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March 10, 2017

First-year docs can work 24-hour shifts under new—and controversial—rules

Daily Briefing

First-year residents can work 24-hour shifts starting in July under new rules issued by the Accreditation Council for Graduate Medical Education (ACGME).

Currently, first-year residents cannot work longer than 16 hours at a time—but the updated rules will put them on even footing with more advanced residents, who already can work longer shifts. An 80-hour per week cap for all residents will remain in place under the new rules, the Associated Press reports.

ACGME officials said the new rules are designed to improve coordination, better prepare young doctors for their careers, and the even the playing field between first-year residents and their peers.

Background on the shift-limit debate

In 2011, ACGME enacted requirements that included a maximum shift duration of 16 hours for post-graduate year-one residents. The shift was motivated in part by a 2004 study that found interns working 24-hour shifts committed 36 percent more serious errors than interns working 16-hour shifts.

Follow-up studies suggested, however, that shorter shifts for interns don't improve patient safety. For instance, a study conducted by researchers from the Philadelphia VA Medical Center and the University of Pennsylvania's Perelman School of Medicine looked at 6.4 million Medicare admissions and found no significant differences in readmission rates or patient deaths after the 16-cap was implemented. Another study published in the New England Journal of Medicine found that patients in programs without shift limits did not face any greater risk of post-operative complications or death.

Some experts also have argued that 16-hour shift limits for first-year residents harm patient safety because they increase the number of times that patients must be handed off between doctors.

Details of the new rules

In November 2016, an ACGME task force proposed that shift limits for first-year residents be raised to 24 hours. The council's board approved the recommendations in February but delayed announcing the vote until its annual education conference, which ends on Sunday, the Los Angeles Times reports.

Under the new rules, shifts can be extended by four hours beyond the 24-hour cap to accommodate care transitions. The proposal would align first-year residents' schedules with existing 24-hour shift limits for second- and third-year residents.

First-year residents will still be limited to a maximum of 80 hours per week and are prohibited from working overnight shifts more frequently than once every three days. In addition, first-year residents will be required to have at least one day per week free from both clinical experience and education.

Moreover, the new rules require residency programs to:

  • Give residents time off for physical and mental health appointments; and
  • Provide resources to foster first-year residents' well-being, fight burnout, and mitigate fatigue.

ACGME comments

Rowen Zetterman, ACGME's board chair, said, "We all agree that nobody wants tired physicians." He argued the new rules would "help eliminate abrupt handoffs of patients and will enhance teamwork among new doctors and their supervisors," AP reports. Zetterman also said the new rules require that first-year residents have supervisors nearby who can step in if needed.

Controversial, first-of-its-kind study: Long shifts don't affect patient safety

Zetterman added that the rules reflect the fact that many doctors work 65 to 70 hours per week for much of their career. "What we want is to be able to say at the end of residency that we have a physician who is highly trained and is ready to go out into practice," he said.

According to Zetterman, the changes have support from the health care industry. "We tried to make these evidence-based," Zetterman said. Forbes reports that the committee heard testimony from more than 60 groups and medical educators, and it reviewed written statements from more than 110 medical organizations.

Some stakeholders voice concerns

But Michael Carome, a doctor who heads Public Citizen's health research group, said the rule change could harm patients. "We know from extensive research, multiple studies, that sleep-deprived residents are a danger to themselves, their patients, and the public," he said. For instance, Public Citizen says sleep-deprived residents are at great risk of needle-stick injuries, depression, and car accidents.

Samantha Harrington, a first-year resident and member of the Committee of Interns and Residents, said her 14-hour shifts already take a heavy toll. "To stay awake while driving home after work," the Times reports, "she sometimes rolls down the window to let the freezing air blast her in the face."

The American Medical Student Association and the Committee of Interns and Residents both oppose the new shift-limit rules (AP/Los Angeles Times, 3/10; Bernstein, "To Your Health," Washington Post, 3/10; Japsen, Forbes, 3/10). 

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