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When Hospital Regulations Go Too Far

A survey of surgical residents found that limiting work hours not only compromises education but leads to worse care for patients.


Most surgeons-in-training dislike new rules that limit how many hours they can work, according to a new study that also found the majority said they skirt the restrictions.

Researchers surveyed 1,013 surgical residents—who train for years alongside more senior surgeons—and found that about two of every three said they disapproved of the 2011 regulations, which aimed to improve patient care as well as the residents' education and quality of life.

"I don't think anybody wants to work 120 hours a week, but I don't think we really want medicine to necessarily have bankers' hours," said Dr. Brian Drolet, the study's lead author and a fourth-year surgical resident at Rhode Island Hospital in Providence.

Under pressure from the public and government officials, in July 2011 the Accreditation Council for Graduate Medical Education (ACGME) restricted the shifts of the most junior trainee surgeons, first-year surgical interns, to 16 hours and capped the shifts of the remaining residents at 28 hours. The regulations built on similar restrictions the organization put in place in 2003, but the policy has raised questions about whether simply restricting the hours doctors-in-training are permitted to work improves their lives or the health of their patients.

About half of the residents said their work schedules were worse after the change and about 22 percent said they were getting less rest despite the limits on work hours.

Some recent studies have suggested, for example, that the new rules create more hand-offs of patient care, and possibly more errors, while shortchanging the doctors' education.

For the new study, Drolet and his colleagues surveyed residents from graduate programs across the U.S. at the end of 2011, six months after the regulations went into effect. Of the 4,140 residents sent the survey, about a quarter answered the 20 questions about patient care and residents' education and quality of life. More than half said that patient safety was unchanged six months after the regulations were put in place. About 40 percent said patient care got worse, however, and about 10 percent said it improved.

As for their own education, about 40 percent of residents said there was no decrease in quality, but another 55 percent said it had gotten worse. About 70 percent also said there was less focus on preparing them to take on a more senior role. The same proportion also felt senior residents had to take on tasks more suited for a less-experienced resident.

About half of the residents said their work schedules were worse after the change and about 22 percent said they were getting less rest despite the limits on work hours.

Overall, there was some improvement in the quality of life of first-year interns, but a much smaller improvement among more senior residents, according to the researchers who published their findings in JAMA Surgery.

The most striking of the results, according to Drolet, is that almost 70 percent of the residents said they were not following the new requirement in some way. About half of the residents said they were underreporting or working between one and five hours more than they should each week, and more than 60 percent said they were falsifying their duty hours "to appear in compliance with regulations."

In a critique accompanying the new study, Dr. Orlando Kirton said the findings on underreporting and falsifying duty hours represent "extremely troubling behavior." "The ACGME rules are the law of the land. It is no longer about adoption but about adaptation and demonstrating resolve. Non-compliance is not an option and must not be encouraged," Kirton writes.

He points out, however, that the study had some limitations, including that only a fraction of the hospitals asked to participate in the survey did so.

But Dr. Sanjay Desai, director of the residency program at The Johns Hopkins Hospital in Baltimore, told Reuters Health he believes the researchers would find similar results if they did the study today. "It takes time for programs to adapt to the new rules," said Desai, who was not involved in the new study. "This just adds to the body of data that I think creates this need to look at this very carefully, partner with everybody concerned to get to the table and look at this more rigorously," he added.