By Evan J. Propst, MD, MSc, FRCSC co-author of Airway Reconstruction Surgical Dissection Manual
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated an 80 hour work week limit for residents. In 2011, this same body mandated a 16 hour shift limit for first year residents. Both of these mandates were introduced to reduce resident fatigue with an eye towards improving patient safety, resident education and resident wellbeing. These regulations are enforced throughout the US and institutions can be fined if residents are found to be working beyond these duty hour restrictions.
Interestingly, a recent systematic review of the literature by Ahmed et al. (2014) revealed that resident duty hour restrictions may be more harmful than beneficial. In brief, the introduction of an 80-hour work week is perceived by health care professionals to have had a negative outcome on patient safety. Resident education appears to have worsened or remained unchanged. Resident wellness appears to be improved. The reduction to a 16-hour duty maximum also appears to have had a negative impact on patient safety, which is believed to be due to decreased continuity of care and an increased number of handovers. Resident education has also suffered due to poorer integration into teams, less opportunities for resident mentorship, increased patient handovers, decreased operative exposure and increased medical errors. Personal satisfaction, preparedness for more senior roles and senior trainee wellness have also been compromised. Many programs have developed a night float system to improve resident education for daytime residents. Unfortunately, the literature suggests a perception of worsening patient outcomes with an inconclusive effect on resident education. There was, however, a small perceived improvement in resident wellbeing. In short, only one objective of the resident duty hour restrictions appears to have been met (improved resident well-being), but this may be at the expense of patient safety and resident education.
The challenge for residency training programs is therefore to provide high impact learning activities in an efficient and effective manner. There are two overarching ways to achieve this: 1) Minimize tasks unrelated to the provision of medically necessary care to maximize the amount of hours available to learn necessary information, and 2) Maximize the amount of learning occurring during available hours. Among the options for achieving the second point are a more structured didactic training course or highly structured hands on surgical sessions on animal or cadaveric human models. Whichever methods turn out to be the most effective, they will likely vary depending on which type of residency training program is being investigated.
About The Author
Evan J. Propst, MD, MSc, FRCSC, is an otolaryngologist-head and neck surgeon at The Hospital for Sick Children in Toronto, and an assistant professor and clinician investigator at the University of Toronto. Dr. Propst has a clinical interest in complex open airway surgery, head and neck surgery, and advanced sleep surgery. He has developed the Disorders Relating to the Airway and Mouth in Sleep (DREAMS) clinic and the clinic for Complex Swallowing Disorders. His research interests include corrosion casting of the blood supply of the airway, tracheal transplantation, and novel treatments for head and neck tumors. Dr. Propst is the fellowship director and site director for residency and undergraduate education, and travels internationally teaching airway surgery through simulation.
Ahmed N, Devitt KS, 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. Ann Surg 2014;00:1–13.