April 14, 2010 (Toronto, Ontario) — New Institute of Medicine recommendations designed to reduce work hours and encourage sufficient sleep are failing to protect residents, a new study shows.
Reporting here at the American Academy of Neurology 62nd Annual Meeting, investigators suggest residents are no more well rested or prepared now that restrictions are in place compared with before. And many residents are complaining their work is less satisfying now.
Why would fewer working hours and more time to sleep leave residents feeling unfulfilled in their job? Study author Andrew Southerland, MD, from the University of Virginia in Charlottesville, told Medscape Neurology that his team found residents are now at higher risk of burnout.
"Residents are checking in and out on patients like shift workers and are feeling less connected," Dr. Southerland said. "There is less continuity of care, and our program is not running as smoothly."
To assess the situation, investigators led by Lori Schuh, MD, from the Henry Ford Hospital in Detroit, Michigan, questioned 30 neurology residents.
They found that contrary to the intentions of the new recommendations, they do not appear to be improving learning or patient safety.
Surprisingly, the mean weekly time spent at work and in lecture, studying, and sleeping did not differ before the restrictions and after. However, quality-of-life measures suggesting an increased risk of burnout significantly increased after the new rules went into effect (P = .03).
Table 1. Mean Difference Before and After Institute of Medicine Recommendation
| Residents | Baseline Month | After Recommendation | P Value |
| Sleepiness after work shift | 3.56 | 3.55 | .99 |
| Sleepiness after on call | 5.88 | 5.62 | .69 |
| Weekly hours slept | 51.1 | 53.7 | .16 |
| Weekly hours at hospital | 56.6 | 58.3 | .56 |
| Weekly personal study | 7.1 | 8.0 | .28 |
| Weekly hours in lecture | 5.0 | 5.0 | .97 |
| Weekly study hours at hospital | 1.5 | 1.5 | .93 |
Table 2. Maslach Burnout Inventory
| Variable | Mean Baseline Month | Mean After Recommendation | P Value |
| Emotional exhaustion | 23.3 | 28.7 | .16 |
| Depersonalization | 8.7 | 12.8 | .03 |
| Personal accomplishment | 35.6 | 34.8 | .87 |
During an interview, William Hicks, MD, chief resident in neurology at Henry Ford Hospital in Detroit, Michigan, said, "Institute of Medicine panelists have made recommendations and extrapolated them across the board as though neurology would fit in the same model."
Neurology residency programs are usually small, and Dr. Hicks said the institute initiated recommendations based on no evidence. "At the very least, we should have been at the table," he said.
The problems, residents say, are having an impact on everyone. "Nurses are having to brief us as we come and go and this isn't their job," he said.
Coauthor Heather Harle, MD, from the University of Virginia in Charlottesville, said there are no data showing that the recommendations have improved patient safety. "Evidence suggests there are no fewer mistakes now compared to before, and the rate of medical errors has remained static."
Fewer Days in Clinic
Investigators report a 21% reduction in the number of resident clinic days in 1 program as residents were pulled from other rotations to provide additional night time coverage.
Pediatric residents have reported similar concerns (Journal of Graduate Medical Education. 2009;1:181-184).
Asked by Medscape Neurology to comment, Orly Avitzur, MD, a neurologist with offices in New York, said she agrees there are problems with the Institute of Medicine restrictions.
"The new recommendations propose changes for maximum shift length, minimum time off between shifts, and maximum number of in-hospital night shifts. They make the assumption that if residents get a regular opportunity for sleep each day, this will reduce fatigue-related errors. However," she added, "this focuses on only one process and one potential source of error. The unintended consequence is that it creates more transitions of care."
One of the biggest sources of error occurs because of patient sign-outs, Dr. Avitzur emphasized. "The more you change hands in patient care, the more opportunity exists for errors." Dr. Avitzur said this also creates more stress for residents because they have to pick up a whole new service of patients on a regular basis, and stress can, in itself, cause errors and workplace dissatisfaction.
The researchers have disclosed no relevant financial relationships.
American Academy of Neurology (AAN) 62nd Annual Meeting: Poster 1.296. Presented April 13, 2010.
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