Written by Clay Smith
Spoon Feed
There was no difference in patient safety between standard resident duty hour restrictions and a more flexible schedule that allowed for longer shifts and no mandated time off between shifts.
Why does this matter?
We know fatigue can increase the chance of making mistakes. Does a change in duty hour restrictions make patients safer by making physicians-in-training less sleepy? See the table below for a summary of differences in the two duty hour restrictions. Yesterday we covered a companion study that did not find a difference in sleep time or alertness with flexible duty hours vs standard. In 2016, FIRST found no difference in surgical outcomes or quality of life for trainees between differing duty hour restrictions.
Can you practice medicine in your sleep?
This was the same study design as yesterday’s summary, a multicenter RCT comparing standard 2011 duty hour restrictions or a more flexible schedule with no mandate on shift length or time off between shifts (see table below). The outcome of today’s study was patient-centered instead of trainee-centered. The primary outcome of 30-day mortality was not inferior in the flexible duty hour group (12.5%) compared to the standard group (12.6%). There was also no difference in readmission rate or other patient safety metrics. Duty hour restrictions were first imposed as a result of a sentinel patient safety event. I trained before the days of duty hour restrictions, and I can attest that it was pretty rough when I walked to my residency program uphill both ways in the snow. Kidding aside, part of training is caring for patients and being a professional when you’re really tired. The editorialists ask, “Can we be sure that we are preparing trainees to handle the challenges of practice in the real world where such [duty hour] protections clearly do not exist?” If the regulations don’t make patients safer and also don’t improve resident quality of life, then what good are they? I am all for a sane schedule that enhances trainee quality of life and patient safety, but the current regulations don’t seem to be the answer.
Source
Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules. N Engl J Med. 2019 Mar 7;380(10):905-914. doi: 10.1056/NEJMoa1810642.
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Reviewed by Thomas Davis
From cited article, Supplementary Appendix, Table S1
While I’m certainly happy to know that patients likely weren’t being "harmed" – ie they can’t find more sentinel events – by the work hours residents used to endure, I don’t think sentinel events represent the total picture. How about the fact people had to be take care of by physicians who were so sleep deprived that they ONLY thing they could really do was ensure they didn’t commit a sentinel event?
This is a story I’m not proud of but it happened to me & I’m sure hundreds of others back in the day. After several months of qod call & virtually no sleep on call days & perhaps 4-6h of sleep on the "off days," I had laid down ≈1:30a & just drifted off when my beeper alarmed. A patient was coding in the ICU. One of those codes that goes on & on & on. After about 2h I remember being firmly convinced that the woman coded "on purpose" just to deprive me of the few minutes of sleep I might have gotten that night, I hated her for it & fervently wished she would just DIE so I could go back to bed. I knew it was irrational at the time but after months of sleep deprivation I had no emotional reserve & no capacity for feeling anything for another human being.
Sentinel events are not the problem with resident work hours. Sleep deprivation is a torture technique for a reason. Having people cared for by doctors who have been systematically stripped of the ability to care about anything beyond self-preservation is the problem with unlimited resident work hours.
Well said. I kind of downplayed it in the post, but four of my six residency years were before duty hour restrictions. It wasn’t walking uphill both ways in the snow, but it was pretty rough. After six months of nonstop q4, q3, and q2 call my intern year, with six more months of call ahead, I told my wife I didn’t want to be a doctor anymore. I was exhausted. She calmly said, “Well, let’s think about this. Um…you don’t have any other marketable skills.” And then we laughed, because she was right. And we had a mountain of debt and three kids, with one on the way. So, we got through it. But it took a toll. Thanks for your candor and courage to speak out. What you say is true. I’ve had thoughts and said things when I was overly tired and in survival mode I wish I could reel back in…