Are we asking the right questions?
Not too long ago in the history of medical education, the resident workweek was completely uncharted territory. Until just over a decade ago, there were no national rules governing how long residents could be kept in the hospital by their training programs—so they rarely ever left. Residents, regardless of specialty, worked longer hours (120 hours was not an uncommon workweek), took more calls, and had fewer, shorter breaks than they do now.
That all changed in 2003 when, after a high-profile case of a young woman in New York dying in the hands of allegedly fatigued and overworked residents, the governing body overseeing resident education (the Accreditation Council for Graduate Medical Education, or ACGME) restricted all residents to an 80-hour workweek. Then in 2011 the ACGME issued another set of rules specifying how those 80 hours could be used—how long shifts could be, how many hours would be given in between shifts, and so forth. Both announcements from the ACGME were followed by heated national debate. Proponents of the duty hour restrictions claimed that the policy decreased resident fatigue, thereby reducing medical errors that could cause harm to patients. Critics argued that a limit on resident work hours would not only decrease resident experience and education, but would also increase the number of transitions of patient care between residents as shifts became shorter; these “handoffs” are widely recognized as a major source of error in hospitals.
Researchers have conducted dozens of massive studies analyzing the impact of this policy over the years and almost all have come to the exact same conclusion: the ACGME’s duty hour limitations have not affected patient outcomes at all. No significant changes in broad, nonspecific markers of patient care such as mortality, length of stay, or readmissions are associated with the new duty hour rules.
This is fantastic news: we have not hurt patient care in the process of trying to make a safer working environment for residents. But it’s also not entirely unexpected news. There are many systems of checks and balances in hospitals—such as attending physician supervision of all residents—to ensure that minor errors like ordering unnecessary medications or tests are avoided or caught early, before they cause any significant harm. These safeguards are a layer of insulation that protects broad metrics of hospital performance like mortality, readmissions, and length of stay from skyrocketing in the face of not just the new duty hours policy, but also the countless other changes happening daily in the teaching hospital environment.
LESS IS MORE
In fact, these metrics are influenced by so many other factors in a hospital that they may not be the best ones by which to gauge the impact of this policy. Studying major patient outcomes alone may not uncover more subtle underlying changes in quality, cost, or efficiency of care. Yet this is all we know about the effect of the duty hours policy, largely because this is all we’ve asked. In the June issue of the Journal of the American College of Surgeons, faculty members at Rhode Island Hospital and I investigated these more subtle changes. We gathered historical data on all patient admissions to the hospital’s trauma center in the four years before and after the 2011 duty hour reform—more than 11,700 patients—and compared the care of those admitted before the reform to those admitted after. In addition to studying the same major outcomes as previous studies, we looked at the amount of resources used for each patient (such as OR visits) and the rates of many specific complications (such as chest cavity infections after chest tube placement). As expected, no major outcomes exhibited meaningful changes.
However, we uncovered a surprisingly strong trend of changing resource utilization habits linked to the time that the policy took effect: after the reform, patients were being taken to the OR more often, getting more x-rays and CT scans, more lab tests, more fluids and meds: on average, more things were being done to each patient without any corresponding improvement in outcomes (and they weren’t any sicker than the patients before the reform, either).
It’s hard to explain why these changes occurred in association with the duty hour reform without much more information. However, one possible explanation is that, compared with their pre-reform counterparts, post-reform residents are less experienced on the floor—or perhaps less informed about their patients, more of whom are now being handed off from shift to shift—and therefore are ordering more unnecessary tests and interventions. Regardless of the true explanation, the results of this study are strong evidence for the existence of more nuanced policy effects. In fact, changing resource use patterns may be a sign that duty hour reform has affected the cost of care in ways that should be studied further.
We don’t yet know enough to decide on the fate of the 80-hour workweek; an understanding of the policy’s effects beyond high-level patient outcomes is a huge part of what we’re missing. Even the FIRST Trial—an ongoing national study being used to guide policymaking on the issue—is not using any new metrics to evaluate the policy’s impact. To be fair, it’s unreasonable to expect large trials to collect data as granular as ours. But having several more retrospective studies like ours—ones that leverage hospitals’ detailed historical records to examine unexpected effects of the policy—would be tremendously valuable to this debate. Without them, we may end up making many of our decisions on duty hours in the dark.