Allowing surgeons in training to work extremely long shifts without breaks had no effect on patient outcomes and created only minor dissatisfaction among the young doctors, research released Tuesday shows.
Patients’ rates of death, serious illness, infection, pneumonia and most other common post-operative complications were no worse in hospitals that permitted the novice doctors to work longer stints for the purposes of the nationwide study than in hospitals that limited work hours.
The "residents," as they are known, said they valued the chance to follow patients for more than 28 hours because of what they learned and did not think that such extended shifts jeopardized their own health. Some research and critics have suggested that the practice places physicians at higher risk for depression, sleep problems and trouble concentrating.
"They told us very clearly that they thought patient care was better” when residents could work longer shifts within more flexible schedules, said Karl Bilimoria, director of the surgical outcomes and quality improvement center at Northwestern Feinberg School of Medicine. Bilimoria led the study, which was published online in the New England Journal of Medicine.
The physicians acknowledged that the extended shifts did have some effect on their lives outside the hospital, especially their time with familes, friends and hobbies. “But they are professionals,” Bilimoria said, “and they are making this trade-off.”
The new findings mark the first randomized, controlled study to examine one of the older and more controversial issues in physician education.
Following a report by the prestigious Institute of Medicine that recommended limits on residents' work schedules, 30-hour shifts were banned in 2011 by the Accreditation Council for Graduate Medical Education. First-year physicians were prohibited from working more than 16 hours consecutively, with a few minor exceptions.
But some involved in training newly graduated doctors say the work-hour limits can be counterproductive. They contend that a beginner learns best by following a case in the critical first 36 hours and that patients are better served when they go through fewer “hand-offs” from doctor to doctor — which happens more often when a physician is required to leave.
In their study, Bilimoria and his fellow researchers found that view generally held true.
“We had residents leaving in the middle of operations and while stabilizing critically ill patients because the clock was up,” he said. “Clearly, that’s not good for patient care or for the [residents’] training. They need to be able to see those cases through.”
The analysis covered the records of nearly 139,000 patients treated by 4,330 general surgery residents in 115 programs during the 2014-2015 academic year. Because the contentious issue had not been tested in a controlled experiment, Bilimoria’s team divided the participating surgical programs into roughly equal halves.
One group followed the current rules: 80-hour work weeks, averaged over four weeks; 16-hour work limits for first-year surgeons and 28-hour limits for second-year surgeons; eight hours off after all shifts; and 14 hours off after a 24-hour work stint.
In the other group, surgeons also worked no more than an average of 80 hours per week. But shifts for first-year surgeons could exceed 16 hours. In the second year of training and beyond, shifts could last more than 28 hours. The time-off rules were also waived.
With the flexible schedule, the study found that surgeons in training were half as likely to miss an operation, leave one or hand off a patient as their counterparts following the current rules. The result was improved continuity of care and education, the researchers found.
Patients were no more likely to suffer post-operative problems such as strokes, heart attacks, acute kidney failure, serious bleeding, infections or wounds openings, the analysis showed. Subgroups of patients — such as those requiring emergency surgery — also did not show any worse effects because of the residents’ extended hours.
The most noticeable difference between the two physician groups was the complaint among surgeons working longer shifts that the hours cut into time with their families, friends and activities outside of work. They also said it affected their health, although the study gives no detail on that.
Long confined to academic circles, the question of whether ultra-long work shifts affect patient care and physician education attracted some public attention last year when The Washington Post reported that an experiment involving 30-hour shifts for internal medicine physicians was underway at hospitals nationwide.
The American Medical Student Association, which includes doctors in the early years of their post-medical-school training, and the advocacy group Public Citizen asked the government to stop that test. The groups contended it was unethical because neither patients nor doctors at the 63 programs were given the chance to consent to the arrangement.
The Department of Health and Human Services has not intervened.