EDITORIAL
Commentary on “Resident Work-Hour Restrictions and Responsibilities to Patients” Frank R. Lewis, MD
M
edicine likes to think of itself as a rational activity, in which decisions and actions are dictated by logic, based on clear evidence. It is therefore remarkable when we look critically at the most radical and disruptive change that has occurred in resident training during the last 3 decades— the imposition of universal work-hour restrictions—and find that there is no credible evidence to demonstrate that unrestricted resident work hours cause inferior patient care or that restricted resident work hours lead to improved patient care. Dozens of laboratory studies have been carried out by sleep researchers to show that sleep deprivation causes deficits in mentation and psychomotor performance, and these have been tacitly extended, without direct evidence, to conclude that such errors must lead to errors in patient care. Such conclusions fail to consider that the laboratory deficits may not affect the decisions made regarding patient care, that the multilayered decision process involved in patient management in any resident environment provides protection from potential errors by a single individual, and that the unintended negative consequences of resident work-hour restrictions on continuity of care and other aspects of resident behavior may outweigh any effects of sleep deprivation. The article by Ahmed et al,1 developed under the auspices of the Royal College of Physicians and Surgeons of Canada, is therefore particularly important, as it provides a comprehensive review of the North American literature on this subject and presents significant evidence that the opposite is true—that the work-hour restrictions have had a detrimental effect on the quality of patient care and resident education. The article presents a meta-analysis of the existing literature during the last 33 years, bridging the time from the initiation of the work-hour debate in 1984, with Libby Zion’s death, to the present. Its chief limitation is the relatively poor quality of the existing literature, and the markedly dissimilar designs of the studies, which makes comparative analysis difficult. Of 709 references initially screened from various databases during the aforementioned period, the authors were able to select 135 articles that provided sufficient data for analysis. They then applied objective criteria to determine the quality of the study and classified 78 of the studies as low or very low in quality and 57 as moderate or high in quality. Approximately half of the studies dealt with general surgical training, which has felt the detrimental effects of work-hour restrictions to a greater extent than any other specialty. The specific outcomes that the authors examined as a function of work-hour restrictions were patient safety, resident education, and resident wellness. Forty-five percent of the studies were surveys, 39% were interventional studies (the intervention was the initiation of duty-hour restrictions), and 6% were observational studies. Results were analyzed in 5 sections. The first section examined the 3 primary outcomes in the 57 moderate- or high-quality studies. Both in actual outcomes and in perceptions of outcomes, these studies overall showed that resident duty-hour restrictions (RDHRs) had a detrimental effect on patient safety and resident education and a beneficial effect on resident wellness. The effects of 16-hour shifts and night float systems were examined independently in sections 2 and 3 and combined in section 4. The aggregate conclusions of these sections, although there was some heterogeneity, were similar to the first section—these 2 changes had negative influence on patient safety and resident education and a positive influence on resident wellness. The last section, specific reports relative to patient morbidity and mortality, shows that overall morbidity increased after the implementation of RDHRs whereas mortality shows less clear changes, with variable results in different studies, and a trend to worsened outcome after RDHRs in the summary random-effects model that does not reach statistical significance. Despite the heterogeneity and variable quality of the studies that were reviewed, the conclusions from the various sections of the article are consistent and indicate that in both perceptions and actual outcomes, the implementation of RDHRs, both in 2003 and in 2011, has had the effect of decreasing patient safety and worsening resident education while improving resident wellness. The improvement
From the American Board of Surgery, Philadelphia, PA. Disclosure: The author declares no conflicts of interest. Reprints: Frank R. Lewis, MD, American Board of Surgery, 1617 John F. Kennedy Blvd, Ste 860, Philadelphia, PA 19103. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/25906-1054 DOI: 10.1097/SLA.0000000000000700
1054 | www.annalsofsurgery.com
Annals of Surgery r Volume 259, Number 6, June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 259, Number 6, June 2014
