UWOMJ Volume 82, No 2, Fall 2013

The paradigm of medical resident duty hours is currently undergoing vast changes, as research has demonstrated the negative effects of sleep deprivation on the wellbeing of both patients and residents alike. These changes began in the United States, where reduced work hour schedules for residents have been implemented within the past decade. However, the effectiveness of these changes has been debated in the literature. In Canada, this issue has only recently come into spotlight. Under the guidance of the Royal College of Physicians and Surgeons of Canada, a task force was assembled in 2012 with two main objectives: gather all evidence related to resident duty hours, fatigue, and patient safety, and to create a national Canadian consensus on resident duty hours. In 1984, New York City was the setting of a new wave of thinking about residency training programs within the medical profession. That year, the death of Libby Zion, a lawyer’s daughter, initiated the Zion vs. New York Hospital case, which would have an indirect impact on international rules for resident work hours. Traditionally, it was not uncommon for residents to work up to 36 consecutive hours with minimal sleep, accumulating well over 100 hours of work in a week. Some considered this a rite of passage into the medical profession, while others saw it as a valuable learning tool. When the death of teenager Libby Zion was traced down to a medical error, more attention was drawn to the effect of sleep deprivation on residents’ performance on the wards. What effect does sleep deprivation have on residents? One review found that with acute sleep deprivation, residents showed decreased performance on tasks that required prolonged, vigilant concentration, but were resilient in performing brief, psychomotor tasks requiring manual dexterity and short-term recall.1 Furthermore, resident mood was affected, with increased anger, hostility, and symptoms of depression being noted – all factors that hinder the physician-patient relationship. In addition, one study found that extended shifts put residents’ safety at risk, by increasing the likelihood of reporting a motor vehicle accident after a call shift.2 A landmark study published in the New England Journal of Medicine compared two different work schedules head-to-head.3 The first schedule, considered “traditional,” had an average of 77-81 work hours per week with up to 34 hours of continuous work and 1 in 3 overnight call. The second, or “interventional” schedule, had 60-63 work hours per week maximum, 16 hours of continuous work maximum, and a day-call versus night-call designation, rather than a whole day of call. These schedules were randomized among internal medicine residents, and patient safety measures were prospectively followed. When researchers compared the traditional schedule and interventional schedule respectively, they found that residents made 35.9% more serious medical errors (136.0 vs. 100.1 per 1000 patient-days), 22.0% more total medical errors (193.2 vs. 158.4 per 1000 patient-days), 20.8% more serious medication errors (99.7 vs. 82.5 per 1000 patient-days), and 96.5% more serious diagnostic errors (21.6 vs. 11.0 per 1000 patient-days), while on the traditional schedule.3 In light of these findings, in 2003 the Accreditation Council for Graduate Medical Education (ACGME) in the United States instituted limits on resident work hours: 16 hours maximum for continuous shifts for PGY-1 (more hours allowed for seniors), 80 hours maximum per week, and 1 day off per week averaged over a 4-week period.4 Any residency program’s accreditation is endangered if their work protocols are not congruent with the ACGME. Unfortunately, data collected after these changes have shown mixed results as to the effectiveness of reduced hours. A systematic review of 7 studies (one of which was conducted after the 2003 ACGME changes) comparing reduced hour schedules with traditional schedules looked at mortality, adverse events, and medication errors as outcomes.5 The results showed that some outcomes improved, others declined, and still others showed no change. For example, mortality was largely unaffected by reduced hours, but medication errors were reduced.5 The authors emphasized a distinction between mortality outcomes, and task-based outcomes, the latter of which may be more susceptible to sleep deprivation. Although there were limitations within the studies in this review, such as the failure to measure baseline characteristics, the point is raised that reduced-hour schedules may not have the effects that were once anticipated. There may be negative consequences with reduced hour work schedules. Proponents of the traditional, long hour work schedules raise the argument that by reducing hours and increasing patient hand-over, an element of discontinuity is introduced which in itself may increase medical errors. In addition, fewer predictable hours may not prepare residents for independent practice, where hours are not limited and may be unpredictable. This may be reflected by an increase in the length of residency programs to allow for adequate clinical exposure. A survey of surgical residents in the United States found that many are unsatisfied with the reduced work-hour changes: 55.1% believed their education declined, and 68.4% felt they were not being prepared for senior roles.6 Although 61.9% of junior surgical residents had an increase in their quality of life, 54.4% of senior residents found a decline in their quality of life, likely due to seniors adopting the work that the juniors could not complete on their reduced hour schedules. Shockingly, 67.6% of surgical residents reported non-compliance with the work-hour limits, and 62.1% reported falsifying duty hours.6 In Canada, the resident association of each province has the daunting task of negotiating collective agreements for medical resTides of change The future of Canadian medical resident work hours Jouseph Barkho (Meds 2015) Faculty Reviewer: Dr. Catherine Yanchula, MD, CCFP, FCFP (Department of Family Medicine)