While the rest of us are calling it a day at five on the nose, surgical residents are toiling away for 80 hours a week. But while the cause is noble, the effect may be fatal: A new study suggests the 80-hour-per-week cap still deprives residents of valuable sleep, putting patient safety in jeopardy.
Working 80 hours a week — or 16-hour days — may sound like torture to those not donning a white coat, but it’s actually a reduction from standards of the past. Before July 2003, residents and nursing staff were free to work around-the-clock shifts, often sleeping in vacant hospital rooms. Fearing for the hospital staffs’ health under these constraints, the Accreditation Council for Graduate Medical Education stepped in. It outlined six standards, which hospitals must now follow.
The problem, however, is that the most valuable components of health care — the people doing the caring — still get a quarter of the daily recommended sleep each night. Even with ample training, researchers of the latest study assert the human body has certain demands, chief among them the ability to recharge overnight. The team of doctors and scientists conducted a review of 135 studies that analyzed resident duty hours (RDH) effectiveness.
Overall, they found there were no improvements in patient outcomes or education. There was also no perception of improvement in either case. Meanwhile, there was actually a slight increase in complication rates in high-acuity patients — those being the most serious cases.
There are two possible explanations for why the shorter workweeks failed. The first is that 80 hours is still too long, which may seem reasonable on its face — too little sleep results in sloppy performance — until you consider that residents went from having a certain amount of work with unlimited time to get it done, to a severely reduced amount of time but no change in the amount of work. If anything, the work may be sloppier.
"We must remember that the objective of residencies is to train expert clinicians,” said Dr. Najma Ahmed, co-researcher and trauma surgeon at St. Michael's Hospital, in a statement. In the case of surgery, this means sustained periods of time in the operating room, under the watchful eye of a mentor. There’s a great deal of coaching involved, as the mentors prepare residents for life as surgeons. It also lets them “provide feedback and then look for progress at the next opportunity,” she said.
There’s also the issue of maintaining continuity with patients. People’s health doesn’t follow predictable patterns that fall during normal business hours. Heart attacks can happen at two in the morning or two in the afternoon, which means the person who initially handles a patient’s records should be the one to resolve the case, too.
Basically, if the point of surgical residency is to prepare students for life as a surgeon, the hours need to reflect the world they’ll be working in. The best way to do this without sacrificing sleep, Ahmed said, is to reduce the work that’s non-educational. In other words, you can’t expect to improve performance by giving students less time to do the same amount of work. What you really need to do is reduce the workload.
"A one-size fits all approach to resident duty hours may not be appropriate for all specialties," she said. Some residents who do non-surgical work may benefit from reduced hours, but for those students who need hands-on learning, "extensive and immersive experiences” may require unique exceptions.
Source: Ahmed N, Devitt K, Keshet I, et al. A Systematic Review of the Affects of Resident Duty Hour Restrictions in Surgery: Impact on Resident Wellness, Training, and Patient Outcomes. Annals of Surgery. 2014.