Medical residents need more sleep

A new report from the Institute of Medicine proposes revisions to medical residents’ duty hours and workloads to decrease the chances of fatigue-related medical errors and to enhance the learning environment for these doctors in training. The report does not recommend further reducing residents’ work hours from the maximum average of 80 per week set by the Accreditation Council for Graduate Medical Education (ACGME) in 2003, but rather reduces the maximum number of hours that residents can work without time for sleep to 16, increases the number of days residents must have off, and restricts moonlighting during residents’ off-hours, among other changes.

Altering residents’ work hours alone, however, is not a silver bullet for ensuring patient safety, stressed the committee of medical and scientific experts that wrote the report. The committee also called for greater supervision of residents by experienced physicians, limits on patient caseloads based on residents’ levels of experience and specialty, and overlap in schedules during shift changes to reduce the chances for error during the handover of patients from one doctor to another.

Financial costs and an insufficient health care work force are the biggest barriers to further revising resident hours, the report notes. It calls for additional funding for teaching hospitals, estimating that the additional costs associated with shifting some work from current residents to other health care personnel or additional residents could be in the ballpark of $1.7 billion per year.

“Fatigue, spotty supervision, and excessive workloads all create conditions that can put patients’ safety at risk and undermine residents’ ability to learn,” said committee chair Michael M.E. Johns, chancellor, Emory University, Atlanta. “Health care facilties can create safer conditions within the existing 80-hour limit by providing residents regular opportunities for sleep and limiting extended periods of work without rest. But these steps should be supplemented by additional efforts to improve patient safety and ensure residents get the full experience they need to safely and competently practice medicine at the end of their training.”

Studies showing the detrimental effects of fatigue on human performance underlie the committee’s recommendations to reduce maximum shift lengths and to increase opportunities for residents to catch up on sleep. Because no single model of scheduling fits all training facilities or medical specialties, the committee offered two options for dealing with extended shifts. Residents either could work a maximum shift of 16 continuous hours or they could work a 30-hour shift provided that they get an uninterrupted five-hour break for sleep after working 16 hours. Sleep breaks during shifts should count toward the 80-hour limit. In addition, the committee recommended:

· There should be defined off-duty periods between shifts based on the timing and duration of shifts.

· The number of mandatory days off should increase.

· Medical moonlighting by residents during their off-hours should be restricted.

Violations of the current limits on duty hours occur frequently and are underreported, the committee found. ACGME’s monitoring of training hospitals’ compliance with the limits should be strengthened by having more frequent visits and making them unannounced.

Residency Review Committees need to establish standards of supervision for residents. The committee found that closer resident supervision leads to fewer errors, lower patient mortality, and improved quality of care. First-year residents, in particular, benefit from careful oversight and should not be on duty without immediate access to a supervisor on the premises, the report says.

Each medical specialty needs to set specific guidelines for the number of patients that residents in different years of post-graduate training should be permitted to treat during a shift, the report adds. Only the Internal Medicine Residency Review Committee has set such guidelines. They are necessary because heavy workloads and the compression of work into fewer hours contribute to safety risks for both patients and residents.

Health care facilities should schedule an overlap of residents’ schedules during shift changes to enable optimal transitions of patients’ care from one team to another, the report adds. Patient handovers have been identified as among the likeliest times for errors to occur, often because of poor communication among care providers.

A major concern stemming from the 2003 duty hour regulations is the effect they have had on the availability of staff to handle teaching hospitals’ caseloads and provide quality care while also providing residents with adequate supervision and training, as workloads have shifted among staffers or been compressed into shorter working hours. The committee acknowledged its recommendations will increase the number of residents, midlevel providers, and trained physicians needed to provide 24-hour coverage in training hospitals and clinics.

To implement the report’s recommendations, some of the work currently performed by residents would have to be done by others. The committee estimated that the cost for additional personnel to handle reduced resident work could be roughly $1.7 billion annually. This is less than half of 1 percent of what Medicare spends on care for older Americans annually. As another IOM report on medication errors noted, the extra medical costs of treating drug-related injuries occurring in hospitals conservatively amount to $3.5 billion a year.

The study was sponsored by the U.S. Agency for Healthcare Research and Quality. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.

Additional information on Resident Duty Hours: Enhancing Sleep, Supervision, and Safety can be found at http://www.iom.edu/residenthours. Copies of the report are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above). In addition, a podcast of the public briefing held to release this report is available at http://national-academies.org/podcast.

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[ This news release and report are available at http://national-academies.org ]


Board on Health Care Services

Committee on optimizing graduate medical trainee (resident) Hours
and work schedules to improve patient safety

Michael M.E. Johns, M.D. (chair)


Emory University


James P. Bagian, M.D.

Chief Patient Safety Officer and Director

VA National Center for Patient Safety

U.S. Department of Veterans Affairs

Ann Arbor, Mich.

Jayanta Bhattacharya, M.D., Ph.D.

Assistant Professor of Medicine

Center for Primary Care Outcomes Research

School of Medicine

Stanford University

Stanford, Calif.

Maureen Bisognano, M.S., R.N.

Executive Vice President and Chief Operating Officer

Institute for Healthcare Improvement

Cambridge, Mass.

Pascale Carayon, Ph.D.

Procter & Gamble Bascom Professor in Total Quality

Department of Industrial and Systems Engineering, and


Center for Quality and Productivity Improvement

University of Wisconsin


Jordan J. Cohen, M.D.

Professor of Medicine and Public Health

George Washington University

Washington, D.C.

David F. Dinges, Ph.D.

Professor and Chief

Division of Sleep and Chronobiology

Department of Psychiatry

School of Medicine

University of Pennsylvania


Javier A. Gonzalez del Ray, M.D., M.Ed.

Professor of Pediatrics and Director

Pediatric Residency Programs

Cincinnati Children’s Hospital Medical Center


Peter J. Kolesar, Ph.D.

Professor Emeritus and Research Director

Deming Center for Quality, Productivity, and Competitiveness

Columbia University

New York City

Brian W. Lindberg, M.A.

Executive Director

Consumer Coalition for Quality Health Care

Washington, D.C.

Kenneth Ludmerer, M.D., M.A.

Professor of Medicine and History

Washington University

St. Louis

Daniel Munoz, M.D., M.P.A.


Division of Cardiology

School of Medicine

Johns Hopkins University


Christopher Parshuram, M.B.Ch.B., D.Phil.


Center for Safety Research; and

Assistant Professor

Department of Critical Care Medicine

Hospital for Sick Children, and

Departmemts of Pediatrics, Health Policy Managementl, and Evaluation

University of Toronto


Ann E. Rogers, Ph.D.

Associate Professor

School of Nursing

University of Pennsylvania


Denise M. Rousseau, Ph.D.

H. J. Heinz II Professor of Organizational Behavior and Public Policy, and


Project of Evidence-Based Organizational Practices

Carnegie Mellon University


Eduardo Salas, Ph.D.

Pegasus Professor of Psychology and University Trustee Chair

Institute for Simulation and Training

University of Central Florida


Bruce Siegel, M.D., M.P.H.


Center for Health Care Quality

School of Public Health and Health Services

George Washington University

Washington, D.C.


Cheryl Ulmer, M.S.

Study Co-Director

Dianne Wolman, M.G.A.

Study Co-Director


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