Whether you make hamburgers, process loans, or take care of patients, fatigue at work leads to errors and mishaps. Among physicians, fatigue can lead to medical errors that may cause great harm. Yet for more than 30 years, the medical profession has been debating limits on how many hours in a row physicians-in-training can work.
Extended and sometimes chaotic work schedules start early in the lives of physicians. During residency, medical school graduates are supervised while they learn to practice in a safe and professional manner. They gain real-world experience with a wide range of diseases, conditions, and procedures. They also learn about the complexities of medicine in outpatient settings, where most care is provided.
Meeting these goals has long meant having physicians-in-training, commonly known as residents, work to exhaustion. Shifts as long as 24 to 36 hours straight weren’t uncommon. The justifications for such lengthy shifts include the need to follow hospitalized patients through their illnesses, learning how to adjust treatment over time, and the opportunity to see unusual cases. Tradition has also played an important role.
A complex and highly publicized case from 1984 brought public attention to the issue of resident work hours. Since then, studies have shown that fatigue among health care workers compromises patient safety by increasing the risk of error, injuries, and accidents.
Fatigue affects the safety of residents, too. Health care workers are more likely to experience accidental needle sticks or cuts when fatigued. One study even showed that interns who worked 24-hour shifts were more than twice as likely to be in a car accident on the way home from work than those who worked 12-hour shifts.
As clinicians, we have personally witnessed the risks associated with fatigue. As representatives of the National Patient Safety Foundation, we support limits on work hours to ensure residents receive adequate rest.
In 2003, partly in response to the evidence of safety risks associated with long hours, and again in 2011, the Accreditation Council for Graduate Medical Education (ACGME) imposed some limits on resident work schedules. Residents currently can work no more than 80 hours a week, averaged over four-week periods. Interns (first-year residents) are limited to 16-hour shifts, while residents in their second year and higher can work up to 24 hours straight. There is some flexibility allowed, up to 30 hours, to ensure continuity of care and learning.
Five years on, we are seeing some early effects of these limits. One consequence has been an increase in handoffs — when a resident at the end of a shift must hand off the care of his or her patients to other health care providers. Miscommunication during handoffs is a common problem that introduces the potential for errors and puts patients at risk. Research is beginning to show ways to improve handoffs, but more work and training are needed to increase the safety of these transitions.
Earlier this year, a study led by the American College of Surgeons found that surgical trainees who worked more flexible schedules (in other words, beyond the ACGME daily limits) had patient outcomes that were “no worse” than trainees who worked the more restricted hours.
But should “no worse” really be the goal we set for patient care and worker safety? Surely we can find higher ground, where residents can get adequate sleep while also being sufficiently trained to practice independently with the dedication, commitment, and empathy that leads to safer patient care.
How to achieve this? The ACGME is currently assessing all of its requirements for residency programs as part of a scheduled five-year review. The National Patient Safety Foundation has urged ACGME to pursue further research on the impact of work hours on safety, professionalism, joy and meaning in work, and burnout among interns and residents. Given the high rates of burnout among physicians and depression among residents, research that more thoroughly examines both patient outcomes and resident safety and morale are needed.
We must work to improve handoffs, communication, and supervision of physicians in training. We also need to integrate duty hour restrictions into comprehensive safety programs that can overcome any potential challenges of reduced schedules. Let’s find ways to give residents the clinical experience they need while optimizing safety for both patients and residents, our next generation of the health care workforce.
Tejal K. Gandhi, MD, is president and chief executive officer of the nonprofit National Patient Safety Foundation; Patricia A. McGaffigan, RN, is its chief operating officer.