by Daniel Ontenient, PGY-3
Starting this summer, first-year residents across all medical specialties in the Unites States will be permitted to work 24-hour shifts, revising the current duty hour restriction that limits interns to 16 consecutive hours of patient care. On March 10, 2017, the American College of Graduate Medical Education (ACGME) announced this controversial decision, in hopes of improving the balance between patient care and resident education. A recent study analyzing the effect of a 16-hour work limitation on patient safety and physician well-being showed that current work hour restrictions were disadvantageous to resident education and, in turn, had no positive impact on patient safety. Moreover, a survey showed that trainees favored a more flexible schedule allowing them to work longer hours, to enhance their knowledge and foster better relationships with their patients and colleagues.
On a larger scale, federal regulation of duty hour restrictions is a fairly novel idea. Rooted in findings by the Bell Commission during their 1989 investigation of the Libby Zion case, regulations for resident hour limitations were not adopted by the ACGME until 2003. Including modifications made in 2011, current regulations include an 80-hour weekly limit for all with 1st year residents not being allowed to work more than 16 consecutive hours during a shift. Alternatively, senior residents can work 24 consecutive hours with an additional 4 hours allotted for continuity of care and education. During this time, residents were encouraged to find time for “strategic napping.” In-house call can take place no more than once every 3 nights. Additionally, interns and intermediate trainees are required to have 8 hours in between shifts (ideally 10 hours) and an average of one in seven days off during a 4-week period. Aside from the increase in intern work hour restrictions, it appears all other regulations will remain in place for the foreseeable future.
As one can imagine, this change in regulation comes with a certain degree of controversy in the debate between patient safety and physician well-being. Proponents of the change believe it will limit errors caused by patient handoff and allow first-year residents to assimilate sooner into a role that more realistically reflects real-world practice. Members of Public Citizen, a consumer health research group, and the American Medical Students Association (AMSA) claim that new regulations are unethical and dangerous to both patients and physicians. While recent studies may indicate a lesser degree of patient morbidity with laxer duty hour restrictions, there is a pervasive thought that sleep-deprived residents are more prone to making medical errors and procedural mistakes, including needle-stick injuries, and are at increased risk of being involved in car accidents. A strong case is also made for resident burnout and depression, which is increasingly recognized in the medical community. To mitigate this, new regulations mandate training programs to provide residents with ways to attend to their physical and mental health, including designated time off for their own health care appointments.
How the change in intern duty hour restrictions will impact new trainees and patient care remains to be seen. What we do know, however, is that advances in medical care will allow an ever-growing patient population to live longer with more comorbidities. This will inevitably prompt further discussion about current duty hour regulations and perpetuate the ageless debate between patient care and physician well-being.