Work-hour limits improve physician safety, health

The 2011 Accreditation Council for Graduate Medical Education (ACGME) guidelines that reduced work hours to a 16-hour limit on consecutive hours for first-year resident physicians result in meaningful improvements in physician safety and health, according to a US study.

“Extended duration shifts and prolonged weekly work hours continue to adversely impact the safety and well-being of resident physicians,” the researchers said. “There is a pressing need to monitor changes in the rates of these adverse outcomes now that extended duration shifts have been reintroduced.”

Medical students matched to a US residency programme from 2002 to 2007 and 2014 to 2017 were all asked to participate in prospective cohort studies. Participants reported work hours, extended duration shifts, and adverse safety outcomes, such as motor vehicle crashes, percutaneous injuries, and attentional failures, each month.

The researchers compared the incidence of each outcome before and after the 2011 ACGME work-hour limit. Generalized linear models adjusted for potential confounders were used to test the hypotheses.

Thirteen percent of all first-year resident physicians nationwide participated in the study, with 80,266 monthly reports completed by 15,276 participants. The implementation of the 16-hour work limit led to a decrease in the mean number of extended duration (≥24-h) shifts per month from 3.9 to 0.2. [Am J Med 2020;133:e343-e354]

The 2011 ACGME guidelines also correlated with a 24-percent decrease in the risk of motor vehicle crash (relative risk [RR], 0.76, 95 percent confidence interval [CI], 0.67–0.85), >40-reduction in percutaneous injury risk (RR, 0.54, 95 percent CI, 0.48–0.61), and 18-percent drop in the rate of attentional failures (incidence rate ratio, 0.82, 95 percent CI, 0.78–0.86).

A 2017 study found that the third leading cause of death for residents was motor vehicle crashes, trailing only neoplastic disease and suicide. [Acad Med 2017;92:976-983]

“Our findings reveal that elimination of extended duration shifts was associated with a significant reduction in the risk of crashes, particularly on the commute from work,” the researchers said. “Driving after extended duration shifts is known to be a high-risk activity.” [N Engl J Med 2005;352:125-134; Sleep 2018;doi:10.1093/sleep/zsx195]

Moreover, extended duration shifts and prolonged weekly work hours were linked to a higher risk of adverse safety outcomes independent of cohort.

“These findings are particularly important now because the 2017 ACGME guidelines lifted the restrictions on extended duration shifts and again permit shifts of 24–28 consecutive hours of work for first-year resident physicians,” the researchers said. [www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf]

Notably, an earlier study showed a sevenfold increased risk of depression among first-year residents who were not sleep deprived prior to their internship but accumulated a chronic sleep debt over the course of their postgraduate year. [Acad Med 2006;81:82-85]

In addition, burnout is two times more common among physicians than the general population, with sleep deficiency being a main contributor. Burnout, depression, sleepiness, and fatigue have also been linked to reported resident motor vehicle crashes. [J Occup Health Psychol 2012;17:175-183; Mayo Clin Proc 2012;87:1138-1144]

“Our findings suggest that work-hour limitations may be an avenue to promote physician wellness,” the researchers said.