A Prescription to
Improve Patient Safety
More Sleep, Better Supervision, and Reasonable Workloads for Medical Residents
When the Institute of Medicine released a report on medical residents' duty hours and workloads in early December, a flurry of debate ensued in online forums, many of the comments casting the topic as a tug of war between patients' safety and the educational needs of doctors in training. Much of the discussion focused on a single element of the report, specifically whether working as many as 80 hours a week or up to 30 hours straight is too much or too little.
But the focus on duty hours overshadowed two other key points of the report. First, the report's package of recommendations is not about shorter or longer scheduling; it's about smarter scheduling. And second, reasonable limits on duty hours by themselves are no guarantee of patient safety; other changes to residents' work environments are necessary as well to improve patient and resident safety and enhance the ability of residents to learn.
Residency is the three- to seven-year period of on-the-job training that gives recent medical school graduates the experience they need to begin practicing medicine independently. These new doctors often work long days with limited time to catch up on their sleep. A cap of 80 hours maximum per week averaged over four weeks was instituted for medical residents in 2003.
The committee of medical and scientific experts that wrote the report recognized the need to balance providing residents adequate opportunities for sleep to reduce the chances of fatigue-related errors with ensuring sufficient time for the rigorous and rich learning experiences residents need to become competent -- and safe -- independent care providers.
Rather than recommending an overall reduction of work hours from the 80-hour cap, the report focused on extended shifts and the need to ensure residents get regular opportunities to sleep. An extensive body of science shows that people's performance begins flagging after 16 hours of wakefulness. The report recommends that residents could work either a maximum shift of 16 continuous hours or up to 30 hours provided they get an uninterrupted five-hour break for sleep after 16 hours.
Spotty supervision also can decrease the chances of intercepting errors that could harm patients. Closer supervision leads to fewer errors, lower patient mortality, and improved quality of care. First-year residents, in particular, should not be on duty without immediate access to a supervisor on the premises.
In addition, the report calls for limits on the number of patients that residents are allowed to handle at a time based on their level of experience and specialty. Each medical specialty needs to set specific guidelines for its residents' patient caseloads. And it urges hospitals to overlap staff schedules during shift changes and to strengthen procedures for the handover of patients from one doctor's care to the next, because there will be more handovers with the schedule changes proposed by the report.
Implementing the report's recommendations inherently will require many teaching hospitals to shift work from residents to other health professionals. The committee estimated the cost for additional personnel to handle reduced resident work at roughly $1.7 billion annually. This is not an insignificant sum. However, it is less than half of 1 percent of what Medicare spends on care for older Americans annually.
Although carrying out these recommendations may be costly and logistically challenging for health care facilities, the committee believes the effort will create safer conditions for residents and patients, a higher quality of care for patients, and improved education during residency. -- Christine Stencel
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, Board on Health Care Services, Institute of Medicine (2008, approx. 480 pp.; ISBN 0-309-12776-9; available from the National Academies Press, tel. 1-800-624-6242; $48.95 plus $4.50 shipping for single copies).
The committee was chaired by Michael M.E. Johns, chancellor, Emory University, Atlanta. The study was funded by the Agency for Healthcare Research and Quality.