New Guideline Will Allow First-Year Doctors to Work 24-Hour Shifts

http://www.nytimes.com/2017/03/10/science/us-doctors-residents-24-hour-shifts.html

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First-year doctors in training will now be permitted to work shifts lasting as long as 24 hours, eight hours longer than the current limit, according to a professional organization that sets work rules for graduates from medical schools in the United States.

In setting the new standard, which goes into effect on July 1, officials at the Accreditation Council for Graduate Medical Education said on Friday that they hoped to avoid confusion and disruptions in care that can result when a patient is handed off to one doctor from another whose shift is ending.

The rules do not change for residents after the first year, who have been permitted to work 24-hour shifts if necessary. The new rules also leave in place a requirement that all residents work no more than 80 hours a week.

But the new guidelines roused the ire of critics who say that exhausted and inexperienced residents will be working too many hours to remain alert and focus on the critical decisions they make. The issue has been a focus of controversy for at least 30 years, after a patient named Libby Zion died under the care of residents in a New York hospital.

“We know sleep-deprived people can have impaired motor skills and their memory can deteriorate,” said Dr. Michael A. Carome, director of health research at Public Citizen, an advocacy group.

Accreditation officials said they once believed as much, too, and had tried to protect first-year students from working too many hours. In 2011, the council required that first-year residents, unlike more experienced residents, work no longer than 16 hours in one stretch.

The hope was that shorter shifts would improve patient care. Those hopes, the group wrote in a new report, “have not been realized.” Instead, the council said, patient care was disrupted when residents’ shifts ended after 16 hours.

First-year residents do not have to work for 24 hours straight — their shifts can be shorter — but if needed they may be asked or may choose to continue to work for that length of time.

Whether a longer shift can be better for patients, and for the training of young doctors, has been rigorously studied in two randomized trials, the accrediting council noted — one involving surgeons in training, and the other involving specialists in internal medicine.

The study involving internal medicine residents is still underway, but the study of surgical residents, published last year in the New England Journal of Medicine, found that shorter shifts had no effect on patient care.

Continuity of care was also better with the longer shifts. Surgical residents in the study reported that they “strongly prefer” the option to work longer shifts, the council said.

The task force held a meeting last year, about the time the randomized study was published, in which representatives of medical organizations told them what, if anything, they would like to change about the rules for first-year residents.

“Everyone agreed that the 80-hour maximum was appropriate, but we heard from a large number of organizations that 16 hours was not successful,” said Dr. Rowen K. Zetterman, co-chairman of the task force, referring to the maximum shifts for first-year doctors.

Such shifts have “had a significant negative impact on the professional education of the first-year residents, and effectiveness of care delivery of the team as a whole,” the council wrote in its report, which also said that residents’ physical and mental health should be monitored carefully, as well.

Dr. Anai Kothari, a third-year surgical resident at Loyola University Medical Center who served on the task force, said he had had a 16-hour maximum shift when he was a first-year student, and much preferred the 24-hour maximum for residents in subsequent years.

“Most people want to be there for the patient if the patient needs them,” he said. No one, Dr. Kothari added, wants to leave in the middle of an operation.

Dr. Stephen Evans, past chairman of the American Board of Surgery and chief medical officer for MedStar Health, a hospital system in the Washington area, also favored giving first-year residents the option to work a longer shift.

“If you are a pediatric first-year resident taking care of a critically ill patient, and the child dies, do you just walk away from the family because the 16 hours are up?” he asked.

Dr. Carome, however, said that if the problem is the handoff from a doctor whose shift is ending, then it is the procedure that needs fixing, not residents’ shifts and sleep.