A Narrative Review of Surgical Resident Duty Hour Limits: Where Do We Go From Here?

摘要

Background: Historical Context Resident duty hour limits have been a point of debate for several years. As recently as the mid-1980s, residency training could be likened to an apprenticeship that had features of indentured servitude. The demand to learn an entirely new craft within a relatively short period of time heightened the intensity of residency training. This stress was compounded by a schedule that included overnight call every other night and 100+ hour workweeks for many residents. This left little room for work-life balance and may have contributed to resident fatigue and possibly early burnout.1,2 Over the past 2 decades, the philosophies and policies regulating resident duty hours have changed dramatically. Duty hours are now tightly regulated, with specific rules mandating sufficient time spent out of the hospital. Also, direct supervision of patient care by attending physicians has become a greater priority.3,4 These policies were designed with the goal of increasing patient safety, but some have argued that they may compromise resident education.5,6 Although the number of hours resident spent at work has decreased, the amount of knowledge needed to be a competent physician is constantly expanding, and the total number of years of residency training has remained unchanged. It is unclear whether duty hour limits have resulted in significant improvement in patient care, and there is concern that the quality of education of residents has been affected by these changes, especially with regard to case volume in the surgical disciplines.7,8 In 1984, Libby Zion, the daughter of Daily News columnist Sidney Zion, was admitted to New York Hospital. She was prescribed multiple medications from several practitioners, including sedatives, antihistamines, antidepressants, narcotic pain medication, and antibiotics.9 During a hospitalization after days of chills, body aches, and fever at home, she died, reportedly as a result of an adverse medication interaction.9 After a campaign by her father against excessive resident duty hours, the case served as a catalyst to restructure resident education and resulted in groundbreaking New York State policies regulating work hours of medical trainees.10 In 1989, New York's health commissioner appointed a committee, headed by Dr Bertrand M. Bell, tasked with making specific recommendations on several aspects of patient care and resident education.11 While the Bell commission emphasized the importance of resident supervision, ensuing debates primarily focused on limiting resident work hours. Although these new policies were made official in New York State, enforcement was relatively lax until the late 1990s.12 In 2003, the Accreditation Council for Graduate Medical Education (ACGME) created nationwide duty hour limits for residency programs across all specialties and subspecialties. The ACGME required a minimum of one 24-hour period off duty each week averaged over a 4-week period, overnight call no more frequent than once every 3 nights, and expanded duty hours to include any assignment to clinical or educational activity, limiting them to 80?hours per week. Subsequently, a committee charged by the Institute of Medicine (IOM) cited studies that continuous time awake upward of 30?hours can result in measurable fatigue13 and called for further modification of the 2003 ACGME duty hour standards. In 2010, the ACGME released a new set of duty hour standards, to become effective in 2011, which shortened the consecutive duty period of first-year residents to 16?hours and required that more senior residents have 14?hours off after a 24-hour call shift. Previously, residents were permitted to stay at the hospital for an additional 6?hours to aid in the transition of care to covering practitioners. This “transition time” was shortened to 4?hours.14 Failure to comply with these standards can result in an adverse action, ranging from citations to probation to loss of accreditation. Recent revision of