COMMENTARY
Time to Refine Resident Duty Hour Guidelines
R
esidents, their supervisors, and their patients have seen the introduction and subsequent refinement of training regulations. Duty hour limits established by the Accreditation Council for Graduate Medical Education (ACGME)1 have attempted to strike a better balance between the complementary, but often competing, demands of patient care, resident education, and quality of life. The latest ACGME duty hour restrictions have been in effect for just over 1 year. In this issue of the Journal of Graduate Medical Education, Drolet and colleagues2 offer another important analysis of the effects of these regulations. In their original paper from 2010 the authors surveyed 11 617 residents across the United States, representatives of all specialties and years of training.3 More than 2500 responses were returned (22% response rate), with most (69%) from residents in their first 3 years of training—the group that is most closely associated with the new ACGME limits for postgraduate year 1 (PGY-1) residents or interns. Prior to the implementation of these standards, large proportions of residents in this survey predicted a positive effect on their quality of life but negative effects on patient care, education, and their preparedness for more senior resident or attending physician roles. One-half of the respondents were concerned that these restrictions would result in lengthening of training. The ACGME duty hour limits were initially developed out of concerns regarding resident fatigue and patient safety. Thus, it is interesting that residents’ responses were divided on the duty hour restrictions’ potential effects on patient safety and medical errors. In an important follow-up study conducted 6 months after these duty hour restrictions took effect, the investigators asked residents whether the actual effects of these duty hour restrictions were the same as what they initially predicted.4 Interestingly, respondents did report an improvement in their quality of life, but this was limited to
All authors are at the London Health Sciences Centre and the University of Western Ontario, London, Ontario, Canada. Adam A. Maruscak, MSc, MD, is Surgery Resident from the Division of General Surgery; Michael C. Ott, MEd, MD, is Assistant Professor of Surgery from the Division of General Surgery; and Thomas L. Forbes, MD, is Professor of Surgery from the Division of Vascular Surgery. Corresponding author: Thomas L. Forbes, MD, Division of Vascular Surgery, London Health Sciences Centre, 800 Commissioners Road East, Room E2-119, London, ON N6A5W9, Canada, 519.667.6794, [email protected] DOI: http://dx.doi.org/10.4300/JGME-D-12-00254.1
Adam A. Maruscak, MSc, MD Michael C. Ott, MEd, MD Thomas L. Forbes, MD
PGY-1 residents, whereas more senior residents noticed a reduction in their quality of life. Although mandatory in-house supervision of PGY-1 residents is an important requirement of the ACGME guidelines, most residents did not report any changes in supervision following their implementation. In their present study, Drolet and colleagues asked respondents to ‘‘share any comments or concerns’’2 they had. Most respondents provided negative perspectives regarding the effects on education and preparation for more senior roles, which are aggregated in the report. Respondents also reported concern that the increased number of patient handovers and lack of continuity of care might have a negative impact on patient safety and care. The authors attempted to objectively evaluate this qualitative data by applying a structured analysis to identify common themes and to quantify the responses. Although these free-text responses are important and help illustrate the issues, their significance should be interpreted cautiously. Just 7% of the population surveyed provided feedback, which raises questions regarding the generalizability of these viewpoints. This small sample size of respondents likely represents those with polarized views and excludes those with more moderate opinions who seldom take the time to fill out the comment sections of surveys. One of the consistent concerns of residents is the effect that the duty hour restrictions will have on their preparedness to take on more senior resident roles and eventually attending physician responsibilities. Furthermore, if their perceived reality of medical practice is what they experience during residency, will they adopt some of these work practices when they begin their postresidency careers as attending physicians? The potential for current residents to work fewer hours when they reach practice has been a significant concern for surgical specialties.5 In a recent report, our group found validity in this concern, with Canadian surgical residents planning on taking less call, working fewer days of the week, limiting postcall activities, and taking parental leave more often when they reach practice than current surgical faculty.6 This raises the real possibility that residents may adopt residency work hour guidelines once they start practice, which will result in significant workforce implications. Given that the most recent iteration of duty hour restrictions has been in place for a year, has there been any Journal of Graduate Medical Education, December 2012 545
COMMENTARY
evidence that the ACGME duty hour guidelines have improved patient safety, resident education, and quality of life? To date, most reports have been mainly opinion based with little objective data. Conservatively, it appears that there has been an improvement that is difficult to measure: resident quality of life.4 However, this quality of life improvement appears to be disproportionately experienced by PGY-1 residents, for whom the most recent changes to ACGME duty hour restrictions apply, and at the expense of more senior residents and attending physicians. The effect of the limits on the quality of education is difficult to determine, with test scores often serving as a surrogate marker. Presently there is no quality evidence that such objective measures have been influenced negatively or positively by any work hour restrictions. Determining effects on patient care is even more problematic because patient outcomes are linked not only with resident performance but also with that of their attending physicians and other health care providers, and are influenced by the higher-acuity patient mix that often presents to teaching hospitals and clinics. Furthermore, there has been no objective evidence to date demonstrating a decrease in medical errors, which was the initial driving force of duty hour restriction. If there is little good objective evidence that these duty hour guidelines have achieved their goals, where does this leave us? We have 2 recommendations for future iterations in the evolution of duty hour guidelines. First, the current ACGME guidelines are disproportionately applicable to more junior residents, and while admittedly improving their quality of life, they do so at the expense of their ability to adopt more senior responsibilities and at the expense of their more senior colleagues’ quality of life. A more uniform approach of duty hour guidelines with equal application to all years of residency would seem more appropriate. This does not mean that the current guidelines should be applied to all years of residency, but a more balanced and moderate set should be consistently
