A Review of Studies on Medical Residency Work Hour Changes

Limits on the number of hours residents can work could negatively impact medical students and patients.

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The number of people who survive surgery when general anesthesia is used has improved, particularly in developing countries.
The number of people who survive surgery when general anesthesia is used has improved, particularly in developing countries.

We first visited the issue of changes in medical residents' work hours in 2011. Now that we have been able to fully examine the impact of these changes—both personally and professionally—on medical students and residents, we thought it was time to offer an update and to review some recent studies on the topic.

The Accreditation Council for Graduate Medical Education published changes in work hour regulations and updated its rules in February 2012, specifying more specialty-specific guidelines. These guidelines represent a significant change in the culture of medical training in the United States and are part of an overseas shift as well.

More than a decade ago, the United Kingdom's European Working Time Directive Law, which imposes a limit of a 48-hour week, was expanded to include doctors in training. While the U.K. limit is lower than the new U.S. guidelines, in reality, many end up waiving the work-hour restriction, so the number of hours worked is longer, like their colleagues in the United States.

Do these initiatives ultimately improve patient care and education? It may be too early to tell, but responses are mixed so far.

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The Journal of Neurosurgery surveyed residency program directors to evaluate the impact of the 80-hour workweek changes by the ACGME in 2003 on neurosurgical residents, who tend to work much longer hours than residents in other specialties. They reported that while the mean United States Medical Licensing Examination scores did not change among these residents, there was a statistically significant decline in resident submission of abstracts, typically an indicator of engagement in research. Ninety-five percent of neurosurgical residency program directors, and 84 percent of chief residents, reported that a reduced workweek would "jeopardize patient care."

One study from the Mayo Clinic, examining the impact of the new 16-hour shift limitation of first-year residents, concluded that residents felt less prepared to deal with cases, and struggled with hand-offs—the transfer of a patient from one resident to another, usually because of a shift change—once the limitation was imposed.

However, some studies, including another recent Mayo Clinic study, found that the impact of the duty hour changes is inconclusive, both in the United States and the United Kingdom, and largely insignificant. And a British Medical Journal study, which states that more data is needed to examine UK training programs, found no evidence that a UK reduction to a 48-hour workweek compromised patient safety, and was not able to conclude that clinical or educational objectives were adversely affected.

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Another BMJ study found that work hour limitations led to a drop in the number of patients that residents had to see, but resulted in a spike in average residency in-service test scores.

But even with the new limitations on work hours for residents, have residents felt that their quality of life has improved?

A recent study in the Archives of Internal Medicine stated that physicians, drawn from a sample of 7,288 physicians—both allopathic and osteopathic—are at higher risk of burnout, as measured by the Maslach Burnout Inventory. The study found that even after residency, physicians are at a higher risk of burnout compared to a general sample of various U.S. workers. The reality is that for many, working as a fully fledged physician can sometimes be harder than being a resident. The ACGME doesn't have to follow your hours anymore. You're on your own.

The data regarding the impact of the July 2011 work hour changes clarifies that the changes improve resident satisfaction in some specialties but not in others. That said, the UK does have a tempting work hour limit: 48 hours per week vs. 80 hours per week in the United States. However, data is starting to show that the consequences of these changes, particularly when residents hand patients over to the next resident, can affect outcomes.

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In the end, these changes may affect patients and medical student education. With residents on shifts struggling to make sure the covering resident has the information she or he needs to keep patients safe, medical students could receive less attention, as well as fewer clinical educational opportunities, as these changes go through.

The U.S. medical establishment is still trying to find ways to make sure residents are safe, medical students are taught, and patients do well. If these changes work, it could not only enhance the quality of medical student teaching, but also make residency more livable.

Ibrahim Busnaina, M.D. is a graduate of the University of Pennsylvania School of Medicine and coauthor of "Examkrackers' How to Get Into Medical School." He has been consulting with prospective medical school applicants, with a special focus on minority and other nontraditional candidates, since 2006.