Inconclusive Findings on Effects of Duty Hour Reduction–In reply–II

We appreciate the comments from Nasca and Philibert regarding our study of a schedule using 16-hour duty periods that found no difference in patient outcomes compared to a schedule with longer duty periods.1 We agree that more research to determine “best practices”—and also to document “failed attempts”—is needed to assist residency programs in creating optimal schedules to meet the new ACGME duty hour requirements while still training to competency standards. Future studies should collect information on patient metrics, educational outcomes, other duty hour parameters, and resident physician perspectives. Nasca and Philibert hypothesize that the increase in intensive care unit (ICU) transfers suggested in our data may be due to residents being more alert. Although this is possible, we examined sleep fatigue with use of the Epworth scale,2 and even though the intervention group had a lower score, the difference was not statistically significant between the residents on the traditional call schedule and the 16-hour schedule in our study. It is possible that the numerically increased ICU transfers resulted from resident discomfort arising from uncertainty about patient issues, which resulted in more requests for ICU transfers. To be fair, the “increase” in ICU transfers was also not statistically significant (P=.08) and may have failed to reach statistical significance because our study was small and underpowered. Such uncertainty only adds to the importance of more well-designed, larger studies looking at clinical consequences of the new duty hour standards. In addition to ongoing research of 16-hour duty schedules, further study of the sign-out and “hand-over” process is needed. Increased frequency of well-performed sign-out may improve patient care by encouraging synthesis of the medical problems into a comprehensive understanding of each patient. In reply to Tabibian, we agree that cost of care and cost-efficient assessments are critical skills to develop during residency. Our residency program has previously published our curriculum that includes education regarding cost of care.3 In our study, patient care metrics associated with costs of care— length of stay4 and readmission rates5—were statistically unchanged during the intervention schedule. We did not track the cost of each episode of care during our study so we cannot comment on the overall changes in cost of delivering care with the intervention. The quantity of patient care experience and education necessary for physician competence is an area of active research. It likely varies on the basis of knowledge retention, patient demographics, and exposure to a diversity of medical conditions. Appropriate coaching and supervision are critical to the education process. In our study, the residents reported a non-significant decrease in satisfaction with the education (P=.16), mostly related to an inability to attend daytime didactic lectures while working overnight shifts. By implementing duty hour guidelines in a way that enhances the supervision of learners, competency may actually be achieved sooner. It is really 10,000 hours of distributed and coached practice that matters, not overall time. Finally, we appreciate the work by Moonesinghe et al,6 which reviewed studies on work hours that addressed patient outcomes. Our study is consistent with their findings that reduced resident duty hours have been shown to neither benefit nor harm patient outcomes. We agree that complex interlinking processes are involved in providing excellent patient care and education and that these processes require further innovation and research to perfect as the new duty hour guidelines are implemented.