Post hoc analyses on work hour restrictions

For those with Archives of Internal Medicine subscriptions – Residency Training in the Modern Era: The Pipe Dream of Less Time to Learn More, Care Better, and Be More Professional

This editorial addresses three observational studies on the changes in work hours requirements that internal medicine programs adopted in 2003. I have blogged often about this issue.

The editorialists ask all the right questions, and make the correct observations:

What can we take away from this information? It appears that at least residents perceive their well-being, sleep, and emotional states are better as a result of the work-hour restrictions. Presumably, this should result in less serious AEs. However, ironically, residents also perceived that it has resulted in less effective care and education. Keating et al9 recently reported a similar finding from a survey study of residents and attending physicians. In their survey, both housestaff and attending physicians perceived that the risk of AEs from the fragmentation in care was greater than the risk of resident fatigue from excess work hours.

The limitation of all this post hoc work is that these conclusions are based on perceptions conveyed in surveys and not based on objective measurements in a more formal evaluation of the policy of work-hour restrictions. But if these perceptions reflect reality, then we urgently need to understand the magnitude of these and other trade-offs. Other theoretical impacts that have been considered as a result of the work-hour restrictions include AEs on continuity of care, professionalism, teacher satisfaction, burnout, and ultimately, the competencies of graduates.10 Unfortunately, we do not have the educational research infrastructure or methods of measuring many of these constructs to evaluate this impact more effectively.

While this work is important, well performed, and interesting, it is too bad that we do not have a more coordinated effort and infrastructure to do better and more representative research. Such research should be multicenter studies with larger sample sizes and better administrative databases and have more linkage with patient-centered data so that we can truly understand the impact of broad educational policy decisions. This is especially true when such policies are not based on sound empirical evidence and may possibly cause more harm than good.

The work-hour restriction policy is not necessarily a bad policy. It appears, however, that it was implemented without a sufficient evidence base and without a mechanism in place to fully evaluate its impact from the many perspectives relevant to residency training. It clearly results in improved trainee well-being, at least in these survey studies. This is a good thing. However, there is no way to know that with more recreational time, housestaff will necessarily use this time in healthy ways. It is possible that some may moonlight more, travel more, or participate in other activities that could result in more fatigue. Also, because housestaff work-hour restrictions typically means work-hour expansion for staff, there should be discussion and research about staff fatigue and its impact on patient care, as well as professional satisfaction. This detrimental lifestyle effect on staff could theoretically counteract the positive effects of work-hour restrictions on attracting students into the field of internal medicine.11 With the shortage of applicants to internal medicine programs (particularly general medicine) and a growing need, we need to find optimal balance in educational programs between lifestyle, professional satisfaction, and educational challenge—for both trainees and teachers of internal medicine—while at the same time assuring that professionalism, quality patient care (to include minimizing the rate of preventable AEs), and competence are achieved and upheld.

Thus, there are numerous challenges for medical education researchers in this modern era of competing demands and less time: measuring the impact of work-hour restrictions on all the relevant outcomes (with more attention to educational, patient, and teacher outcomes); establishing ways to measure and track professionalism; devising alternative methods of learning and teaching that are more efficient in accomplishing the curricular goals (and are more closely aligned with real practice)12; and finally, improving the methods of educational research at the Graduate Medical Education level, which should include better and more systematic collaboration among residency programs.

Improving residency training is a complex process and clearly more than just improving the well-being of trainees, although this is obviously important. All future interventions to improve training should be open to the law of unintended consequences, and policy makers should be ready to evaluate their impact on multiple domains, just as we expect to rigorously evaluate the impact of our medical interventions, both positive and negative. We still need to better understand all the many real trade-offs of the most recent intervention of work-hour restrictions. To think we can actually shorten the available time for learning in the context of patient care, and not pay a price for it in other ways, is a pipe dream.

Very well said! Those who make decisions without considering the externalities lack true leadership. I believe that too many decisions in medical education occur without an appropriate understanding of the consequences. And that we should all regret!