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Letters to the Editor  |   June 2007
Limitations of Survey-Based Assessments on Duty-Hour Work Standards
Author Affiliations
  • Richard McDonald, JD, PhD
    Senior Principal Scientist Product Development Associate Director GenoVar Biosciences St Clair Shores, Michigan
Article Information
Medical Education / Graduate Medical Education
Letters to the Editor   |   June 2007
Limitations of Survey-Based Assessments on Duty-Hour Work Standards
The Journal of the American Osteopathic Association, June 2007, Vol. 107, 214-233. doi:10.7556/jaoa.2007.107.6.214
The Journal of the American Osteopathic Association, June 2007, Vol. 107, 214-233. doi:10.7556/jaoa.2007.107.6.214
To the Editor: Aspects of the July 2005 JAOA—The Journal of the American Osteopathic Association medical education article on resident duty-hour limits demonstrate that attitudes or perceptions, though useful to some extent, are not necessarily accurate reflections of reality (ie, statistically significant but not clinically important).1 The authors report that—consistent with previous findings2—general surgery residents were more likely to feel that duty-hour standards “will have a serious, negative effect on training future physicians.” My contention is that a “feeling” based on a quantitative assessment (ie, the total number of procedures performed during residency training) is not equivalent to assessment reached through qualitative measurements (ie, the total number of procedures performed during residency training when one is fully alert). Studies of resident duty hours should then focus on assessing qualitative issues rather than quantitative ones. Why? 
In the same issue of the JAOA, Brian H. Foresman, DO, cites ample evidence to show that prolonged work hours at any job are hazardous.3 Similarly, a 2004 study showed that mistakes tripled when nurses work more than 12 hours.4 In addition, not one study has demonstrated that workers can build tolerance for long work hours. Clearly, working long hours can lead to problems, and the duty-hour mandate, from my point of view, is headed in the right direction—regardless of some residents' feelings based on quantitative assessments. 
Duty-hour limits for residents were initially sparked by the accidental death of a journalist's daughter in 1984, forcing the state of New York to institute regulations5 that eventually lead to nationwide reform.6,7 
As Zonia and coauthors1 note, some trainees argued that the duty-hour limits will result in a lower level of resident exposure to medical procedures and patient cases, compromising the quality of physician training. Indeed, as Zonia and her coinvestigators1 report, some survey respondents believed that the “standards will prolong residency training,” similar to what others have suggested.8 I disagree. 
In fact, the perceived negative impact of the 80-hour work week on medical education has no real basis—except perhaps in terms of a decline in patient numbers. I believe that this loss is counterbalanced by the gains made in terms of an increase in the quality of patient care and safety, as well as the strengthening of acquired knowledge because residents will be more alert, make fewer mistakes, and have increased productivity. This viewpoint is not new, and is supported by numerous studies. For example, duration of work hours compared with the duration and quality of sleep, are viewed as factors that influence health-care quality.9 Similarly, Howard and colleagues10 reported that resident skill level was negatively affected, and “post-call conditions were near or below levels associated with clinical sleep disorders,” justifying reforms for residents' work and duty hours. In two studies of intensive care units, the Harvard Work Hours and Health Study Group concluded that attention failures decreased with significant increase in sleep during night work hours11 and there were “substantially more” serious medical errors with frequent 24-hour shifts.12 Similar results were found in a smaller scale study.13 Additional studies, all on simulations of laparoscopic surgeries, showed that more errors (ie, limited dexterity, impaired speed, accuracy, economy of motion) occurred as sleep loss increased and after multiple nights on call.14-17 One of these studies showed that performance decreased after 17 hours,4 consistent with results reported elsewhere for nurses.4 In addition, some evidence exists that problems related to sleep-deprivation extend for 2 days beyond a sleepless night.18 It is my contention that residents with healthier sleep patterns will establish better habits of alertness and mental focus for their individual medical readings and projects, as well as their journal clubs, seminars, and conferences. All of this will benefit residents as future physicians—ultimately benefiting patients. 
How does one convince residents that a limit of 80 duty-hours per week is better than no duty-hour restrictions? 
A follow-up study might take the following form: 

Please answer the following questions for the residents in your program, regardless of the year in training.

