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Week of April 1, 2013

Research

Work-hour restrictions for medical residents may increase errors, study says

At hospitals around the country, young doctors fresh out of medical school help care for patients of all kinds — and work intense, long hours as part of their residency training.

Traditionally, residents were allowed to work more than 24 hours without a break. In 2011, new rules cut back the number of hours they can work consecutively to 16, in the name of protecting patients from errors by sleepy physicians.

But a new study of more than 2,300 doctors in their first year of residency at over a dozen hospital systems across the country raises questions about how well the rules are protecting both patients and new doctors.

While work hours went down after new rules took effect in 2011, sleep hours didn’t go up significantly and risk of depression symptoms in the doctors stayed the same, according to a new paper published online in JAMA Internal Medicine by a team led by Medical School researchers.

Most concerning: The percentage of residents reporting that they had committed medical errors that harmed patients went up after the new rules took effect.

The results, especially the increase in errors, surprised Dr. Srijan Sen, assistant professor of psychiatry and the report’s first author.

“In the year before the new duty hour rules took effect, 19.9 percent of the interns reported committing an error that harmed a patient, but this percentage went up to 23.3 percent after the new rules went into effect,” he says. “That’s a 15 to 20 percent increase in errors — a pretty dramatic uptick, especially when you consider that part of the reason these work-hour rules were put into place was to reduce errors.”

The findings echo anecdotal reports about the impact of the 2011 duty hour rules.

Co-author Dr. Sudha Amarnath, a resident in the radiation oncology program at the University of Washington, says, “Many interns entering after the new work hour restrictions took effect felt that they were expected to do the same amount of work as in previous years, but in a more limited amount of time, leading to more harried and tiring work schedules despite working fewer hours. Overall, they felt that there was less ‘down time’ during the work day compared to pre-2011 work schedules, which may partially explain some of the unexpected findings.”

All the interns assessed in this study were working under the duty hour restrictions that went into effect in 2003 — limiting residents to no more than 80 hours of work in a week, and other restrictions. Some studies have suggested that these rule changes, recommended by the Accreditation Council for Graduate Medical Education, did result in better safety for patients cared for by residents. But in an effort to achieve even greater safety, the ACGME recommended further changes that were implemented in 2011.

Each year, Sen and colleagues send out surveys to students entering residency programs around the United States. The research team then surveys these interns every three months throughout that first year, asking questions that gauge mental health, overall well-being, sleep habits, work hours and performance on the job.

By comparing the interns serving before the new ACGME rules (called the 2009 and 2010 cohorts) with the interns serving after the new rules were implemented (the 2011 cohort), the research team assessed the effects of the new duty hour rules.

In addition to the increase in self-reported medical errors, 20 percent of the residents screened positive for depression.

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