Evidence-Based Policy Change Regarding Resident Work Hour Applauded by Experts

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Widespread debate and the development of policies regulating resident duty hours was first prompted by a jury decision in 1984.
Widespread debate and the development of policies regulating resident duty hours was first prompted by a jury decision in 1984.

Health-policy experts are applauding the new revisions to residents' duty hours just issued by the Accreditation Council for Graduate Medical Education (ACGME).

The revisions limit resident workweeks to 80 hours, but also extend shifts from 16 to 24 hours — revisions that the ACGME says are based on evidence, not opinion.

“What is meaningful about the recent ACGME rules is that they are based on stronger evidence and on a more disciplined approach to developing the kind of evidence that ought to inform policy of such reach,” say lead author David Asch, MD, MBA, professor of medicine at the University of Pennsylvania and the Philadelphia VA Medical Center, both in Philadelphia, and two co-authors in a recent review in The New England Journal of Medicine.1

Widespread debate and the development of policies regulating resident duty hours was first prompted by a jury decision in 1984, which ruled that the death of an 18-year-old hospital patient was due to long resident hours and poor supervision of graduate medical education, the authors explain. 

Designing regulations to reduce sleep deprivation, thereby addressing one cause of errors, has been a major focus for the ACGME, they write.

However, the authors argue, policies also need to reduce patient handoffs between shifts — another cause of medical errors — to as few as possible and to prevent medical residents from entering a “shift mentality,” which the authors say can reduce professionalism. 

At the same time, policies guiding resident work need to make sure that hospitals continue to receive the affordable labor that is provided by residents and that they depend on, the authors add. 

“At times, the debate has seemed like a shouting contest, rooted in opinion rather than evidence,” Dr Asch and his colleagues commented. 

Instead, health policy that has a broad impact on patients — such as rules addressing the education of residents — should be based on evidence, just as drug approvals are based on randomized controlled trials, they argue.

Two of their own randomized controlled trials of surgical and medical residency programs in the US are providing some of that data, the authors say. 

The studies compare patient outcomes among residents whose workweeks are structured either by duty-hour rules or by more flexible rules, with no limits on their shift length or the time they are allowed to take off.

One trial revealed no differences in patient outcomes between duty-hour rules and flexible rules. The ACGME used evidence from this trial to craft the new rules, which maintain a cap of 80 hours per week for residents, averaged over four weeks, but also extend shifts from 16 to 24 hours and permit within-shift flexibility. Results from the second trial have yet to be analyzed. 

“There are many other questions that can be tested with future studies of the training environment. In the meantime, the ACGME has recognized that far-reaching health policies deserve to be based on the same kind of science as far-reaching health treatments,” the authors conclude.

 

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Reference

  1. Asch DA, Bilimoria KY and Desai SV. Resident Duty Hours and Medical Education Policy — Raising the Evidence BarThe New England Journal of Medicine. 2017. doi: 10.1056/NEJMp1703690 [Epub ahead of print]

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