This Alert is brought to you by AHLA’s Academic Medical Centers and Teaching Hospitals Practice Group.
The implementation of the 2003 Accreditation Council for Graduate Medical Education (ACGME) regulations on physician resident work hours led many to speculate whether the limitation on such work hours would allow physicians adequate time to gain the necessary training to practice independently without compromising quality. Although some studies have examined the effect of work hour reforms on the quality of care provided by resident physicians while in training, a recent study led by Anupam B. Jena uniquely addresses the impact of the reforms on post-training physician performance. In their study released in July in the British Medical Journal (BMJ), Jena, et al., examined the impact on key quality metrics of the medical residency work hour reforms implemented by the ACGME.
While the clinical education and hands-on training of medical residencies is vital to preparing physicians for independent practice, research has documented the inextricable connection between fatigue and clinical performance. In response to the growing body of research, the ACGME implemented resident work hour reforms in 2003, including limiting work hours for all residents to an 80-hour weekly maximum with shifts of no more than 24 hours, limiting in-hospital call to every third night, and one day off in seven, averaged over four weeks. Prior to these changes, the Agency for Healthcare Research and Quality (AHRQ) reported that resident physicians “routinely worked 90-100 hours per week, for up to 36 consecutive hours without rest, for the entire duration of residency training.”1 Since 2003, ACGME has implemented additional work hour reforms, but the cornerstone requirements described above have remained the same.
In their study, Jena et al. sought to examine whether there are differences in 30-day mortality, 30-day readmissions, and inpatient spending between physicians who underwent residency training after the implementation of ACGME’s work hour reforms and physicians who completed their residency training prior to implementation. The researchers concluded that the marginal reduction in residency work hours did not lead to higher inpatient costs of care or worse outcomes in post-residency physician care with respect to patient mortality, readmissions, or costs of care. In other words, limiting medical training work hours had no statistically significant effect on the competency of those physicians—physicians can provide the same quality of care for the same price. The study was based on comparing the records of Medicare beneficiaries aged 65 years or older treated by physicians in their first year of independent practice and those treated by 10th-year physicians who completed their residency training prior to the work hour reforms in 2003.
This study provides further insight into the long-term impact of training reforms. It could also form the basis for future training reforms and studies. The researchers note several questions that remain, including whether the effect of the reduction in total residency work hours was “offset by greater consolidation of clinical knowledge mediated by reductions in resident fatigue and increased teaching by residency programs.” Additionally, the researchers note that the increased use of advanced practitioners, integration of multidisciplinary teams, implementation of electronic health systems, and inpatient pharmacists may have accounted for improved outcomes and lowered costs among first year physicians but not among older physicians, which would bias the findings. A number of physicians, especially those whose residencies occurred prior to the 2003 ACGME hours change, continue to argue that the decrease in clinical residency hours also has led to a decrease in soundness under pressure. That noted, as the researchers observed, future reforms and discussions on this topic should recognize that the impact of individual physicians in delivering care is increasingly mitigated by the incorporation of teams and technological advances in how medical care is delivered.
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1 AHRQ, Duty Hours and Patient Safety.