Work Hour Restrictions

Continuing on with my recent theme of super-long hours in the hospital, partially for myself, but mostly for my residents, it's worth mentioning the big elephant in the room for Canadian residency programs: resident work hour restrictions.

Long work hours have been identified as a potential cause of a lot of problems in medicine, both for providers and receivers of that care. The obvious solution then is to have providers - in particular the overworked residents - spend fewer hours on the job. While most countries with similar residency systems have implemented some form of work hour restrictions, Canada has not outside of Quebec. As such, it remains a topic of rather passionate debate, with fairly strong, opposing viewpoints from those at all levels of training.

Canadian practitioners are most familiar with how work hour restrictions came to be in the US, which were first implemented nationwide in 2003. The initial impetus for this change came from the death of Libby Zion, who, under the care of two overworked junior residents, was given a medication that when combined with her normal daily medications, resulted in a life-threatening condition that was not caught and eventually resulted in her death. The argument for work hour restrictions was fairly straight-forward: tired residents cannot deliver optimal care, so capping their hours (along with other restrictions on the distribution of those hours) will lead to more rested, more capable residents who would minimize mistakes for patients. There is more than enough evidence to support the notion that overworked or exhausted individuals are not the greatest workers and are prone to mistakes

The other justification, not always mentioned prominently in the debate, was to maintain the health and well-being of those residents. After all, residents are people too, who shouldn't be worked to the point of exhaustion. There is also quite a bit of evidence that long work hours contribute to medical or personal problems.

The argument against work hour restrictions was equally straight-forward: experience is the only way to make a competent physician, so work hour restrictions mean missed learning opportunities and less-competent physicians. There is also a large body of evidence for this argument, particularly in surgical specialties. You can't be competent with a surgical procedure until you've done it over and over again, so missed opportunities to scrub in add up.

It's now been 12 years since the first round of American work hour restrictions went into place and they've received a fair bit of scrutiny. The result? On all three points of consideration - patient outcomes, resident fatigue, and resident competency - the answer seems to be... mmmaaaaayyyybe...? In all respects, there seem to be studies which say work hour restrictions hurt, some which say they help, some which say they didn't make much different. On the whole, the answer seems to be that residents provide the same level of care, are just as tired, and just as competent as they were before the work hour restrictions.

Many of these studies come with fairly significant problems. With strong opinions on the subject being rather prevalent, bias in study design or result interpretation is a major concern that is difficult to address. Another large limitation is that actual hours worked before and after is rarely investigated. Some studies simply looked at results before and after the work hour restriction policy was put in place, without considering what effect that policy actually had on hours worked. Others used self-reported hours from residents which, as later investigations demonstrated, were often falsified to make it look like programs were in compliance with the regulations when they were routinely going over limits. Hard to see a change in outcome without a change in inputs.

A further criticism was that the work hour restrictions were still fairly permissive - 80 hours per week averaged over 4 weeks was the major cutoff. That's an average of about 11 and a half hours each and every day of the week, including weekends - hardly a light schedule. There were some other restrictions, such as 10 hours off between shifts, shifts that couldn't be longer than 24 hours (with an additional 6 for handover/education), one day off every week (on average) that were meant to make things a bit more palatable, but we're still not talking anything close to a 9-5 or even 7-5 job with weekends off.

There are also a lot of confounding factors when it comes to studying these interventions, which haven't been well addressed in previous literature. First is the challenge of handing over patients. Medicine sucks at transferring care between practitioners - it's a major opportunity for errors. When residents are prevented from working long shifts, it leads to more transfers of care, and more opportunities for mistakes to happen. The obvious response here is "fix the transfers", but that's easier said than done, so it remains a valid confounder. Another wrinkle in the intended effect of work hour restrictions is that residents don't always sleep when given more time. With 80+ hour work weeks, residents weren't just lacking sleep, they were lacking time to exercise, socialize, eat well, do domestic duties, spend time with their partner and/or children, whatever was important to them outside of medicine. When given the chance to spend less time at the hospital, sleep wasn't always the priority.

Unofficial duties also pop up outside the official work week. Every resident studies on their own time. Many participate in educational projects or research. "Homework" of a sort is pretty common. From my own experience, part of the challenge of dealing with 11 hour workdays is that I do 1-3 hours of studying, schoolwork, or EC tasks when I get home in the evening. In an environment where career opportunities are much less available than in the past, the impetus to go above and beyond, including using spare time, may eat up some extra time off.

When I started looking into the issue of resident work hours, my incoming opinion was that work hour restrictions were a painfully obvious solution to a painfully obvious problem. Given the available evidence, flawed as it may be, it's hard to maintain that view - work hour restrictions are not the disaster the detractors predicted, but neither is it a magic bullet. There are too many other factors to resident fatigue that need to be addressed in conjunction with work hours. We should be trying alternative approaches to reduce resident fatigue and evaluating them as intensely as we have work hour restrictions. In conjunction with or perhaps even in place of work hour restrictions, alternative approaches may provide the fatigue reduction many residents clearly need. It's hard to fathom that someone can work over 80 hours a week and be well-rested - there's simply no substitute for a good night's sleep - but I'm open to the idea if I can see some convincing evidence.

However, what are the alternatives? Safe transportation has come up, to prevent tired residents from driving home, but this is expensive and for many residents, costly in terms of time - a 15 minute drive home means more sleep than a 45 minute bus ride, for example. Another option, though not one I'd consider ethical, is medication. Some stimulants have been shown to improve wakefulness for tired workers, but sets a very dangerous precedent if it were to become compulsory. Past that, most discussions on this subject don't often provide realistic alternatives to improving resident fatigue. We should be open to any reasonable solutions to improving resident fatigue, but without workable alternatives to consider, effective implementation of resident work hour restrictions may be the only option for the moment, even if as a first step. Work hour restrictions may not be sufficient, and may not be optimally implemented in some jurisdictions, but they just might be necessary. Canada should consider an evidence-based approach to reducing resident working hours.