It seems the Accreditation Council for Graduate Medical Education (ACGME) may have made a mistake by reducing the maximum amount of hours allowed in a work shift from 30 to 16 for a first-year resident. Although previous studies have shown that performance begins to decline after 16 hours, more recent studies have shown that, among other things, shorter shifts are leading to a reduced number of operative experiences, which are critical for the residents' education, MedPageToday reported

"If the 16-hour work shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume," researchers wrote in the study.

They also said that residents moving into their second year with less experience could cause "a domino effect on subsequent competence."

The Study

For the study, the case logs of 249 general surgery interns at nine California residency programs, and one Hawaii program, were examined from 2007 to 2012. The ACGME changed the hours-per-shift rule in July 2011, so the study was able to determine the before-and-after effects of the rule. Dr. Christian de Virgilio, of Harbor-University of California Los Angeles Medical Center, and his team, found that the annual number of operative cases dropped from 88.8 to 65.9 for total cases, 80.5 to 54.9 for major cases, and 20.7 to 11.1 for first-assistant cases, or, by 25.8 percent, 31.8 percent, and 46.3 percent, respectively.

The reduced number of experiences were seen across most types of surgery, including abdominal, endocrine, head and neck, basic and complex laparoscopy, pediatric, thoracic, and soft tissue/breast.

Researchers speculated that the reason for the reduction in case volumes was "that many programs, no longer able to allow interns to take home call, have shifted to an intern night-float system to accommodate the 16-hour rule," they wrote. This means that those residents who worked nights had a lesser chance of operating on a patient.

Other Concerns Regarding Shorter Shifts

Questions have also arisen about how much residents are learning outside of the operating room, and about patient safety. A March editorial in JAMA Internal Medicine argued that shorter workdays force residents to cram their workload. On top of this, shorter shifts prevent residents from seeing illnesses evolve in their patients, since they are required to hand off their responsibility to another doctor — this can also lead to errors if details regarding the patient aren't communicated clearly, Kaiser Health News reported.

"The 2011 rules have led to many unintended consequences," Sanjay Desai, director of the internal medicine residency at Johns Hopkins Hospital, told Kaiser. He said the 16-hour maximum shift length was "imposed without [sufficient] data showing it would be beneficial."

Why Did the ACGME Decide to Shorten Shifts?

The new rules for shift length were changed after a series of events prompted the ACGME to change them. In 1984, 18-year-old Libby Zion died of cardiac arrest in a Manhattan hospital while being treated by an intern who had been taking care of over 40 patients during a 36 hour shift. New York passed rules limiting residents to 24-hour shifts, at a maximum of 80 hours a week. Some states followed suit, while others didn't, and it was common for surgery residents, who sometimes worked 60-hour shifts, to fall asleep at the operating table.

With other industries, such as aviation and aerospace, providing studies that fatigue reduced performance, the ACGME imposed the 80-hour workweek in 2003.

Sixteen-hour shifts were first proposed in 2008 after a report suggested that more sleep would increase safety. But the idea of limiting shift hours was rejected by the ACGME until 2011.

Is There a Solution to this Problem?

The reduced operative experiences are a "predictable consequence" of the hour restrictions, Julie Ann Freischlag, of the Johns Hopkins Medical Institutions, said.

"Hopefully, as experience with the 16-hour rule is further expanded, we will be able to get the interns in the operating room more," she wrote in a commentary. "There are three ways to do this: (1) emphasize to the interns and the senior and chief residents that they need to get into the operating room at least three cases a week; (2) use other health care deliverers to help with the floor work, intensive care unit coverage, and clinics to allow the interns to get to those cases; and (3) make sure the faculty understands the plan so they allow the intern to get to the operating room and that they allow the intern to actually do the operation!"

Source:

Schwartz S, Galante J, Kaji A, et al. Effect of the 16-Hour Work Limit on General Surgery Intern Operative Case Volume: A Multi-institutional Study. JAMA Surgery. 2013.

Goitein L, Ludmerer K. Resident Workload - Let's Treat the Disease, Not Just the Symptom. JAMA Internal Medicine. 2013.