in resident wellness is clearly desirable and intended, but in any balancing of tradeoffs, it does not seem ethically acceptable that it should come at the expense of patient safety and resident education. It is not clear whether it is possible to optimize all 3 of these outcomes through changes in the work-hour requirements or whether there will always be conflicts and tradeoffs such as those shown here. What is clear, however, is that the present work-hour restrictions, which were arrived at without adequate foundation in studies or data related to patient care, must change; it is clearly unacceptable that we are harming patients as a result of restricting work hours. Earlier in 2013, a similar article was published by the staff of the Accreditation Council for Graduate Medical Education,2 also based on a meta-analysis of the existing literature, which reached similar conclusions regarding the effects on surgical patients, although with less detail than the present study. That article also found that the literature with regard to the effects of RDHRs on medical patients differed from that on surgical patients and overall were neutral or showed slight improvement in patient safety. Since the broad implementation of RDHRs in 2003, it has become apparent that the impacts on different specialties are highly variable. The majority of residency programs, which deal mainly with elective patient problems presenting during weekdays and daytime, are not significantly affected by them; only those specialties in which urgent and emergent patient problems are common are principally affected, because it is only in those specialties that a high percentage of night and weekend work is required; nearly all of these are surgical.3 General and trauma surgery are most prominently affected, along with neurosurgery and orthopedics. Vascular and thoracic surgery, and urology, are perhaps next in acuity. The creation of RDHRs was done in various settings by different groups of experts who did not appreciate the differences in the nature of the work done by different specialties, nor the impact of a high volume of urgent and emergent patients on the nature of resident work. Because of these differential effects, it is time to consider different work-hour standards for different specialties, depending on the nature of the work they do. The other principal factor that was not adequately appreciated in setting the work-hour restrictions was the price that would be paid in decreased continuity of care and patient “ownership” by house officers. Disruptions in continuity of care and increased numbers of handoffs seem to be the principal cause of the decrement in the quality of care for patients, as handoffs must inevitably increase in proportion to increasing restrictions on shift length, and with each handoff, there is another opportunity for communications failure with regard to patient condition, monitoring, and treatment. Obviously, care cannot be given continuously by one surgeon throughout a critically ill patient’s entire hospital stay, but the old system, in which a single service maintained responsibility for a given patient, rather than handing the responsibility off twice or 3 times daily to other teams, allowed for much greater consistency and continuity among a smaller group of people than the present system.
C 2014 Lippincott Williams & Wilkins
Commentary
We cannot return to a system in which residents work 100 hour weeks and spend every other night in the hospital on call. At the same time, the present system is not designed, nor optimized, to provide the best quality of care for surgical patients, consistent with realistic and practical work-hour rules for residents. The specifics of workhour rules regarding shift lengths are absurdly rigid for an activity as complex as patient care. Greater flexibility in implementation of the rules must become the norm, and greater discretion must be given to residents in determining when they need sleep, based on individual circumstances, and when they need to stay to care for a patient. The present rules have created significant dishonesty among residents in reporting their hours, because of their desire to stay and care for patients when they see unique opportunities for learning or feel personal responsibility for a patient’s welfare. The medical ethic that maintains the primacy of the patient’s welfare over that of the doctor, evolved during 2000 years, is turned on its head when we send a resident home because the clock reaches an arbitrary mark and thus tell him or her that the clock and his or her personal sleep cycle have become more important than anything affecting the patient. Such teaching conveys to the resident that he or she is a shift worker and has no intrinsic involvement, investment, or personal responsibility for the patient’s welfare. In a recent survey of program directors of postresidency gastrointestinal fellowships,4 it was noted that 38% of incoming fellows did not exhibit appropriate patient “ownership” and personal responsibility for management. If we continue to train residents this way, a central and essential ethic of medicine with regard to personal moral responsibility to patients will be lost, to the extreme detriment of both patients and the profession. The article, despite having a significantly flawed body of literature to start with, has done a remarkable job of teasing meaningful conclusions out of that literature. It is hoped that the dissemination of these conclusions will cause the relevant regulatory bodies, and the body of medicine as a whole, to realize that the present workhour restrictions are having serious unintended consequences that are harming patients and resident education and that a rational and informed discussion is needed to formulate improved and more flexible guidelines. If the present work leads to this outcome, it will be one of the most important publications this year.
