For Resident Doctors, Shorter Shifts Mean More Mistakes

March 26, 2013— -- Mandated shorter on-duty shifts for resident physicians has not improved patient care nor has it noticeably reduced the numbers of sleepy house staff, a pair of new studies found.

In both studies, the authors sought to determine if limiting doctors-in-training to work shifts of no more than 16 hours -- a change mandated by the Accreditation Council for Graduate Medical Education (ACGME) in 2011 -- resulted in better patient care and less resident fatigue than the 30-hour work week limit introduced in 2003.

The results were the same: disappointing. Both studies were published online March 25 in JAMA Internal Medicine.

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In the first study, residents and nurses said quality of patient care was so diminished with the 16-hour shift models, that the study was halted early, according to Dr. Sanjay V. Desai of Johns Hopkins, and colleagues.

Handoffs, which signalled an increased risk for medical errors, rose 130 percent to 200 percent using that model, the study authors wrote.

The second study, a report from the Intern Health Study -- a survey of interns taken at 3, 6, 9, and 12 months of PGY-1 -- found similar concerning trends.

Compared with responses of those whose first year of postgraduate training was under the old work hour requirements, (2009-2010) interns responding in 2011 said they were not getting more rest and they were had the same rate of depression, and same level of concern about personal well-being, wrote Dr. Srijan Sen of the University of Michigan, Ann Arbor, and colleagues.

But the 2011 interns were significantly more worried about making mistakes -- 23.3 percent compared to 19.9 percent.

Desai and colleagues randomized 43 house staff to 3-month rotations as controls (30 hour work week, every fourth night on call) or to one of two 16-hour shift models (every fifth night on call or night float schedule).

The house staff randomized to the 16-hour, night-float schedule did sleep longer than controls, 8 hours versus about 5 hours. Likewise, those in the every fifth night overnight schedule logged more than 10 hours sleep post call versus controls 7.5 hours.

In addition to increasing handoffs, both models also reduced education opportunities and reduced daytime work hours.

The authors said their findings echoed those of several earlier studies that also concluded that the 2011 ACGME regulations were not necessary to patient safety. They cited studies of pediatric, neurology, coronary, ICU, Medicare and Veterans Affairs residents and/or patients that showed "no reduction in mortality" for patients.

In the Intern Health Study, Sen and colleagues surveyed 2,323 medical interns from residency programs at 14 university and community-based medical institutions.

"Although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being," the study said, "but has been accompanied by an unanticipated increase in self-reported medical errors."

Interns who reported depression in the 2011 sample, also reported medical errors at almost twice the rate as nondepressed interns -- 35.3 percent compared to 17.8 percent. The authors noted previous studies that showed interns report "substantial increase" in depression during internship.

"Different strategies for improving resident education and patient care may be necessary to achieve the desired impact of ACGME reforms," Sen et al wrote.

Shorter Shifts, More Mistakes?

Adopting work schedules that "account for circadian phase" may be necessary, the authors suggested, as well as including funding for additional clinical staff.

They noted the association between "increased work compression" and "poorer clinical performance and decreased satisfaction among residents."

The trial by Desai et al was limited by its small size -- just 43 participants from an internal medicine training program at one institution -- which raise doubts about the generalizability of its findings. Also, "we could not exclude the possibility that some of the dissatisfaction and perceptions of interns might be a result of unfamiliarity with or prejudice against the new models, as well as reluctance to systematic change," they wrote.

The Intern Health Study was limited by its self-report model and well as the fact that only 58 percent of those invited did participate. Additionally, "our study assessed only the effects of duty hour reforms during the first year of their implementation. Studies should assess changes in interns' sleep and rates of depression and medical errors in future years, after hospital systems have had time to adjust to the new duty hour restrictions."