Janice Lloyd, USA TODAY March 25, 2013
Efforts to cut back long hours for medical residents may have the unintended consequence of leading to more errors, studies say.
A workplace regulation designed to limit hours worked by doctors in training to improve patient safety and enhance medical residents’ well-being has backfired and needs to be re-evaluated, according to two reports out today.
At the heart of both studies appearing in the Journal of the American Medical Association is the length of time a young doctor is allowed to work without taking a break. A medical oversight board decreased that time from 30 hours to 16 in 2011 in part to “protect patients from errors made by sleepy doctors,” according to a study done at the University of Michigan Medical School.
Those researchers say the shorter shift has not improved young doctors’ depression rates or how long they sleep. Most concerning: Medical errors harming patients increased 15% to 20% among residents compared with residents who worked longer shifts.
“Teaching hospitals haven’t invested in providing extra help to shoulder any of the clinical work that has to be done,” says physician Elizabeth Wiley, president of the American Medical Student Association, who is not associated with the study. “It could be the interns are required to do the same amount of work in less time.”
Federal regulations, which oversee most workplace hours, do not apply to residency programs. The Accreditation Council for Graduate Medical Education sets the guidelines and has been revising them since 2003. The changes have “unintended consequences” and have been under scrutiny because there wasn’t good data to support them, according to Sanjay Desai, lead author of the other study and director of the internal medicine residency program at the Johns Hopkins Hospital in Baltimore.
The shorter shift, he says, has “many negative downsides,” including increasing the number of “handoff risks.” The number of times a patient’s care changes hands — handoffs — increases when shorter work schedules boost the size of the health care team.
“Handoffs and patient safety is a highly complex science,” he says.
Desai says the reduction in work hours also decreased training time.
Both reports found residents failed to increase the amount of sleep they get overall per week. Neither report investigated why, but Desai speculated that “young people might not try to get more sleep when given the chance,” and trying to do the same amount of work in a shorter time increases stress and shortens sleep.
In the Michigan study, the researchers sent out surveys to students entering 2009, 2010 and 2011 residency programs around the USA. Every three months, the residents were asked questions about mental health, overall well-being, sleep habits, work hours and performance on the job. A total of 2,323 interns at more than 14 teaching hospitals responded.
In addition to the increase in self-reported medical errors, 20% of the residents screened positive for depression.
“We need to keep evaluating schedules,” says Desai, adding that the study showed educational opportunities suffered on the 16-hour schedule and trainers and nurses alike said the 30-hour model provided a better quality of care.