WEDNESDAY, March 6, 2019 — Despite years of worry over young doctors’ grueling work hours, a new study finds that longer shifts do not jeopardize patients’ safety.
The trial is one of two recent efforts to test an assumption about doctors’ work hours — that shorter hospital shifts should mean better-rested physicians and fewer medical errors.
In 2011, new restrictions were put in place to limit residents’ shifts to 16 hours or less. (Residents are doctors-in-training.)
Since then, however, there have been signs that the hoped-for benefits were not being realized. A 2016 trial of surgical residents found that patients fared no better under the 16-hour rule, versus those treated by doctors who were allowed to work longer shifts.
The new trial found the same was true for residents in internal medicine. The results are in the March 7 issue of the New England Journal of Medicine.
“Patients cared for by residents on longer shifts did just as well,” said Dr. David Asch, the senior researcher.
The findings may seem counterintuitive. It’s “natural,” Asch noted, to expect residents on shorter shifts to be more alert and do a better job.
“But there are other competing issues,” said Asch, a professor of medicine at the University of Pennsylvania. “It’s not just, ‘Is your doctor tired?'”
For example, he said, when residents’ shifts are shorter, there’s more “passing off of care.” And a tired doctor who’s familiar with you might be preferable to a fresher doctor who has never met you, Asch said.
Beyond that, the trial found that residents on shorter shifts did not actually get more sleep, on average.
Because of the 2016 trial, things have already changed: In 2017, the Accreditation Council for Graduate Medical Education relaxed the 16-hour shift rule.
These latest findings offer “more reassurance” that the change will not put patients at risk, said Dr. Daniela Lamas.
Lamas, a critical care specialist at Brigham and Women’s Hospital in Boston, wrote an editorial published with the study.
She said that patients’ well-being does not hinge on how many hours a resident has worked that day. “There’s a lot of redundancy at a hospital, and a lot of people are actually ‘in charge,'” Lamas said.
Asch made the same point. The 16-hour rule may be gone, but there are other checks in place. For example, residents cannot average more than 80 hours on duty each week, and there are rules on supervision by senior doctors.
The concern about residents’ hours goes back to 1984, when an 18-year-old hospital patient named Libby Zion died under the care of a resident and intern who were nearing the end of very long shifts.
Since then, though, various safety rules have been put in place, Asch said. His team looked only at the effects of relaxing the 16-hour limit.
For the study, the researchers randomly assigned 63 U.S. residency programs to either stick with the 16-hour rule or have a more flexible setup. In that latter group, program directors could design residents’ shifts at their discretion; they could keep shorter shifts for some rotations, and change to extended shifts for others.
After one year, the study found, there were no signs that flexible programs compromised patient safety.
The average 30-day death rate among Medicare patients dipped slightly in both study groups — to just above 12 percent. And there was no difference in hospital readmissions, or in complications like infections and blood clots.
In a separate analysis, Asch’s team looked at residents’ sleep patterns by having a subgroup wear activity monitors for two weeks. The doctors also took a test of alertness and rated their sleepiness each workday.
Overall, residents in both study groups averaged about seven hours of sleep a day — though those in the flexible programs were less alert after their shifts. That did not translate into differences in patient safety, however.
What’s missing from trials like this, Lamas said, is how patients and families feel about their care in a setting where “your doctor” inevitably shifts.
Often, she noted, family members become critical in ensuring the “continuity of care,” by asking questions and communicating with the hospital staff.
The nonprofit Leapfrog Group has advice on staying safe in the hospital.
Posted: March 2019
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