The New Resident Duty Hours —Yay or Nay?

The most recent duty hour restrictions implemented by the Accreditation Council for Graduate Medical Education (ACGME) have turned out to be controversial, if not downright unpopular.  

To bring you up to speed— in 2011 residency programs implemented duty hour regulations that limit first-year residents (aka interns) to working only 16 hours consecutively.  Additionally, first year residents must have an appropriate level of supervision, meaning they can no longer be on call alone, – at least not until late in the year, when they have more experience and expertise.  These 2011 rules are an addition to the 2003 duty hour restrictions that established the 80-hour work week. 

Early reports suggest that the new rules are more bad than good:  they appear to be complicating schedules and increasing handoffs, while quality of care appears to be unchanged or even worse.  One large study (n=6202) reported that 54% of residents across all specialties disapprove of the new regulations. 

So far, only one research study  has looked at the effects of the new rules for psychiatry residents.  This small study found that the majority (64%) of respondents (n=25) in one residency program preferred their new call system.  Many residents also reported better attentiveness and performance on call.  However, this program made significant changes beyond the ACGME requirements, such as hiring outside physicians to cover weeknight shifts, which limit the study’s generalizability to other psychiatry residencies. 

Seeking more data, I contacted Dr. Brian Drolet, author of the above-mentioned large survey, who provided a sub-analysis of his data for psychiatry residents (n=305).  According to this data, fewer psychiatry residents (34%) expressed their disapproval of the new regulations compared to residents in general (54%). 

In my program, the changes seem to be generally well-regarded, with some caveats.  To comply with the new regulations, traditional long calls have replaced by a short calls and a night float.  The most obvious consequence has been that the interns appear to be more rested.  While learning the basics of psychiatry, they sleep in their own beds and are never awakened by the sound of a beeping pager.  They no longer miss our weekly Tuesday afternoon didactics due to being post-call.  

My opinion is that this is a more rational and humane approach to training.  Sure, I still gripe with the other senior residents that the new interns seem less efficient, less responsible, and less independent than we were.  (“When I was an intern,” I tell the wide-eyed medical students, “I had only three supervised calls before I was on my own, and I worked for thirty hours straight.”)   

But the new interns also seem less terrified and less depressed, and I hope they have more time to read (though recently, two interns informed me otherwise).  That said, our first class of residents to train under the new system is now in their third year, and I find them to be extremely competent. 

Duty hour reform has become a topic of national concern of late, given its implications for patient safety. Some in this conversation argue that the real problem with training is that residents are doing more work in less time.  

From 1990 to 2010, for example, admissions to teaching hospitals have increased by 50%, while the number of doctors increased by only 10%.  Hospital stays are shorter, patients are sicker, and documentation more time-consuming.  Some small studies have found that when residents care for fewer patients in the hospital, patient outcomes improve.  In this view, the 2011 duty hour regulations fall short by merely rearranging schedules without addressing the issue of workload. 

I find this perspective compelling, as the intensity of resident workload is indeed profound. I hope that future research keeps this issue in mind. 

For now, the longitudinal effects of the new duty hour regulations remain to be seen, as does the future of residency reform. 

What do you think about the most recent duty hour rules for residents, and specifically for psychiatry?   

References

1. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013 Apr 22;173(8):649-655.

2. Drolet BC, Christopher DA, Fischer SA. Residents’ response to duty-hour regulation—A follow-up national survey. N Engl J Med 2012;366:e35.

3. Goitein, L, Ludmerer KM. Resident workload—let’s treat the disease, not just the symptom. JAMA Intern Med. 2013;173(8): 655-656.

4.  Chen, Pauline W.  The Impossible Workload for Physicians In Training.  New York Times.  Apr 18, 2013.  Accessed online September 19, 2013.  https://well.blogs.nytimes.com/2013/04/18/doing-the-math-on-resident-work-hours/ 

Leigh Jennings, MD, is a senior psychiatry resident in the Department of Neurology and Psychiatry at Saint Louis University School of Medicine.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.