 

  1. How many residents do you have in your medical residency program?
  2. Of this number, how many residents do you trust to perform a surgical procedure on you or on one of your family members?

 
These two questions would establish a baseline for the survey's remaining questions: 

 

  • 3. Of the number of residents you would trust to perform a surgical procedure on you or on one of your family members, how many residents would you trust after they had been working for 10 hours straight?
  • 4. Of this number, how many residents would you still trust after they had been working for 15 hours straight?
  • 5. Of this number, how many residents would you still trust after they had been working for 22 hours straight?

 
If answered honestly, such survey questions could help researchers begin to address issues about the underlying quality of medical education within the context of the duty-hour restrictions. Would the survey or its results change the attitude of residents whose primary focus is on quantity rather than quality in their medical training? Probably not, but again, this information is worth finding out. 
As the husband of a DO who recently completed her fourth year of residency training in an obstetrics/gynecology program approved by the American Osteopathic Association—and as someone involved in biomedical research and development and associated legal issues in my own career—I think quality in residency programs outweighs quantity any day. And again, how does one measure quality? 
Is one a better surgeon, for example, because one performed 60 procedures in a 24-hour period, 40 of which were performed after hour 16 at work? Or is one a better surgeon because one performed 35 procedures in a 24-hour period, all of which were performed between hours 5 and 8 at work? Is doing 30 personal histories and physical examinations in 1 hour by one resident better for the resident, patients, or the hospital than doing 15 in the same 60-minute period? What are our expectations, and are they realistic? My guess would be that the answer depends on whom you ask. 
I can tell you one thing for certain: our society should not tolerate allowing the legal system to determine our answers for us. 
Zonia SC, LaBaere RJ II, Stommel M, Tomaszewski DD. Resident attitudes regarding the impact of the 80–duty-hours work standards. J Am Osteopath Assoc. 2005;105:307-313. Available at: http://www.jaoa.org/cgi/content/full/105/7/307. Accessed June 25, 2007.
Whang EE, Mello MM, Ashley SW, Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg. 2003;237:449-455.
Foresman BH. Resident-physicians' duty hours: perceptions and cultural expectations in medicine [editorial]. J Am Osteopath Assoc. 2005;105:305-306. Available at: http://www.jaoa.org/cgi/content/full/105/7/305. Accessed June 25, 2007.
Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23:202-212.
New York State Health Code. The Bell Regulations. N.Y.C.R.R. §405.4 (1989).
Friedman WA. Resident duty hours in American neurosurgery. Neurosurgery. 2004;54:925-931.
Loehr J, Schwartz T. The Power of Full Engagement: Managing Energy, Not Time, Is the Key to High Performance and Personal Renewal. New York, NY: Free Press; 2003:56-57.
Duane M, Dovey SM, Klein LS, Green LA. Follow-up on family practice residents' perspectives on length and content of training. J Am Board Fam Pract. 2004;17:391-393. Available at: http://www.jabfm.org/cgi/content/full/17/5/377. Accessed June 25, 2007.
Firth-Cozens J, Cording H. What matters more in patient care? Giving doctors shorter hours of work or a good night's sleep? Qual Saf Health Care. 2004:13:165-166.
Howard SK, Gaba DM, Rosekind MR, Zarcone VP. The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med. 2002;77:1019-1025.
Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP, et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med. 2004 :351:1829-1837.
Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838-1848.
Drazen JM. Awake and informed [editorial]. N Engl J Med. 2004;351:1884 .
Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Laparoscopic performance study after one night on call in a surgical department: prospective study. BMJ. 2001:323:1222-1223. Available at: http://www.bmj.com/cgi/content/full/323/7323/1222. Accessed June 25, 2007.
Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator [letter]. Lancet. 1998;352:1191 .
Koslowsky M, Babkoff H. Meta-analysis of the relationship between total sleep deprivation and performance. Chronobiol Int. 1992;9:132-136.
Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Laparoscopic performance after one night on call in a surgical department: prospective study. BMJ. 2001;323:1222-1223. Available at: http://www.bmj.com/cgi/content/full/323/7323/1222. Accessed June 25, 2007.
Howard SK, Gaba DM, Rosekind RM, Zarcone VP. The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med. 2002;77:1019-1025.