Physician training has long been notorious for marathon shifts, sleepless nights on call, and holidays worked. But that began to change in 2003, when the medical profession placed restrictions on work hours during residency. However, experts wondered, can we train residents in fewer hours and still make good doctors?
A new study in the BMJ says yes. The researchers, led by Dr. Anupam Jena, a professor of health care policy and medicine at Harvard Medical School, looked at the performance of internal medicine doctors in their first year of unsupervised medical practice after completing their training.
They compared the outcomes for patients of two groups of physicians: those trained before 2003, when the typical work week was 100 hours; and those trained later under the new rules, which capped weekly hours at a mere 80, with no individual shift exceeding 30 hours. For the three quality measures examined — mortality within 30 days of being hospitalized, readmissions, and hospital services used (a measure of efficiency) — they found no differences between the groups.
Looking at the data for just the sickest patients in the hospital, a “group of patients for whom the experience and training of a doctor is really important,” said Jena, the authors again found no difference in these three outcomes.
“If anything, it’s reassuring,” said Dr. Sanjay Desai, director of the internal medicine residency program at Johns Hopkins who was not involved in the study.
Jena and his team based their analysis on a random sampling of patient records from the Medicare database, including 450,000 hospitalizations at over 4,000 hospitals in the U.S., for each year from 2000 to 2012.
Though the data are old, Desai said it’s a timely paper. Other reforms were made after 2003, but the 80-hour cap and 30-hour shift limits studied in this paper are similar to what’s in practice today, he said. Since 2017, when the latest reform was implemented by the Accreditation Council for Graduate Medical Education, the cap remains 80 clinical and educational work hours per week averaged over a four-week period, with no shift exceeding 28 hours.
Dr. Thomas J. Nasca, CEO of the accreditation group, said in a statement that the study supports its work rule, “which allows for flexibility within maximums while supporting patient safety, quality improvement, and physician well-being.”
Jena said he chose to study only the first year of a new doctor’s career because that’s when the effects of residency training should be most evident. “If doctors who just completed a residency had insufficient training during residency because they worked fewer hours,” he said, “then we should expect to see some differences really early on” before “real world” experience.
In 2006, co-author Dr. Jay Bhattacharya, professor of medicine and economics at Stanford University, looked at mortality of patients treated by residents before and after the changes implemented in 2003. He found that capping weekly hours decreased short-term mortality among high-risk patients.
“Previous literature said that tired doctors hurt and kill patients. In 2006, short-term results showed that lower hours during residency reduced mortality in hospitals. But no one had assessed long-running quality of doctors,” said Bhattacharya.
“This study is unique because it studied outcomes after training,” said Desai.
The study also found that physicians with 10 years of experience provided higher quality care than the first-year doctors, as expected, but the gap in care was the same whether the new doctors trained before or after the cap was put in place. Over the 10 years studied, the study team also noticed a decrease in overall mortality, which accounts for nationwide trends that suggest hospitals are providing better care overall, said Jena.
The authors noted that in the hospital setting, physicians work in big teams with specialists, nurses, social workers, and other advanced practitioners, which mutes the impact of any single physician on patient outcomes.
What we need to know next, said Desai, is what residents are doing with their 80 hours. How much time is spent with patients? At the computer? Doing procedures?
“The real meaning in the hospital is where you spend those hours,” said Desai. “In addition to [examining] patient safety outcomes, we need to think very hard and study more rigorously how physicians are shaped” during residency.
A limitation of the study, mentioned by both Desai and the authors, is that it looked only at one specialty — internal medicine doctors. Surgeons and other doctors who perform procedures may be affected differently by hour restrictions because it would limit the number of procedures they perform under supervision.
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