DL, Silber JH, Jobes DR. Do regulations limiting residents’ work hours affect patient mortality? J Gen Intern Med. 2004;1:1-7
6. Lim KG, Dunn WF, Klarich KW, et al. Internal medicine resident education in the medical intensive care unit: the impact on education and patient care of a scheduling change for didactic sessions. Crit Care Med. 2005;33:1534-1537.
7. Chang VY, Arora VM, Lev-Ari S, et al. Interns overestimate the effectiveness of their hand-off communication. Pediatrics. 2010;125:491-496.
8. Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755-1760.
9. Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation system--rationale and benefits. New Engl J Med. 2012;366:1051-1056.
10. Rosenbaum L, Lamas D. Residents’ duty hours-toward an empirical narrative. New Engl J Med. 2012;367 (21):2044-2049.