Dive Brief:
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The Accreditation Council for Graduate Medical Education (ACGME) announced it will lift a cap that limits shift lengths for first-year residents from 16 hours to 24 hours, with up to four additional hours allowed to manage care transitions.
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The updated requirements are the same for all other residents and fellows and are intended to promote patient safety by reducing disruptions to care that can occur during patient hand-offs.
- The organization stated the total number of clinical and educational hours for residents has not changed. Averaged over four weeks, residents have an 80-hour cap on clinical hours, require at least one day out of seven free from clinical hours or education, and limited on-call availability every third night.
Dive Insight:
The long shifts worked by doctors have been the subject of criticism for years. ACGME responded and shifted to a 16-hour limit on shift lengths from a 24-hour cap beginning in 2011, after the Institute of Medicine warned against the risks associated with long shifts and recommended the changes in 2008.
There is reason for concern over long hours worked by doctors. For instance, the AAA Foundation for Traffic Safety has determined that a driver with less than four hours of sleep in a 24-hour period is 11.5 times more likely to crash than a driver with seven or more hours of sleep. The risk is comparable to that of driving while drunk. Dr. James Hamblin, senior editor at the Atlantic, recently wrote how lack of sleep during residency left him prone to bouts of anger and despair. He never felt lack of sleep was putting patient safety at risk “but as with drunkenness, one of the first things we lose in sleep deprivation is self-awareness.”
Research consistently shows there are negative effects to sleep deprivation, but not much evidence suggests it has harmed patient outcomes in healthcare settings. For instance, ACGME pointed to data showing a decline in performance after 16 hours of wakefulness in the 2010 report that led to a 16-hour cap on shift length for first-year residents. However, the report also said there was little evidence to suggest a harmful link to patient safety, likely due to redundancies in teaching hospital’s safety programs.
Researchers recently explored clinical hour limits in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, which included 118 general surgery residency programs. First-year residents in one-half of the programs were allowed to work up to 20 hours per shift and take less time off between shifts than allowed by ACGME requirements, which were applied to the rest of the programs.
There were no significant differences in patient outcomes between the two groups in the FIRST trial, suggesting safety doesn’t decline with less restrictive clinical hour requirements. Additionally, residents with less restrictive clinical hour requirements reported benefits for patients, continuity of care and professionalism. These results lend a defense to those who want less restrictive policies for first year residents.
There was a downside to working longer hours. Residents working under less restrictive policies reported negative effects on personal time for socializing, resting and other extracurricular activities, although there was no significant difference in overall well-being. However, a low bar has been set when it comes to well-being among medical students and doctors.
More than a quarter of medical students have reported depression or depressive symptoms and more than one in 10 reported suicidal ideation, according to a study published December 2016 by JAMA. Only about 15% of affected students sought treatment for their symptoms.
Demands of the job don’t stop having an effect on well-being when residency ends. More than one-half of doctors report symptoms of burnout compared to about one-quarter of the general workforce. Around 300 to 400 doctors commit suicide each year and the topic of mental health in the medical community is slowly drawing more attention.
Society demands significant sacrifices from its doctors. Simply changing clinical hour requirements for first year residents is unlikely to significantly impact overall well-being among doctors in either direction. However, as evidence accumulates and healthcare organizations increasingly address the mental health of their doctors, perhaps healthcare will find a sweet spot that mitigates a negative impact on patient safety and influences a positive impact on the well-being of doctors.