Key Scientific Studies
In recent years a body of scientific evidence has begun to mount calling into question the safety of long work hours for both patients and resident physicians. Below is a listing of the key academic findings on the topic of resident work hours published in recent years. Click on the citation for a more detailed abstract of the study or to download a full text version of the article.
New Research, 2010:
- Recently published perspective in the NEJM explores the ethics of informing (or not informing) a patient scheduled for elective surgery about his surgeon’s level of sleep deprivation (NEJM, 2010).
- New study finds harm to patients in hospitals are common and the number of harmful incidents have not decreased over time (NEJM, 2010).
- Study shows concerns about the 2003 duty hour recommendations eroding resident professionalism and furthering the development of a “shift work” mentality have been overstated (MilBank Q, 2010).
- A new study reveals medical interns perform significantly better, in a clinical simulation test, after working a shortened overnight shift compared with a traditional extended shift; findings which are consistent with real-time hospital studies using the same shift schedule (Academic Medicine, 2010).
- Comprehensive study of university hospitals finds quality of care at university hospitals are no better than the quality of care at non-university hospitals. Explanatory factors may relate to the extended work hours of interns and residents (CareChex University Hospital Quality Study, 2010).
- New findings indicate that Americans strongly favor tighter regulation of the number of consecutive hours that resident physicians are allowed to work. This is the first systematic study of public perceptions of resident work hours (BMC Medicine, 2010).
- This systematic review published in the journal Sleep found that reduction or elimination of resident shifts exceeding 16 hours led to improvements in resident quality of life and patient safety / quality of care. In addition, this study found – contrary to the concerns of critics of work hour reform, who have said that reducing work hours would lead to degraded medical education – that resident education did not deteriorate when shifts were reduced to 16 hours (4/14 studies actually found it improved; 9/14 unchanged; 1/14 worsened) (Sleep 2010).
Recent studies have found that on-call shifts of 24 consecutive hours or more:
- increased the incidence of preventable medical errors sevenfold (Public Library of Science Medicine, 2006);
- increased the risk residents faced of needle sticks and other accidental percutaneous injuries that expose them to potentially harmful bodily fluid by 61 percent (Journal of the American Medical Association, 2006);
- led to decreased performance on tests of response and vigilance (Sleep, 2005);
- more than doubled the likelihood residents would get into a motor vehicle accident on the after-work commute (New England Journal of Medicine, 2005);
- led to performance impairments similar to subjects in a control group with a 0.05% blood alcohol level (Journal of the American Medical Association, 2005);
- caused medical interns to be twice as likely to suffer attentional failures at night and 35.9 percent more likely to commit a serious medical error (New England Journal of Medicine, 2004).
- produced cognitive psychomotor deterioration equivalent to a 0.1% blood alcohol level (Dawson D, Reid K. “Fatigue, alcohol and performance impairment.” Nature, 1997;88:235).
- led residents to show impaired reaction times and decreased vigilance, both pre- and post-call when performing in-house call (Q4-7). This suggests that recovery periods from overnight-calls exceeded several days. Residents were found to be unaware of their impairment (Sleep 2005).
Other important findings include:
- Study exploring individual variation and vulnerability to sleep deprivation (The American Clinical and Climatological Association, 2009).
- Most medical interns’ schedules violate the ACGME resident work hour regulations in some way (Journal of the American Medical Association, 2006);
- shorter hours have improved patient care in several key areas (Annals of Internal Medicine, 2007);
- In VA hospitals, stricter hour limits were associated with improved mortality rates for patients with 4 common medical conditions (Journal of the American Medical Association, 2007);
- tighter work hour regulations were associated with decreased mortality among high-risk patients (Annals of Internal Medicine, 2007).
- The federal Agency for Health Research and Quality (AHRQ) recommended that hospitals “limit shifts of more than 24 hours for medical residents” in their 2006 publication 10 Patient Safety Tips for Hospitals (AHRQ, 2006);
- Ingrid Philibert, the ACGME’s Director of Field Activities, acknowledged the likelihood that “residents may experience significant performance decrements under the current minimum [ACGME work hour] standards” in a meta-analysis of 60 previous studies of the effects of sleep deprivation (Sleep, 2005);
- In reviewing their research on the effects of fatigue on residents, Harvard sleep researchers conclude that “residency programs routinely make evidence-based decisions in clinical practice and even in selecting trainees, but have appeared reluctant to rely on such data to develop safe resident work hour schedules” (Clinical Orthopaedics & Related Research, 2006).
- Among surgical attendings in postnighttime cases with 6 hours or less of sleep opportunity, there
was a substantially elevated rate of complication compared with cases in which sleep opportunity exceeded 6 hours (JAMA, 2009).
Publications on Changing the Culture of Medicine
- “Of Puppies and Dinosaurs: Why the 80-Hour Work Week Is the Best Thing That Ever Happened in American Surgery” (Archives of Surgery, 2010).
- “Making Sense: Duty Hours, Work Flow, and Waste in Graduate Medical Education” (Journal of Graduate Medical Education, 2009).
- “Toward a New Paradigm in Graduate Medical Education in the United States: Elimination of the 24-Hour Call” (Journal of Graduate Medical Education, 2009).
- “Limiting Resident Work Hours Is a Moral Concern” (Academic Medicine, 2009).