Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules and Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine

Silber JH, Bellini LM, Shea JA, et al. N Engl J Med 2019; 380:905-14. [CrossRef]

Basner M, Asch DA, Shea JA, et al. N Engl J Med 2019; 380:915-23. [CrossRef] [PubMed]

In 2003 the American Council on Graduate Medical Education (ACGME) limited resident work-hour limits. In 2011 the ACGME enacted even more stringent requirements. However, waivers were granted allowing some flexibility in shift length, as well as time off between shifts; caps on weekly hours worked, total days off, and the frequency of overnight call were maintained. Some argued that there was a paucity of evidence to support these changes and some new risks, such as those associated with increased handoffs of care or inadequate educational exposure. The Arizona Thoracic Society was amongst those who urged the ACGME to conduct randomized trials. In today’s edition of the New England Journal the results of two of these trials are reported.

The first report used Medicare claims data to assess patient outcomes. Mortality, readmissions and payments did not differ in programs with flexible hours worked standard hours. The second study found that sleep duration also did not differ in flexible programs as compared with standard programs, with interns in both groups averaging approximately 7 hours of sleep per night. Essentially, interns made up for lost sleep on extended shifts by sleeping more during time off.

A thoughtful editorial by Rosenbaum and Lamas summarizes the data and points out that there may be some downsides to the resident hour restrictions including increased handoffs of care or inadequate educational exposure.