Work Hours and Handovers

A major argument against restriction of work hours for residents (or staff, though that gets less attention) is the notion of increased handovers. The basic story goes that when you have residents work fewer hours, or at least fewer hours in a row, they have to handover the care of their patients to other residents more often and since handovers are well-established as leading to error, more handovers mean more errors. It is thus hypothesized that any gains made on resident fatigue by restricting hours will be eliminated by increased problems associated with handovers.

When work hour restrictions were put in place in the US, studies on healthcare quality came back pretty equivocal, so the hypothesis appeared valid and has been seized upon by many with an interest in medical education, particularly those opposed to work hour restrictions. I accepted this theory as well, since it seemed to fit the evidence and was plausible in theory.

Now, acceptance of this theory didn't change my views on reducing work hours in medicine, since handovers are not an inherent problem, but rather one that could be addressed and improved. Moreover, since our current system necessarily involves a lot of handovers, fixing them should be a top priority anyway. As a result, any losses in care due to increased handovers associated with shorter working hours should, if anything, get better as time goes on, allowing any gains from those shorter hours to be realized.

However, the more I look at the problem, the less I'm convinced this theory holds much water in the first place, at least not in many cases.

For example, shorter shifts don't necessarily lead to more handovers for the majority of patients. Individuals on call for 24 hour shifts don't typically just take care of their own patients, they take care of patients on their "team", many of which are cared for by other team members. When I'm on call during my current rotation, I am responsible for up to 30 patients, yet most days I only care for 4-6 patients. Residents often take on a bit more work, but even then, they're unlikely to be familiar with more than 10 patients. They need to be updated - or receive handover - from the other members of the team. If we had two distinct shifts taking care of a set of patients, one day shift and one night shift, the total number of handovers would be virtually unchanged for the majority of patients.

Likewise, not all handovers are created equal - handing over a patient that both parties are reasonably familiar with is a much different situation than handing over a patient that the receiving party has never cared for before. This gets back to a more fluid concept of continuity of care which I've written about before, where continuity of care doesn't mean one physician caring for one patient, but rather one physician maintaining the same role in caring for that one patient.

So how do I explain the rather equivocal results from studies on resident work hour restrictions? My current belief is that work hour restrictions failed to achieve their process goal, which was improving resident fatigue. Through a combination of increased work intensity, scheduling loopholes, and well, simply ignoring the restrictions, residency programs simply found creative ways to continue to work their residents far, far too hard. We didn't see a change in patient outcomes, because we never really saw a change in resident working conditions, simply trading one inadequate resident work system for another.

I can't dismiss handovers as a factor entirely, since I've seen first-hand how poor handovers can cause substantial problems for patients. Yet, when it comes to work hour restrictions, I'm coming around to the conclusion that they're used a bit as a red herring, part of a rhetoric thrown out to justify maintaining the status quo on work hours, without much conclusive evidence to demonstrate that the status quo should be maintained.