Jennifer Rodney, MD, a fifth-year resident physician in the department of otorhinolaryngology at the University of Oklahoma Health Sciences Center in Oklahoma City, never really understood the work hours limitation on first-year interns. Under rules put in place in 2011, first-years were limited to 16-hour shifts, while other physicians could still work 24-hour shifts.
Under revised rules that went into effect July 1, 2017, that limitation was lifted and all residents can work the same number of hours.
Good, said Dr. Rodney.
“It didn’t make a whole lot of sense to have the limitation and have them have to clock out at a certain time each day,” she said. “And when July 1 hit this year, all of a sudden that rule doesn’t apply, and they have to stay until the end of the day when the patient is done being seen. That’s the thing about medicine. … You can’t go home at a certain hour. You go home when your patients are taken care of. It was just unrealistic to treat an intern differently than the rest of the residents, because they’re going to be out of that position the next year anyway.”
In the long run, the Accreditation Council for Graduate Medical Education (ACGME) agreed. Rowen Zetterman, MD, chair of ACGME’s board, said that when the hours limit was set in 2011, it was with the understanding that the threshold would be reviewed after five years. A similar review of the new rules will take place in 2022, or sooner if new evidence warrants it.
“We heard from residents who were in the middle of an operative case,” Dr. Zetterman said. “A patient that had admitted in the previous 16 hours needed an emergency operation … and 16 hours came in the middle of the case, and they were told to go home. That was clearly an issue.”
The ACGME reviewed more than 1,000 studies and, in March 2016, held a two-day conference to which it invited 60 medical groups and organizations “to testify to us about what should be done in the learning/working environment,” Dr. Zetterman said. “Of all the 60 medical organizations that were there, the majority said we needed to return to 24 hours for first-year residents,” he added. “Most of them cited the impact it had on team-based care.”
That’s the thing about medicine…You can’t go home at a certain hour. You go home when your patients are taken care of. It was just unrealistic to treat an intern differently than the rest of the residents, because they’re going to be out of that position the next year anyway.” —Jennifer Rodney, MD
Continuity of Care
Otolaryngologist Nilesh Vasan, MD, an associate professor at the University of Oklahoma Health Sciences Center, specialist in head-and-neck oncologic surgery, and program director for his hospital’s otolaryngology–head and neck surgery residency program, said that continuity of care is a major factor in weighing out the change in work hours.
First to consider is the paramount importance placed on patient care. “Following through with a patient from when you might meet them to how you make a diagnosis to subsequently initiating some sort of treatment is important, obviously, for the patient,” said Dr. Vasan. “But it’s just as important for the physician who is learning how to manage these patients.”
Second, patient care is helped along when staff are able to reduce the number of hand-offs and transitions of care. Limiting one member of a team to an hours limit to which others don’t have to adhere to opens the door to a problem in transferring information. “If you were to have frequent handovers, there’s potential for error,” Dr. Vasan added. “That’s why companies now exist that utilize software as a means to minimize errors and to make sure that everyone’s on the same page. This is something new that has been created because of work-hour restrictions.”
Dr. Zetterman said there is one major study that looked at hours limits and their impact on patient outcomes. The review, which was published in The New England Journal of Medicine in February 2016 and involved 117 U.S. general surgery residency programs and 151 hospitals, found that longer shifts and less time off between shifts were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group) or of any secondary postoperative outcomes studied (N Engl J Med. 2016;374:713-727). “That was certainly an added factor,” Dr. Zetterman said.
The third leg of the proverbial stool that is continuity of care is the health of physicians themselves, Dr. Vasan said. To wit, the NEJM surgical study found “no significant difference in residents’ satisfaction with overall well-being and education quality.”
“That’s one of the things the ACGME stresses, that physicians receive education in terms of recognizing fatigue and fatigue mitigation,” Dr. Vasan added. “It is important for physicians to have an opportunity to rest; that goes hand-in-hand with having these doctors work potentially 24 hours now.”
Dr. Rodney said that the 16-hour limit on interns meant that they could work a few of those shifts in a row, which could be more dangerous for them. “Sixteen hours on paper looks better than 24, but working 16 hours day after day instead of 24 hours with a post-call day off does not result in better quality of life,” she said, “and may actually lead to worse quality of life for the resident.”
Maintaining a Balance
Dr. Zetterman emphasized that while first-year otolaryngology residents and their program directors may be focused on raising the hours cap, the newly unveiled revision to the ACGME Common Program Requirements, the formal name of the rules that govern residents, is much broader. The five-year review placed a greater emphasis on patient safety and quality improvement, added a section to address the critical importance of physician well-being to graduate medical education and patient care, and implemented more explicit requirements regarding team-based care and professionalism, coupled with a framework for clinical and educational work hours that allows for flexibility, with a maximum that aims toward the ultimate goals of physician education and patient care.
Dr. Rodney said any changes that add plasticity to the rules for residents are good changes. “Inflexibility is a bad thing in medicine, because this is not a 9-to-5 job,” she added.
Dr. Vasan added that ACGME has a challenging task to ensure that residents are learning safely. But being equal to their senior peers is a major boon to first-year residents under the revised rules.
“Interns for otolaryngology are now within our specialty for six months out of 12 months,” he said. “Previously, they may have rotated through, say, one rotation of ear, nose, and throat, and the rest of the year would have been general surgery, and so on … If they’re going to be involved in patient care, they should be, in my opinion, working under the same work-hour limits, restrictions, or maximums as their contemporaries.”
That said, as a residency program director, he appreciates ACGME’s review of the available evidence every few years to tweak work hours, ensuring the best outcomes for patients and physicians. “There’s a very fine balance,” Dr. Vasan added, “between getting residents maximum experience within, say, a four to five-year block versus having a period of mental and physical rest that’s adequate throughout their training.”
Richard Quinn is a freelance writer based in New Jersey.