Greater satisfaction and no negative effect on educational outcomes seen in residents with limited work shifts

First-year medical residents who are limited to 16-hour work shifts were generally more satisfied with their training and work-life balance than those who were “flexed” to accommodate longer shifts. Training directors, however, were less satisfied with the limited shifts, according to a study published in The New England Journal of Medicine.

“The effects of limiting trainee duty hours were not known,” said lead author Sanjay Desai, MD, associate professor of medicine and director, Osler Medical Training Program, Johns Hopkins University School of Medicine, Baltimore, MD. “A randomized trial with many institutions and generalizable findings was needed to inform the issue,” he added.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established policies that limited resident work weeks to 80 hours and shifts to 30 hours. In 2011, ACGME policy was changed to limit shifts for first-year residents to 16 hours.¹ After these policies were implemented, program directors reported a reduced quality of training and professional maturation, increased handoffs of care, and decreased continuity, with no improvements in patients’ safety or quality of care.^2,3

Previously, training program guidelines and regulations usually specified no limits on shift lengths for interns, and many doctors in training worked more than 90 hours per week on shifts that could be as long as 36 hours. The long hours were often under pressure and with little sleep and were justified as proper preparation for the lifetime of learning and patient treatment required of physicians. Continuity of care was also cited as a reason for less frequent shift changes.

The limits on shift times were controversial, and many training directors argued that interns needed to follow patients for longer, continuous periods to learn how to properly care for them.

“Many educators have worried that the shift work created by limited duty hours will undermine the training and socialization of young physicians,” said principal investigator David Asch, MD, John Morgan Professor of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. “Educating young physicians is critically important to health care, but it isn’t the only thing that matters. We didn’t find important differences in education outcomes, but we still await results about the sleep interns receive and the safety of patients under their care.”

For the study, 63 internal medicine residency programs were assigned to adhere to standard duty-hour policies of the 2011 ACGME or to more flexible policies with no specific limits on shift length or mandatory time off between shifts. Those on the limited-hour policies were required to complete 16-hour shifts with at least 8 hours off between shifts, for an 80-hour weekly maximum, with 1 day off every 7 days.

Drs. Desai and Asch and their fellow researchers assessed activities of first-year residents and intern exam scores, and surveyed interns, residents, and faculty members. The daily routines of 80 interns, 44 with flexible-hour programs and 36 with limited hours, were followed by 23 trained research observers.

They found no significant between-group differences in the mean percentage of time interns spent in direct patient care (12% to 13% on face-to-face patient care) and education (7%), in intern perceptions of what comprised an appropriate balance between clinical demands and education, or in program director and faculty assessments of whether trainee workload exceeded their capacity.

In a survey of the 1,200 interns from the 63 programs, researchers found that interns who were in the flexible program were more likely to report dissatisfaction with the aspects of training, including educational quality (OR: 1.67; 95% CI: 1.02-2.73) and overall well-being (OR: 2.47; 95% CI: 1.67-3.65). Directors of flexible programs, however, were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (OR: 0.13; 95% CI: 0.03-0.49).

Interns in flexible programs were less likely to report that they were dissatisfied with the number of admissions they were able to complete (OR: 0.48; 95% CI: 0.27-0.85), and less likely to perceive the negative effects of duty-hour rules on continuity of care (OR: 0.35; 95% CI: 0.22-0.57).

Rates of burnout were high in both groups, and interns had a similar likelihood of high or moderate scores on the Maslach Burnout Inventory subscale for emotional exhaustion. Interns in the flexible programs scored 79%, compared with 72% for those in the standard programs. Both groups also had high or moderate scores on the depersonalization subscale (75% vs 72%, respectively) and low or moderate scores on the personal accomplishment subscale (71% vs 69%).

According to the researchers, these scores were slightly lower in surgical trainees and slightly higher in emergency medicine trainees.

Mean intern scores for emotional exhaustion and depersonalization were higher compared with the general population, and higher than those from many other professions such as university faculty.

In the flexible programs, trainee average scores on in-training exams were 68.9%, compared with 69.4% for those in the standard programs, which did not meet the noninferiority margin of 2 percentage points (P=0.06 for noninferiority).

“The takeaway is that interns were overall less satisfied with the flexible policies, and the program directors were less satisfied with the standard approach,” said senior study author Judy Shea, PhD, professor of medicine and associate dean of medical education research, Perelman School of Medicine, University of Pennsylvania. “The lenses of teachers and trainees are different, though both provide an image of how medical training should be seen.”

Data on patient mortality and other clinical outcomes from the 63 hospitals, and on intern sleep deprivation, are forthcoming.

Until then, Dr. Desai called for the creation of “a far more collaborative process for making schedules than has been used in the past.”

This study was funded by the National Heart, Lung, and Blood Institute and the ACGME.

References:

1. Nasca TJ, Day SH, Amis ES Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.
2. Drolet BC, Khokhar MT, Fischer SA. The 2011 duty-hour requirements—a survey of residency program directors. N Engl J Med. 2013368:694-697.
3. Garg M, Drolet BC, Tammaro D, Fischer SA. Resident duty hours: a survey of internal medicine program directors. J Gen Intern Med. 2014;29:1349-1354.