Weekly Article: It's July. Are duty hours reform really enough?

by Priya Gopwani
Children's National

Seeing as how it is July, I started thinking a bit about the new interns coming in – which then got me wondering when we would see the next rendition of duty hour regulations, and if any of these changes were actually doing any good.

We’ve all heard arguments on both sides:

Pro – Shorter shifts = better rested trainees = Less errors, learn more, etc.

Con – Shorter shifts = fewer patients seen, less continuity, more handoffs (!!)

And then there is the “Back when I was an intern…” argument – Who can argue with that? J

Well, this group (out of Hopkins) looked at internal medicine interns and compared 3 groups. Both the 2nd and 3rd groups were in compliance with the new 2011 duty hour regulations (group 1 was in compliance with the 2003 rules, not 2011). What they found was that these new rules may be having unintended consequences.

Group 1 - typical q4, 30h calls

Group 2 - q5 call schedule, with shifts limited to 16 hours

Group 3 - night float system – shifts limited to 16 hours

What they found
Interns in group 1 slept less (by about 3 hours per 48h period – not statistically significant but it’s still 3 hours!).
BUT…
Interns in groups 2 and 3 (following the new rules) had decreased educational opportunities – Interns had fewer admissions over the course of the month, and followed fewer patients over the course of the month. They also had 25% fewer opportunities to attend noon conference and 13-30% less time in the hospital during “normal business hours” – as in when the attending is around to teach. And yes, handoffs went up astronomically (130-200%). They also found that these interns that had all these extra hours to sleep only used 21% of those hours to sleep. And trainee satisfaction scores were lower in both of these experimental models.

So what, you ask? I’m not saying that we should go back to 100 hour work weeks and interns living in the hospital. But I do wonder if simply adjusting duty hours isn’t enough. I wonder if we need to re-structure things a bit more. If we are limiting the number of hours trainees can work, then maybe we should put more efforts into making sure that those hours are spent in a useful way. 

• Maybe incorporate morning rounds for the morning team, and night rounds for the night team
• Touch base with the family AND provide some teaching to the interns overnight 
• Maybe incorporate a system where the night float intern stays through rounds the next day so they can get feedback on the admissions they did
• Maybe encourage night float interns watching the noon conference from that day, some time around 3 am? And maybe some more education on handoffs? (yes, a shameless plug…) 

There are lots of other ideas - but we should probably start thinking about making the best of each of those 16 hours on a shift.

Desai SV, et al. Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models on Sleep Duration, Trainee Education, and Continuity of Patient Care Among Internal Medicine House Staff: A Randomized Trial. JAMA Intern Med. 2013.