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

The 3 letters submitted in response to the March 2011 issue of Mayo Clinic Proceedings together illustrate the complexity of issues surrounding residents' duty hours. These include the challenge of balancing the needs of society and the profession from a regulatory perspective (Nasca and Philibert), the desire to enhance cost-conscious practice in a resource-constrained health care system (Tabibian), and the limitations of empirical evidence to guide reform (Moonesinghe and Beard). We appreciate the letter from Nasca and Philibert, and we commend the ACGME for tackling the very difficult problem of regulating residents' duty hours. The new 2010 standards represent a middle ground between more stringent proposals1 and the current regulations. As medical students looking ahead to residency (R.M.A. and S.M.T.), we endeavored to understand program directors' views of the new proposed duty hour standards. Our survey asked respondents to consider not only the numeric aspects of the new proposed standards but also the requirements regarding supervision, learning objectives, and moonlighting. Although the survey instrument was not designed to focus exclusively on the numeric aspects of the new standards, we agree with Nasca and Philibert that the 16-hour shift limit for interns raised substantial concern among program directors,2 and we cannot imagine why program directors' concerns about hours would not have influenced their views about the ability of trainees to master competencies. Our study was a cross-sectional survey of internal medicine, pediatrics, and surgery program directors across the United States; therefore, it represents a snapshot of opinion at a single point in time. Although the timing of the survey was not a methodological limitation per se, it is an important lens through which the results must be viewed. We polled program directors on the proposed standards released in June 2010,3 not on the final standards published in September 2010.4 However, duty hour standards in medicine continue to evolve, and it is important to survey opinion as major changes are proposed. The letter by Tabibian is a call for greater emphasis on cost-conscious practice in residency training. Within the context of residents' duty hours, the pertinent question is: How do residency programs incorporate this “additional” education in the face of declining hours? Do we dare add more lectures or Web-based modules to already compressed training programs? Perhaps this is where role modeling and teaching by example become particularly relevant. Research suggests that, if faculty role models consistently demonstrate desired behaviors (in this case, appropriate use of health care resources), learners are likely to adopt these behaviors in their own practice.5,6 Intentional role modeling is one educational strategy that may be used to influence institutional culture to achieve desired behaviors7 while being “time-neutral” with respect to duty hours. This may be part of the solution to the concerns raised by program directors in our survey regarding residents' ability to develop competency in the face of further duty hour reform. Moonesinghe and Beard describe their comprehensive systematic review of the duty hours literature from the United States and the United Kingdom in which they concluded that duty hour reductions have had little effect on patient safety and education.8 We conducted similar reviews focused on studies of ACGME-accredited programs in the United States and Canada,9,10 and found similar results. Although reducing duty hours theoretically should decrease resident fatigue and in turn enhance patient safety, Moonesinghe and Beard explain that the literature does not consistently demonstrate this because duty hours are just one of many factors contributing to patient safety. Furthermore, the methodological limitations of the body of evidence as a whole impair the ability to draw meaningful conclusions.8-10 In a recent New York Times article, Dr Pauline Chen11 examined the findings of the review by Moonesinghe et al8 and reflected on whether a well-rested doctor is truly a better doctor. She suggests that more and higher quality research is needed to answer this question. Although the reviews of the literature by Moonesinghe and others indicate that the effects of duty hour reductions on patient safety are inconclusive, Nasca and Philibert point out that the public views this evidence differently. While public opinion and the role of the ACGME in balancing the needs of society and the profession are outside the scope of this study, we whole-heartedly agree that professional self-regulation is an important responsibility that must be maintained. It is our hope that scientific inquiries, such as this, will strengthen the evidence base and stimulate further research. Areas for future investigation include interventions that examine the effects of the new standards and robust longitudinal competency assessment.