546 Journal of Graduate Medical Education, December 2012
applied to all years to achieve balance in quality of life and education throughout residency. Second, as Drolet and colleagues4 state, one size does not fit all when it comes to medical education. Just as a surgeon’s practice is different from that of an internist, family physician, or radiologist, the training required should differ as well. Medical educators understand this when it comes to curriculum content development, but the duty hour restrictions implemented by ACGME do not. Residency is a prequel to medical practice and needs to adequately prepare our future physicians. Training them in an environment that is different than what is expected once they enter practice does them and their future patients a disservice. Work hour guidelines are important in all specialties but should be customized to meet the present and future demands of the individual specialties. Future renditions of these guidelines will require input from specific specialty boards and national specialty societies to develop specialty-specific work hour guidelines. Resident work hour guidelines are here to stay, but the current ACGME duty hour restrictions should be seen as the current edition of an evolving process. We need to continue to evaluate the effects of these guidelines rigorously as we hopefully get closer to that elusive balance of excellent medical education and outstanding patient care. References 1 Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288(9):1112–1114. 2 Drolet BC, Soh IY, Shultz PA, Fischer SA. A thematic review of resident commentary on duty hours and supervision regulations. J Grad Med Educ. 2012;4(4):454–459. 3 Drolet BC, Spalluto LB, Fischer SA. Residents’ perspectives on ACGME regulation of supervision and duty hours–a national survey. N Engl J Med. 2010;363(23):e34. 4 Drolet BC, Christopher DA, Fischer SA. Residents’ response to duty-hour regulations–a follow-up national survey. N Engl J Med. 2012;366(24):e35. 5 Antiel RM, Van Arendonk KJ, Reed DA, Terhune KP, Tarpley JL, Porterfield JR, et al. Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education Core Competencies. Arch Surg. 2012;147(6):536–541. 6 Maruscak AA, Vanderbeek L, Ott MC, Kelly S, Forbes TL. Implications of current resident work-hour guidelines on the future practice of surgery in Canada. J Surg Educ. 2012;69(4):487–492.
Time to Refine Resident Duty Hour Guidelines
R
esidents, their supervisors, and their patients have seen the introduction and subsequent refinement of training regulations. Duty hour limits established by the Accreditation Council for Graduate Medical Education (ACGME)1 have attempted to strike a better balance between the complementary, but often competing, demands of patient care, resident education, and quality of life. The latest ACGME duty hour restrictions have been in effect for just over 1 year. In this issue of the Journal of Graduate Medical Education, Drolet and colleagues2 offer another important analysis of the effects of these regulations. In their original paper from 2010 the authors surveyed 11 617 residents across the United States, representatives of all specialties and years of training.3 More than 2500 responses were returned (22% response rate), with most (69%) from residents in their first 3 years of training—the group that is most closely associated with the new ACGME limits for postgraduate year 1 (PGY-1) residents or interns. Prior to the implementation of these standards, large proportions of residents in this survey predicted a positive effect on their quality of life but negative effects on patient care, education, and their preparedness for more senior resident or attending physician roles. One-half of the respondents were concerned that these restrictions would result in lengthening of training. The ACGME duty hour limits were initially developed out of concerns regarding resident fatigue and patient safety. Thus, it is interesting that residents’ responses were divided on the duty hour restrictions’ potential effects on patient safety and medical errors. In an important follow-up study conducted 6 months after these duty hour restrictions took effect, the investigators asked residents whether the actual effects of these duty hour restrictions were the same as what they initially predicted.4 Interestingly, respondents did report an improvement in their quality of life, but this was limited to
All authors are at the London Health Sciences Centre and the University of Western Ontario, London, Ontario, Canada. Adam A. Maruscak, MSc, MD, is Surgery Resident from the Division of General Surgery; Michael C. Ott, MEd, MD, is Assistant Professor of Surgery from the Division of General Surgery; and Thomas L. Forbes, MD, is Professor of Surgery from the Division of Vascular Surgery. Corresponding author: Thomas L. Forbes, MD, Division of Vascular Surgery, London Health Sciences Centre, 800 Commissioners Road East, Room E2-119, London, ON N6A5W9, Canada, 519.667.6794, [email protected] DOI: http://dx.doi.org/10.4300/JGME-D-12-00254.1
Adam A. Maruscak, MSc, MD Michael C. Ott, MEd, MD Thomas L. Forbes, MD
