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Duty Hour Regulations of Physicians in Training and Circadian Considerations

  • Eric J. OlsonEmail author
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Abstract

Residency and fellowship training of physicians are marked by long hours, night call, and shift work. While this prepares trainees for independent practice, it also produces sleep deprivation and circadian disruptions that may imperil personal wellbeing, professional development, and patient safety. Accordingly, duty schedules have been increasingly controlled, yet not without controversy due to varying effects on trainee wellness, education, and patient care. Regulation of house staff work conditions has primarily focused on limiting work hours and less on mitigating occupational circadian disturbances. This chapter reviews the interaction of trainee work schedules on sleep and circadian physiology, the personal and professional effects of sleep/circadian disruptions on trainees, the evolution of the duty hour regulations in the United States, and the mixed impacts of those policies on healthcare providers and their patients.

Keywords

Accreditation Council for Graduate Medical Education (ACGME) Fellow Institute of Medicine Harvard Work Hours Health and Safety Group Intern Night float Resident 

References

  1. 1.
    Borbely AA. A 2 process model of sleep regulation. Hum Neurobiol. 1982;1:195–204.PubMedGoogle Scholar
  2. 2.
    Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388:235.PubMedCrossRefGoogle Scholar
  3. 3.
    Baldwin DC Jr, Daugherty SR, Tsai R, Scotti MJ Jr. A national survey of residents’ self-reported work hours: thinking beyond specialty. Acad Med. 2003;78:1154–63.PubMedCrossRefGoogle Scholar
  4. 4.
    Richardson GS, Wyatt JK, Sullivan JP, et al. Objective assessment of sleep and alertness in medical hour staff and the impact of protected time for sleep. Sleep. 1996;19:718–26.PubMedGoogle Scholar
  5. 5.
    Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns’ compliance with accreditation Council for Graduate Medical Education work-hour limits. JAMA. 2006;296:1063–70.PubMedCrossRefGoogle Scholar
  6. 6.
    Watson NF, Badr MS, Belenky G, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of sleep medicine and Sleep Research Society. J Clin Sleep Med. 2015;11:591–2.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Van Dongen HPA, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep. 2003;26:117–26.PubMedCrossRefGoogle Scholar
  8. 8.
    Wertz AT. Effects of sleep inertia on cognition. JAMA. 2006;295:163–4.PubMedGoogle Scholar
  9. 9.
    Friedman RC, Bigger T, Kornfeld DS. The intern and sleep loss. N Engl J Med. 1971;285:201–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Weinger MB, Ancoli-Isreal S. Sleep deprivation and clinical performance. JAMA. 2002;287:955–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Veasey S, Rosen R, Barzansky B, Rosen I, Owens J. Sleep loss and fatigue in residency training: a reappraisal. JAMA. 2002;288:1116–24.PubMedCrossRefGoogle Scholar
  12. 12.
    Rosen IM, Bellini LM, Shea JA. Sleep behaviors and attitudes among internal medicine housestaff in a U.S. university-based residency program. Acad Med. 2004;79:407–16.PubMedCrossRefGoogle Scholar
  13. 13.
    Philibert I. What is known: examining the empirical literature in resident work hours using 30 influential articles. J Grad Med Edu. 2016;8:795–804.CrossRefGoogle Scholar
  14. 14.
    Reuben DB. Depressive symptoms in medical house officers: effects of training and work rotation. Arch Intern Med. 1985;145:286–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, and mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81:82–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Jacques CH, Lynch JC, Samkoff JS. The effects of sleep loss on cognitive performance of resident physicians. J Fam Pract. 1990;30:223–9.PubMedGoogle Scholar
  17. 17.
    Hillson SD, Dowd B, Rich EC, Luxenberg MG. Call nights and patients care: effects on inpatients at one teaching hospital. J Gen Intern Med. 1992;7:405–10.PubMedCrossRefGoogle Scholar
  18. 18.
    Marcus CL, Loughlin GM. Effect of sleep deprivation on driving in housestaff. Sleep. 1996;19:763–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Steele MT, Ma OJ, Watson WA, Thomas HA, Muelleman RL. The occupational risk of motor vehicle collisions for emergency medicine residents. Acad Emerg Med. 1999;6:1050–3.PubMedCrossRefGoogle Scholar
  20. 20.
    Parks DK, Yetman RJ, McNeese MC, Burau K, Smolensky MH. Day-night pattern in accidental exposures to blood-borne pathogens among medical students and residents. Chronobiol Int. 2000;17:61–70.PubMedCrossRefGoogle Scholar
  21. 21.
    Bellini LM, Baime M, Shea JA. Variation of mood and empathy during internship. JAMA. 2002;282:3143–6.CrossRefGoogle Scholar
  22. 22.
    Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125–34.PubMedCrossRefGoogle Scholar
  23. 23.
    Ayas NT, Barger LK, Cade BE, et al. Extended work shift duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006;296:1055–62.PubMedCrossRefGoogle Scholar
  24. 24.
    Barger LK, Ayas NT, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failure. PLoS Med. 2006;3:e487.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Owens JA. Sleep loss and fatigue in medical training. Curr Opin Pulm Med. 2001;7:411–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Van Dongen HPA, Baynard MD, Maislin G, Dinges DF. Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of a trait-like differential vulnerability. Sleep. 2004;27:423–33.PubMedGoogle Scholar
  27. 27.
    Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28:1392–402.PubMedCrossRefGoogle Scholar
  28. 28.
    Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–48.PubMedCrossRefGoogle Scholar
  29. 29.
    Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns’ work hours on sleep and attentional failures. N Engl J Med. 2004;351:1829–37.PubMedCrossRefGoogle Scholar
