JAMA Internal Medicine: Health Professions Workforce Topic Collection

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 2011 vs 2003 Duty Hour Regulation–Compliant Models

Desai SV, Feldman L, Brown L, et al. — Mon, 22 Apr 2013 00:00:00 GMT

Importance

On July 1, 2011, the Accreditation Council for Graduate Medical Education implemented further restrictions of its 2003 regulations on duty hours and supervision. It remains unclear if the 2003 regulations improved trainee well-being or patient safety.

Objective

To determine the effects of the 2011 Accreditation Council for Graduate Medical Education duty hour regulations compared with the 2003 regulations concerning sleep duration, trainee education, continuity of patient care, and perceived quality of care among internal medicine trainees.

Design and Setting

Crossover study design in an academic research setting.

Participants

Medical house staff.

Intervention

General medical teams were randomly assigned using a sealed-envelope draw to an experimental model or a control model.

Main Outcome Measures

We randomly assigned 4 medical house staff teams (43 interns) using a 3-month crossover design to a 2003-compliant model of every fourth night overnight call (control) with 30-hour duty limits or to one of two 2011-compliant models of every fifth night overnight call (Q5) or a night float schedule (NF), both with 16-hour duty limits. We measured sleep duration using actigraphy and used admission volumes, educational opportunities, the number of handoffs, and satisfaction surveys to assess trainee education, continuity of patient care, and perceived quality of care.

Results

The study included 560 control, 420 Q5, and 140 NF days that interns worked and 834 hospital admissions. Compared with controls, interns on NF slept longer during the on call period (mean, 5.1 vs 8.3 hours; P = .003), and interns on Q5 slept longer during the postcall period (mean, 7.5 vs 10.2 hours; P = .05). However, both the Q5 and NF models increased handoffs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with NF that it was terminated early.

Conclusions and Relevance

Compared with a 2003-compliant model, two 2011 duty hour regulation–compliant models were associated with increased sleep duration during the on-call period and with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.

Resident Workload—Let's Treat the Disease, Not Just the Symptom Comment on “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” Resident Workload

Goitein L, Ludmerer KM. — Mon, 22 Apr 2013 00:00:00 GMT

Work compression is doing the same amount of work in fewer hours. The term is often used to describe an effect of the restriction of residents' work hours by the Accreditation Council for Graduate Medical Education (ACGME). But before work hour limitations were implemented in 2003, residents were already experiencing work compression. From 1990 to 2010, annual admissions to major teaching hospitals increased by 46% (Katherine Brandenburg, Association of American Medical Colleges, written communication, December 11, 2012), while first-year residency positions, limited by restrictions in Graduate Medical Education funding, grew only 13%. During the same period, length of stay fell by almost one-third, and intensity of care per admission greatly increased. In short, by the time ACGME restrictions were implemented, residents were already doing much more, in less time and for more and sicker patients, than were previous generations of house staff.

Burnout Exists: Cut the Fuel and Use the Fire Hose

Girbes AJ, Zijlstra JG. — Mon, 22 Apr 2013 00:00:00 GMT

Shanafelt et al again underscore the embarrassing incidence of burnout symptoms among physicians. However, in the discussion, 2 important issues should be addressed. Attributing burnout score differences between the general population and physicians to job characteristics can only be done after correction for baseline differences in proneness for burnout. Maybe students choosing medicine are somewhat more neurotic or less resilient. These students, and this is the second issue, start a professional life in an emotionally, physically, and financially exhausted condition. During training they have to survive in a highly competitive atmosphere, with still extreme working hours, and will end with large debts. In the meantime they have to find a relation and start a family. And then they are ready for a profession with a discolored aura.

Declining Proportion of Physician-Owned Practices Possibly Related to Increasing Burnout

Joshi S, Nehaul R, Broome MA. — Mon, 22 Apr 2013 00:00:00 GMT

In their article “Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population,” Shanafelt et al do an excellent job identifying increased rates of burnout among physicians, especially those in primary care. Their findings deserve immediate action to address the underlying causes.

Physician Burnout: An Urgent Call for Early Intervention

Mirrakhimov AE, Rimoin LP, Kwatra SG. — Mon, 22 Apr 2013 00:00:00 GMT

We read the study by Shanafelt et al with great interest. The authors surveyed 7268 US physicians for professional burnout in comparison with nonmedical US workers. They showed that physicians have a higher prevalence and a significantly greater risk for professional burnout compared with the general population. We are thankful to the authors for studying this extremely important topic. The major question that remains is why this happens, and more importantly, what we can do to prevent physician burnout?

Physician Burnout: An Urgent Call for Early Intervention—Reply

Shanafelt TD, Dyrbye LN, West CP. — Mon, 22 Apr 2013 00:00:00 GMT

In reply