Looking Back at Four Years of National Work Hour Limits

Okie, Susan. “An Elusive Balance – Residents’ Work Hours and the Continuity of Care.” NEJM 2007; 356: 2665-2667. (Download in PDF)

Yoon, Harry H. “Adapting to Duty-Hour Limits – Four Years On.” NEJM 2007; 356: 2668-2670. (Download in PDF)

Four years have passed since the ACGME mandated that US teaching hospitals adopt resident work hour regulations limiting the maximum shift length to 30 hours and the maximum work week to 80 hours averaged over four weeks. Although numerous recent studies have found that even these limits do not adequately prevent the sleep deprivation and impairment that endanger physicians and patients alike, at the time in 2003 these ACGME regulations constituted a major change in US medical training. Accustomed to a long-standing system in which resident work hour limits were neither a formal reality nor a concern, teaching hospitals griped that the new ACGME regulations would make it impossible to manage their ever-increasing patient workload and result in a catastrophic deterioration of both patient care and medical education. Four years later, these exaggerated fears have proved to be unfounded.

Marking the anniversary of this significant event in medical training, the June 28th issue of the New England Journal of Medicine (NEJM) contains two “Perspective” pieces examining the effect that these regulations have had on medical practice and training in the US since their implementation. As the scientific evidence of the need to further shorten work hours continues to accumulate, the experiences of hospitals in instituting the 2003 regulations can provide practical lessons for strategies to additionally reduce work hours.  

The first NEJM piece, authored by Susan Okie, MD, examines the best ways to reduce hours while preserving the continuity of care and protecting against errors stemming from increased patient hand-offs. Key to achieving this goal are improved and standardized patient sign-out procedures, according to Okie. She cites research by Laura Petersen “demonstrating that using a standard, computerized sign-out form to transmit key information about patients could prevent such errors, but less than 5% of U.S. hospitals have adopted such procedures.” Okie adds that in the near future “the ACGME will probably address hand-off procedures in a revision of its residency-accreditation requirements.” Such requirements to improve hand-off procedures will be integral to laying the foundation for further work hours reform.

The second NEJM piece, written by Harry H. Yoon, MD, explores a number of the various scheduling approaches that hospitals across the US have implemented to limit resident work hours while “maintain[ing] the highest standards of patient care, resident education, and professionalism.” Among the residency programs profiled by Yoon are those at the University of California at San Francisco, Johns Hopkins, Brigham and Women’s Hospital, and New York-Presbyterian. While different approaches fare better in some hospitals more than others, the article demonstrates how, though innovative thinking that takes into account the unique needs and circumstances of each individual hospital, resident work hours can continue to be reduced to levels that are safe for both resident physicians and their patients.