REFERENCES 1. Ahmed NN, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty-hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259:1041–1053. 2. Philibert I, Nasca T, Brigham T, et al. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med. 2013;64:467–483. 3. Lewis FR, Klingensmith ME. Issues in general surgical residency training— 2012. Ann Surg. 2012;256:553–559. 4. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258:440–449.
www.annalsofsurgery.com | 1055
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Commentary on “Resident Work-Hour Restrictions and Responsibilities to Patients” Frank R. Lewis, MD
M
edicine likes to think of itself as a rational activity, in which decisions and actions are dictated by logic, based on clear evidence. It is therefore remarkable when we look critically at the most radical and disruptive change that has occurred in resident training during the last 3 decades— the imposition of universal work-hour restrictions—and find that there is no credible evidence to demonstrate that unrestricted resident work hours cause inferior patient care or that restricted resident work hours lead to improved patient care. Dozens of laboratory studies have been carried out by sleep researchers to show that sleep deprivation causes deficits in mentation and psychomotor performance, and these have been tacitly extended, without direct evidence, to conclude that such errors must lead to errors in patient care. Such conclusions fail to consider that the laboratory deficits may not affect the decisions made regarding patient care, that the multilayered decision process involved in patient management in any resident environment provides protection from potential errors by a single individual, and that the unintended negative consequences of resident work-hour restrictions on continuity of care and other aspects of resident behavior may outweigh any effects of sleep deprivation. The article by Ahmed et al,1 developed under the auspices of the Royal College of Physicians and Surgeons of Canada, is therefore particularly important, as it provides a comprehensive review of the North American literature on this subject and presents significant evidence that the opposite is true—that the work-hour restrictions have had a detrimental effect on the quality of patient care and resident education. The article presents a meta-analysis of the existing literature during the last 33 years, bridging the time from the initiation of the work-hour debate in 1984, with Libby Zion’s death, to the present. Its chief limitation is the relatively poor quality of the existing literature, and the markedly dissimilar designs of the studies, which makes comparative analysis difficult. Of 709 references initially screened from various databases during the aforementioned period, the authors were able to select 135 articles that provided sufficient data for analysis. They then applied objective criteria to determine the quality of the study and classified 78 of the studies as low or very low in quality and 57 as moderate or high in quality. Approximately half of the studies dealt with general surgical training, which has felt the detrimental effects of work-hour restrictions to a greater extent than any other specialty. The specific outcomes that the authors examined as a function of work-hour restrictions were patient safety, resident education, and resident wellness. Forty-five percent of the studies were surveys, 39% were interventional studies (the intervention was the initiation of duty-hour restrictions), and 6% were observational studies. Results were analyzed in 5 sections. The first section examined the 3 primary outcomes in the 57 moderate- or high-quality studies. Both in actual outcomes and in perceptions of outcomes, these studies overall showed that resident duty-hour restrictions (RDHRs) had a detrimental effect on patient safety and resident education and a beneficial effect on resident wellness. The effects of 16-hour shifts and night float systems were examined independently in sections 2 and 3 and combined in section 4. The aggregate conclusions of these sections, although there was some heterogeneity, were similar to the first section—these 2 changes had negative influence on patient safety and resident education and a positive influence on resident wellness. The last section, specific reports relative to patient morbidity and mortality, shows that overall morbidity increased after the implementation of RDHRs whereas mortality shows less clear changes, with variable results in different studies, and a trend to worsened outcome after RDHRs in the summary random-effects model that does not reach statistical significance. Despite the heterogeneity and variable quality of the studies that were reviewed, the conclusions from the various sections of the article are consistent and indicate that in both perceptions and actual outcomes, the implementation of RDHRs, both in 2003 and in 2011, has had the effect of decreasing patient safety and worsening resident education while improving resident wellness. The improvement
From the American Board of Surgery, Philadelphia, PA. Disclosure: The author declares no conflicts of interest. Reprints: Frank R. Lewis, MD, American Board of Surgery, 1617 John F. Kennedy Blvd, Ste 860, Philadelphia, PA 19103. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/25906-1054 DOI: 10.1097/SLA.0000000000000700
1054 | www.annalsofsurgery.com
Annals of Surgery r Volume 259, Number 6, June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 259, Number 6, June 2014
