16 hours is a nice start to the shift

Changes to the 2017 ACGME program requirements:

Maximum Duty Clinical Work and Education Period Length

Duty periods of PGY-1 residents must not exceed 16 hours in duration.
Duty periods of PGY-2 residents and above may be 547 scheduled to a maximum of 24 hours of continuous duty in the hospital. Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.

The first chapter in the experiment in trying to make residents lives better is coming to a close. The 16-hour rule is going away. That’s because:

The requirements were revised to reflect that residency/fellowship education must occur in a learning and working environment that fosters excellence in the safety and quality of patient care. With that priority as their foundation, highlights of the changes include:

— greater emphasis on patient safety and quality improvement
— a dedicated section addressing the critical importance of physician well-being to graduate medical education and patient care
— more explicit requirements regarding team-based care a framework for clinical and educational work hours that allow for flexibility with a maximum toward the ultimate goals of physician education and patient care

Now, the 16-hour rule has always been controversial. As I’ve discussed before, its implementation within the current training paradigm of high work density shifts and a long (80+) workweek leaves a lot to be desired. There’s no doubt, for example, that interns doing less work on some services automatically leads to upper levels doing more. Likewise, because of the coveted post-call day off, it is for many services better to work a few long shifts than a bunch of shorter ones. I would argue that all things being equal, working a short shift would be nicer than working a long shift. The problem is that all things are not equal, and working a long shift and then coming right back to work the next morning sucks.

This change is supposedly evidence-based on the back of the FIRST trial. If you haven’t heard of it, I discussed it here. Frankly, believing that the take home message of the FIRST trial is that working longer hours is better is a very generous reading of its data.

As a general rule, an arbitrary shift length limitation by itself can do almost nothing to combat physician burnout or its effects on patient safety, because those effects are predominately related to chronic fatigue, which comes from indefinitely working an unsustainable schedule and juggling too many patient care tasks at once while often being treated like a subhuman. A shift length of 16 hours at a time just means that it partially prevents a very particular variant of acute fatigue, during which inexperienced interns might be more susceptible to doing stupid things. And that assumes you can get home, eat, get a good amount of sleep, and make it back during that 8-10 hour break.

But the idea that abdicating the reins and momentum on top-down measures to control resident work-hours is concordant with both “a greater emphasis on patient safety” and “the critical importance of physician well-being” is sadly only true in the parallel universe the ACGME occupies. Even the FIRST trial showed that “Residents working longer shifts indicated that their educational experience improved, but at the expense of time with friends and family, extracurricular activities, rest, and health.”

Of course, between working 16 hours for 80 hours or 24 hour shifts up to 60 hours, which would you choose? A long shift can be a good shift, but it’s hard to have a work life balance or avoid “work compression” if you’re always at work.

The 16-hour rule only made sense in a world where as a country we’ve decided to take a proactive centralized approach to ensuring doctors are trained in a way that is compatible with the values we want, not just the self-destructive values we’ve had.

16-hours for an individual shift without addressing 1) how much work must get done per shift and 2) how many hours are worked over time is meaningless. As a component of a sustainable training regiment, it may have actually had a chance to improve patient care. Certainly, the public thinks so. But in a world where 80 hours is the ideal but unforced limit, we’re not there yet.

I think there are valid arguments that an arbitrary universal shift max that short may be unproductive and that it is possible to mitigate some fatigue effects during a longer shift in the appropriate work environment. Certainly scrubbing out of a surgery at the critical moment because you hit a limit is probably stupid. But so is working 80 hours a week for months or years at a time. So is having a job where you’re forbidden from using your vacation or are shunned for getting sick.

We’re in trouble when residents don’t tell the truth about how long they work, how hard they work, or how independently they work for fear of censure or—worse—getting their program in trouble. But that’s how basically every program where residents truly suffer works.