The Hidden Threat of the 80-Hour Resident Workweek: How Caps on Hours Threaten Healthcare
Welcome to part three of our ‘Hidden Threats’ series, a series where we summarize some of the latest research regarding medical errors and structural issues that can impact the quality of patient care, both in obstetrics and in medicine generally.
Every two weeks, we’ll be providing a short summary of the latest trends, research articles and news that patients may want to know about the way they get their healthcare.
This week’s focus is the 80-Hour Resident Workweek.
The 80-Hour Workweek for Medical Residents
What the Resident Work Limit Was Meant to Do; What Caps on Hours Actually Did
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) put a cap on the number of hours that medical residents can work in a given time frame. The most important regulation was capping resident work hours at an average of 80 hours a week (averaged over 4 weeks). Other regulations included a mandate on how much sleep/personal time residents had (10 hours between shifts), as well as the maximum length of shifts (16 hours at a time for 1st-year residents, 24 hours for 2nd and 3rd year residents, with 30-hour maximums) and the number of overnight calls to no more than once every three days.
This regulation was designed to combat resident fatigue and overwork, especially after the Libby Zion case, where a young patient died after fatigued residents missed the signs of a fatal drug interaction. Research has shown that medical residents have poorer fine motor coordination (1) after long periods of continuous care. One study even found that 24 hours of wakefulness in non-doctors resulted in hand-eye coordination losses equivalent to people with a blood alcohol level of 0.08% (2). Residents in obstetrics and gynecology report working long hours with little sleep. The 80 hour workweek helped improve resident satisfaction with their programs – but there was one unintended consequence: less experience in their programs.
Balancing Resident Satisfaction and Competency: Case Volume Matters
The result of the 80-hour workweek has meant that residents are able to curb fatigue to some degree, but in turn, this means that clinical work hours have declined, resulting in fewer clinical encounters. (3) Students scoring in the top 20% on subject tests reported that they had a greater number of cases encountered. (3) One of the key pieces in developing clinical competency is volume. The fewer cases a resident sees, the less likely he or she is to develop competency in handling cases of that type. Consistently, hospitals with higher volumes have lower operative mortality rates (4). With respect to patient outcomes, volume matters – not just within hospitals, but across specialities (4):
- In interventional cardiology, physicians with higher volumes had more success in impacting stenotic lesions. They had lower rates of needing to go to coronary artery bypass grafts.
- In the NICU: NICUs with more than 100 very low birthweight (VLBW) neonates/year had a 10% lower mortality rate than units with 50-100 VLBW neonates and 20% lower than units with less than 25 VLBW neonates per year.
- In labor and delivery units: Labor and delivery units that perform fewer deliveries have higher rates of complications, especially perinatal asphyxia. Obstetricians with lower annual patient volume had higher C-section rates. Urinary or gastrointestinal injuries were less common in women whose C-section was performed by high-volume surgeons.
What does this mean for patients? Residents may be getting less experience (lower case volume) during their residency training because of these work-hour limits (7). In turn, less experience means greater rates of error and complications. Lower volumes are especially marked in more junior resident positions (residents in years 1 and 2 after medical school). Total operative volume for first-year students dropped 51%; total operative volume dropped 73% for second-year students (7), impacting their experience in a fashion the study authors described as ‘startling.’
Further, multiple studies have found that “resident’s reduction in duty hours may have been achieved at the expense of outpatient clinic experience (5).” Residents start off in inpatient clinics, and their inpatient experience was not impacted by the implementation of the 80 hour workweek. However, after the implementation of 80-hour limits, their outpatient clinic experience dropped significantly. It appeared that outpatient experiences by residents were being cut in order to maintain coverage of inpatient care. (5).