in resident wellness is clearly desirable and intended, but in any balancing of tradeoffs, it does not seem ethically acceptable that it should come at the expense of patient safety and resident education. It is not clear whether it is possible to optimize all 3 of these outcomes through changes in the work-hour requirements or whether there will always be conflicts and tradeoffs such as those shown here. What is clear, however, is that the present work-hour restrictions, which were arrived at without adequate foundation in studies or data related to patient care, must change; it is clearly unacceptable that we are harming patients as a result of restricting work hours. Earlier in 2013, a similar article was published by the staff of the Accreditation Council for Graduate Medical Education,2 also based on a meta-analysis of the existing literature, which reached similar conclusions regarding the effects on surgical patients, although with less detail than the present study. That article also found that the literature with regard to the effects of RDHRs on medical patients differed from that on surgical patients and overall were neutral or showed slight improvement in patient safety. Since the broad implementation of RDHRs in 2003, it has become apparent that the impacts on different specialties are highly variable. The majority of residency programs, which deal mainly with elective patient problems presenting during weekdays and daytime, are not significantly affected by them; only those specialties in which urgent and emergent patient problems are common are principally affected, because it is only in those specialties that a high percentage of night and weekend work is required; nearly all of these are surgical.3 General and trauma surgery are most prominently affected, along with neurosurgery and orthopedics. Vascular and thoracic surgery, and urology, are perhaps next in acuity. The creation of RDHRs was done in various settings by different groups of experts who did not appreciate the differences in the nature of the work done by different specialties, nor the impact of a high volume of urgent and emergent patients on the nature of resident work. Because of these differential effects, it is time to consider different work-hour standards for different specialties, depending on the nature of the work they do. The other principal factor that was not adequately appreciated in setting the work-hour restrictions was the price that would be paid in decreased continuity of care and patient “ownership” by house officers. Disruptions in continuity of care and increased numbers of handoffs seem to be the principal cause of the decrement in the quality of care for patients, as handoffs must inevitably increase in proportion to increasing restrictions on shift length, and with each handoff, there is another opportunity for communications failure with regard to patient condition, monitoring, and treatment. Obviously, care cannot be given continuously by one surgeon throughout a critically ill patient’s entire hospital stay, but the old system, in which a single service maintained responsibility for a given patient, rather than handing the responsibility off twice or 3 times daily to other teams, allowed for much greater consistency and continuity among a smaller group of people than the present system.
C 2014 Lippincott Williams & Wilkins
Commentary
We cannot return to a system in which residents work 100 hour weeks and spend every other night in the hospital on call. At the same time, the present system is not designed, nor optimized, to provide the best quality of care for surgical patients, consistent with realistic and practical work-hour rules for residents. The specifics of workhour rules regarding shift lengths are absurdly rigid for an activity as complex as patient care. Greater flexibility in implementation of the rules must become the norm, and greater discretion must be given to residents in determining when they need sleep, based on individual circumstances, and when they need to stay to care for a patient. The present rules have created significant dishonesty among residents in reporting their hours, because of their desire to stay and care for patients when they see unique opportunities for learning or feel personal responsibility for a patient’s welfare. The medical ethic that maintains the primacy of the patient’s welfare over that of the doctor, evolved during 2000 years, is turned on its head when we send a resident home because the clock reaches an arbitrary mark and thus tell him or her that the clock and his or her personal sleep cycle have become more important than anything affecting the patient. Such teaching conveys to the resident that he or she is a shift worker and has no intrinsic involvement, investment, or personal responsibility for the patient’s welfare. In a recent survey of program directors of postresidency gastrointestinal fellowships,4 it was noted that 38% of incoming fellows did not exhibit appropriate patient “ownership” and personal responsibility for management. If we continue to train residents this way, a central and essential ethic of medicine with regard to personal moral responsibility to patients will be lost, to the extreme detriment of both patients and the profession. The article, despite having a significantly flawed body of literature to start with, has done a remarkable job of teasing meaningful conclusions out of that literature. It is hoped that the dissemination of these conclusions will cause the relevant regulatory bodies, and the body of medicine as a whole, to realize that the present workhour restrictions are having serious unintended consequences that are harming patients and resident education and that a rational and informed discussion is needed to formulate improved and more flexible guidelines. If the present work leads to this outcome, it will be one of the most important publications this year.
REFERENCES 1. Ahmed NN, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty-hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259:1041–1053. 2. Philibert I, Nasca T, Brigham T, et al. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med. 2013;64:467–483. 3. Lewis FR, Klingensmith ME. Issues in general surgical residency training— 2012. Ann Surg. 2012;256:553–559. 4. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258:440–449.
www.annalsofsurgery.com | 1055
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