PGY-1 residents, whereas more senior residents noticed a reduction in their quality of life. Although mandatory in-house supervision of PGY-1 residents is an important requirement of the ACGME guidelines, most residents did not report any changes in supervision following their implementation. In their present study, Drolet and colleagues asked respondents to ‘‘share any comments or concerns’’2 they had. Most respondents provided negative perspectives regarding the effects on education and preparation for more senior roles, which are aggregated in the report. Respondents also reported concern that the increased number of patient handovers and lack of continuity of care might have a negative impact on patient safety and care. The authors attempted to objectively evaluate this qualitative data by applying a structured analysis to identify common themes and to quantify the responses. Although these free-text responses are important and help illustrate the issues, their significance should be interpreted cautiously. Just 7% of the population surveyed provided feedback, which raises questions regarding the generalizability of these viewpoints. This small sample size of respondents likely represents those with polarized views and excludes those with more moderate opinions who seldom take the time to fill out the comment sections of surveys. One of the consistent concerns of residents is the effect that the duty hour restrictions will have on their preparedness to take on more senior resident roles and eventually attending physician responsibilities. Furthermore, if their perceived reality of medical practice is what they experience during residency, will they adopt some of these work practices when they begin their postresidency careers as attending physicians? The potential for current residents to work fewer hours when they reach practice has been a significant concern for surgical specialties.5 In a recent report, our group found validity in this concern, with Canadian surgical residents planning on taking less call, working fewer days of the week, limiting postcall activities, and taking parental leave more often when they reach practice than current surgical faculty.6 This raises the real possibility that residents may adopt residency work hour guidelines once they start practice, which will result in significant workforce implications. Given that the most recent iteration of duty hour restrictions has been in place for a year, has there been any Journal of Graduate Medical Education, December 2012 545
COMMENTARY
evidence that the ACGME duty hour guidelines have improved patient safety, resident education, and quality of life? To date, most reports have been mainly opinion based with little objective data. Conservatively, it appears that there has been an improvement that is difficult to measure: resident quality of life.4 However, this quality of life improvement appears to be disproportionately experienced by PGY-1 residents, for whom the most recent changes to ACGME duty hour restrictions apply, and at the expense of more senior residents and attending physicians. The effect of the limits on the quality of education is difficult to determine, with test scores often serving as a surrogate marker. Presently there is no quality evidence that such objective measures have been influenced negatively or positively by any work hour restrictions. Determining effects on patient care is even more problematic because patient outcomes are linked not only with resident performance but also with that of their attending physicians and other health care providers, and are influenced by the higher-acuity patient mix that often presents to teaching hospitals and clinics. Furthermore, there has been no objective evidence to date demonstrating a decrease in medical errors, which was the initial driving force of duty hour restriction. If there is little good objective evidence that these duty hour guidelines have achieved their goals, where does this leave us? We have 2 recommendations for future iterations in the evolution of duty hour guidelines. First, the current ACGME guidelines are disproportionately applicable to more junior residents, and while admittedly improving their quality of life, they do so at the expense of their ability to adopt more senior responsibilities and at the expense of their more senior colleagues’ quality of life. A more uniform approach of duty hour guidelines with equal application to all years of residency would seem more appropriate. This does not mean that the current guidelines should be applied to all years of residency, but a more balanced and moderate set should be consistently
546 Journal of Graduate Medical Education, December 2012
applied to all years to achieve balance in quality of life and education throughout residency. Second, as Drolet and colleagues4 state, one size does not fit all when it comes to medical education. Just as a surgeon’s practice is different from that of an internist, family physician, or radiologist, the training required should differ as well. Medical educators understand this when it comes to curriculum content development, but the duty hour restrictions implemented by ACGME do not. Residency is a prequel to medical practice and needs to adequately prepare our future physicians. Training them in an environment that is different than what is expected once they enter practice does them and their future patients a disservice. Work hour guidelines are important in all specialties but should be customized to meet the present and future demands of the individual specialties. Future renditions of these guidelines will require input from specific specialty boards and national specialty societies to develop specialty-specific work hour guidelines. Resident work hour guidelines are here to stay, but the current ACGME duty hour restrictions should be seen as the current edition of an evolving process. We need to continue to evaluate the effects of these guidelines rigorously as we hopefully get closer to that elusive balance of excellent medical education and outstanding patient care. References 1 Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288(9):1112–1114. 2 Drolet BC, Soh IY, Shultz PA, Fischer SA. A thematic review of resident commentary on duty hours and supervision regulations. J Grad Med Educ. 2012;4(4):454–459. 3 Drolet BC, Spalluto LB, Fischer SA. Residents’ perspectives on ACGME regulation of supervision and duty hours–a national survey. N Engl J Med. 2010;363(23):e34. 4 Drolet BC, Christopher DA, Fischer SA. Residents’ response to duty-hour regulations–a follow-up national survey. N Engl J Med. 2012;366(24):e35. 5 Antiel RM, Van Arendonk KJ, Reed DA, Terhune KP, Tarpley JL, Porterfield JR, et al. Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education Core Competencies. Arch Surg. 2012;147(6):536–541. 6 Maruscak AA, Vanderbeek L, Ott MC, Kelly S, Forbes TL. Implications of current resident work-hour guidelines on the future practice of surgery in Canada. J Surg Educ. 2012;69(4):487–492.
