Policies to reduce medical residents' fatigue may compromise quality of training

Patient safety has long been a critical concern for hospitals, in particular for those training new doctors. Since 1984, when the death of 24-year-old Libby Zion at a New York hospital was attributed to an overtired medical resident, training programs have faced restrictions on the length of work shifts for the least-experienced medical doctors. Last year, the ACGME, which oversees residency programs, issued the most restrictive guidelines to date: Residents should serve no longer than 16-hour shifts in the hospital.

"Our results showed that the duty-hour limitations may not be a quick fix to an important problem," says Mayo Clinic internist and co-author Darcy Reed, M.D., M.P.H.

The survey sent to directors of residency programs around the country found that many are concerned that the duty-hour limitations to be implemented by July 2011 will impinge on physician education. Of the nearly 500 respondents from the fields of surgery, internal medicine and pediatrics, 87 percent of program directors felt that the shortened shifts will interrupt the interactions between residents and hospitalized patients. "Many survey respondents expressed concern that the limits will decrease the continuity of care. As residents face more handoff of responsibilities within a 24-hour period, they have less opportunity to see and learn how patients' care progresses," Dr. Reed says.

Significantly, up to 78 percent of directors felt the restricted shifts are likely to result in graduates who fall short in the key competency areas defined by the ACGME. Those core areas include patient care, medical knowledge, interpersonal and communications skills, and professionalism. Among the various fields surveyed, directors of surgery programs expressed the greatest concern. "Further research is necessary to understand the particular concerns of directors of surgery programs," Dr. Reed says, "but it's possible some directors may feel residents will not get sufficient time in the OR."

Moreover, residency directors were skeptical about whether the new limits will reduce physician fatigue, the problem they are designed to address. Among respondents, 65 percent felt that the limits will have no effect on fatigue, and 6 percent felt the restrictions may even increase fatigue. "Other studies have found that reducing work hours doesn't necessarily lead to people going home to sleep," Dr. Reed says.

The results of the study suggest that resident schedules require further evaluation and perhaps other tweaks to ensure both patient safety and high standards of physician education. "This will probably not be the final iteration of recommendations that are set in place," says Dr. Reed. "Obviously patient outcomes are of the utmost importance, but training the future workforce of excellent physicians also is in patients' interests. I believe we'll continue to see these policies evolve."

Provided by Mayo Clinic