Reduced Complexity and the Impact on Proficiency
More advanced surgical procedures take more time to complete. Research has found that the 80-hour workweek cap is reducing the overall complexity of procedures emergency surgical residents perform. Even though in some cases overall surgical volume may not have changed much, residents are performing fewer complicated procedures and more basic procedures. After the caps were instated, residents had a 40% drop in the number of advanced procedures they perform as the primary surgeon, with a 44% increase in basic procedures (6). There was also a 54% decrease in the number of cases they took on as first assistant, and operative continuity of care (where the same resident does a second operation as the first operation) dropped to 26% from 60%. This study firmly concluded that “The ACGME regulatory environment is adversely affecting the emergency operative experience of surgical residents. Our findings underscore the need to develop alternative methods to augment the residents’ operative experience. “
Direct quotes from related studies include:
- “First, our results show that under the new regulatory environment, senior residents perform significantly less advanced, technically demanding, emergency procedures. At the same time, simpler cases traditionally delegated to the junior members of the team are now taken over by the upper level resident on call. This fundamental shift in the distribution of operative experience between senior and junior residents has not been previously reported, yet its effect is clear from our data. In other words, senior residents are now preserving their “numbers” by encroaching on the operative experience of their juniors. The long-term consequences of this phenomenon are obvious and must be addressed (6).”
- The second compensatory mechanism is a decrease in operative volume as first assistant. This experience is a key component of surgical training on which the new 80-hour work week has a particularly strong effect. An 82% reduction in the opportunity to participate as a learning first assistant in a major abdominal trauma procedure means that a senior resident will often be called on to do a major trauma case without ever having had the opportunity to see one…Surgical training is thus evolving into a “read one, do one” situation. Simply put, under the old call system, almost every emergency case (both trauma and non-trauma) presented an opportunity for 2 senior residents to acquire operative experience, working together under faculty supervision. Under the new regulations, this no longer applies because the majority of cases are done by the senior resident on call with an attending surgeon. The traditional graded operative experience, one of the hallmarks of surgical education, has thus been fundamentally altered (6).”
- “Continuity of operative care by residents was another key educational principle of the past that cannot be adhered to in the new regulatory environment: only 1 in 4 reoperations in group 2 was performed by the same resident who did the original procedure, as compared with 60% under the previous system (6).”
- The staff surgeons at our institution have witnessed a decrease in the number of surgical residents “scrubbing in” on their cases in the operating room. Whereas in the past we had the opportunity to mentor [fifth-year] residents while they were teaching other residents, or to discuss important operative findings with [first-year] residents holding retractors, we now typically have only 1 single resident available to participate in operations. As noted by others, these changes have altered the time-honored approach to operative teaching . Residents have fewer opportunities to develop surgical self-confidence and independence as teaching assistants. Also, residents now act as primary operative surgeons before having ever observed the surgical procedure (7).”
Overall, the conversion to an 80-hour workweek from a capped workweek have negatively impacted resident’s technical skills, clinical judgement, and patient responsibility.
The Balance: Work/Life and Professional Duties
The 80-hour workweek restriction is a complex topic. On the one hand, such restrictions prevent some measure of poor decision-making by reducing fatigue and sleep deprivation. On the other, the 80 hour workweek negatively impacts the competency of medical residents in terms of case volume and/or complexity, making them ill-prepared for independent operations. It is the responsibility of medical training programs to enforce the appropriate measures to ensure that residents are finishing their programs with the proper training and experience. Otherwise, patients suffer the brunt of those residents’ mistakes.
- Ayalon Roy et al. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology students. Am J Obstet Gynecol 2008; 199:576.e1-576.e5.
- Defoe Deidre M et al. Graduate Education: Long Hours and Little Sleep: Work Schedules of Residents in Obstetrics and Gynecology. Obsetrics and Gynecology 97(6):1015-1018.
- Jenna Janiga. Does Clinical Experience Influence Medical Knowledge on Obstetrics and Gynecology Clerkships? Obstetrics & Gynecology VOL. 125, NO. 5 (SUPPLEMENT), MAY 2015, page 38S.
- Caughey, Aaron B. In clinical care, volume matters. American Journal of Obstetrics & Gynecology , Volume 215 , Issue 1 , 6 – 8.
- Spencer, Ariel U. et al. Impact of Work-Hour Restrictions on Residents’ Operative Volume on a Subspecialty Surgical Service. Journal of the American College of Surgeons , Volume 200 , Issue 5 , 670 – 676
- Feanny MA et al. Impact of the 80-hour work week on resident emergency operative experience. American Journal of Surgery [01 Dec 2005, 190(6):947-949]
- Arthur M. Carlin, et al. Effect of the 80-hour work week on resident operative experience in general surgery. The American Journal of Surgery 193 (2007) 326–330