  30. 30.
    Zion S. “Doctors know best?” New York times, 13 May 1989, https://www.nytimes.com/1989/05/13/opinion/doctors-know-best.html. Accessed 29 Jan 2019.
  31. 31.
    Temple J. Resident duty hours around the globe: where are we now? BMC Med Edu. 2014;14(Suppl 1):S8.CrossRefGoogle Scholar
  32. 32.
    Pastores SM, O’Connor MF, Kleinpell RM, et al. The accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing intensive care units. Crit Care Med. 2011;39:2540–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Ulmer C, Wolman D, Johns M, editors. Resident duty hours: enhancing sleep, supervision, and safety. Washington DC: National Academies Press; 2008.Google Scholar
  34. 34.
    Accreditation Council for Graduate Medical Education. Common program requirements. 2011. https://www.acgme.org/Portals/0/PFAssets/ProgramResources/Common_Program_Requirements_07012011.pdf?ver=2015-11-06-120650-183. Accessed 28 Jan 2019.
  35. 35.
    Bilimoria KY, Chunng JW, Hedges LV, et al. National cluster-randomized trial of duty hour flexibility in surgical training. N Engl J Med. 2016;374:713–27.PubMedCrossRefGoogle Scholar
  36. 36.
    Desai SV, Asch LM, Bellini KH, et al. Education outcomes in a duty hour flexibility trial in internal medicine. N Engl J Med. 2018;378:1494–508.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Yang AD, Chung JW, Dahlke AR, et al. Differences in resident perceptions by postgraduate year of duty hour policies: an analysis for the flexibility in duty hour requirements for surgical trainees (FIRST) trial. J Am Coll Surg. 2017;224:103–12.PubMedCrossRefGoogle Scholar
  38. 38.
    Silber JH, Bellini LM, Shea JA, et al. Patient safety outcomes under flexible and standard resident duty-hour rules. N Engl J Med. 2019;380:905–14.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Accreditation Council for Graduate Medical Education. Common program requirements section VI with background and intent. 2017. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_Section%20VI_with-Background-and-Intent_2017-01.pdf. Accessed 28 Jan 2019.
  40. 40.
    Poulose BK, Ray WA, Arbogast PG, et al. Resident work hour limits and patient safety. Ann Surg. 2005;241:847–56; discussion 856–60.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Gopal R, Glasheen JJ, Miyoshi TJ, et al. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595–600.PubMedCrossRefGoogle Scholar
  42. 42.
    Arora V, Dunphy C, Chang VY, et al. The effects of on-duty napping on intern sleep time and fatigue. Ann Intern Med. 2006;144:792–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reforms. JAMA. 2007;298:973–83.Google Scholar
  44. 44.
    Jagannathan J, Vates GE, Pouratian N, et al. Impact of the accreditation Council for Graduate Medical Education wotk-hour regulations on neurosurgical resident education and productivity. J Neurosurg. 2009;110:820–7.PubMedCrossRefGoogle Scholar
  45. 45.
    McCoy CP, Halvorsen AJ, Loftus CG, McDonald FS, Oxentenko AS. Effect of 16-hour duty periods on patient care and resident education. Mayo Clin Proc. 2011;86:192–6.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine hour staff: a randomized trial. JAMA Intern Med. 2013;173:649–55.PubMedCrossRefGoogle Scholar
  47. 47.
    Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013;173:657–62; discussion 663.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Bolster L, Rourke L. The effect of restricting residents’ duty hours on patient safety, resident well-being, and resident education: an updated systematic review. J Grad Med Educ. 2015;7:149–63.CrossRefGoogle Scholar
  49. 49.
    Fletcher KE, Underwood W 3rd, Davis SQ, Mangrulkar RS, McMahn LF, Saint S. Effects of work hour reduction on residents’ lives: a systematic review. JAMA. 2005;294:1088–100.PubMedCrossRefGoogle Scholar
  50. 50.
    Fletcher KE, Reed DA, Arora VM. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules. J Gen Intern Med. 2011;26:907–19.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Philibert I, Nasca T, Brigham T, Shapiro J. Duty hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Ann Rev Med. 2013;64:467–83.PubMedCrossRefGoogle Scholar
  52. 52.
    Reed D, Fletcher K, Arora VM. Systematic review: association of shift length, protected sleep time, and night float with patient care, residents’ health, and education. Ann Intern Med. 2010;153:829–42.PubMedCrossRefGoogle Scholar
  53. 53.
    Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard JD. Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review. BMJ. 2011;342:d1580.PubMedCrossRefGoogle Scholar
  54. 54.
    Jamal M, Doi SA, Rousseau M, et al. Systematic review and meta-analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients. Br J Surg. 2012;99:336–44.PubMedCrossRefGoogle Scholar
  55. 55.
    Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF, Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med. 2004;141:851–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Baldwin K, Namdari S, Donegan D, Kamath A, Mehta S. Early effects of resident work-hour restrictions on patient safety: a systematic review and plea for improved studies. J Bone Joint Surg Am. 2011;93:e5.PubMedCrossRefGoogle Scholar
  57. 57.
    Lin H, Lin E, Auditore S, Fanning J. A narrative review of high-quality literature on the effects of resident duty hours reforms. Acad Med. 2016;91:140–50.PubMedCrossRefGoogle Scholar
  58. 58.
    Burchiel KJ, Zetterman RK, Ludmerer KM, et al. The 2017 common work hour standards: promoting physician learning and professional development in a safe, human environment. J Grad Med Edu. 2017;9:692–6.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2020

Authors and Affiliations

  1. 1.Department of Medicine, Division of Pulmonary and Critical Care Medicine, and Center for Sleep Medicine, Mayo ClinicRochesterUSA

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