National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies

Awakening Change-Embracing Disability in Medical Training

This essay describes the author’s experience as a medical trainee with narcolepsy with cataplexy, highlighting the toll of self-sacrifice and the need for a cultural shift in medicine to better support trainees with disabilities.

Public opinion of resident physician work hours in 2022

OBJECTIVE

The purpose of this study was to characterize public awareness and opinion regarding resident physician work hours in the United States.

METHODS

We conducted a nationally representative cross-sectional survey among adults in the United States. Demographic quota-based sampling was conducted by Qualtrics to match 2020 United States Census estimates of age, sex, race, and ethnicity. Descriptive statistics are presented. Hypothesis testing was conducted to identify characteristics associated with agreement with current resident physician work-hour policies.

RESULTS

4763 adults in the United States participated in the study. 97.1% of the public believes that resident physicians should not work 24-hour shifts and 95.6% believe the current 80 hours resident work week is too long. 66.4% of the participants reported that the maximum shift duration should be 12 consecutive hours or fewer, including 22.9% who recommended a maximum shift length of 8 hours. Similarly, 66.4% reported that maximum weekly work hours should be 59 or fewer, including 24.9% who recommended a maximum of 40 weekly work hours.

CONCLUSIONS

Nearly all US adults disagree with current work-hour policies for resident physicians. Public opinion supports limiting shifts to no more than 12 consecutive hours and weekly work to no more than 60 hours, which is in sharp contrast to current regulations that permit of 28 hours shifts and 80 hours of work per week.

The impact of home-based call on sleep patterns and wellness in genetics and metabolism physicians compared with subspecialists

Purpose

With increases in precision medicine initiatives and genetically defined rare diseases, the genetics and metabolism workforce is necessary to provide around-the-clock care for patients. Here, we describe the impact that home-based call has on the geneticist and metabolist workforce.

Methods

Physicians from 3 populations were self-identified (pediatric subspecialist, geneticist, metabolist) and completed a survey regarding the impact of home-based call service on their sleep and wellness.

Results

Estimated sleep while serving on home-based call was reduced from 7.5 to 5.4 hours per night. Safety concerns were noted by geneticists and metabolists for themselves (55%) and their families (28%), similar to other subspecialists. Geneticists and metabolists were more likely than other pediatric subspecialists to be worried about their patient's safety while on home-based call (48% vs 9%). Themes from open-ended questions regarding the impact of home-call included positive responses, decreased access to wellness activities, sleep exhaustion, impact on life responsibility, and impact on mood. Reported coping mechanisms included work-based initiatives, off-loading personal responsibility, and creating personal accommodations.

Conclusion

Institutional-based supports for home-based call were endorsed by only 29% of respondents; thus, interventions at the institutional level would be expected to have a large effect on overall provider wellness.

Fatigue and fallibility: the perils of prolonged shifts for neonatologists

Sleep deprivation is a major challenge for neonatologists, who face increasing demands in the complex healthcare system. Current neonatal intensive care unit (NICU) schedule models often include extended shifts and overnight call, which can lead to sleep deprivation. This lack of sufficient sleep poses adverse health risks to neonatologists and can impair cognitive function, which increases the risk of medical errors and compromises patient safety. This paper proposes reducing shift durations and implementing policies and interventions to reduce fatigue among neonatologists and improve patient safety. The paper also offers policymakers, healthcare leaders, and NICU physicians valuable insights on potential ways to promote the health of the neonatologist workforce and safety in the NICU.

Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study

Objective

To determine whether long weekly work hours and shifts of extended duration (≥24 hours) are associated with adverse patient and physician safety outcomes in more senior resident physicians (postgraduate year 2 and above; PGY2+).

Design

Nationwide, prospective cohort study.

Setting

United States, conducted over eight academic years (2002-07, 2014-17).

Participants

4826 PGY2+ resident physicians who completed 38 702 monthly web based reports of their work hours and patient and resident safety outcomes.

Main outcome measures

Patient safety outcomes included medical errors, preventable adverse events, and fatal preventable adverse events. Resident physician health and safety outcomes included motor vehicle crashes, near miss crashes, occupational exposures to potentially contaminated blood or other bodily fluids, percutaneous injuries, and attentional failures. Data were analysed with mixed effects regression models that accounted for dependence of repeated measures and controlled for potential confounders.

Results

Working more than 48 hours per week was associated with an increased risk of self-reported medical errors, preventable adverse events, and fatal preventable adverse events as well as near miss crashes, occupational exposures, percutaneous injuries, and attentional failures (all P<0.001). Working between 60 and 70 hours per week was associated with a more than twice the risk of a medical error (odds ratio 2.36, 95% confidence interval 2.01 to 2.78) and almost three times the risk of preventable adverse events (2.93, 2.04 to 4.23) and fatal preventable adverse events (2.75, 1.23 to 6.12). Working one or more shifts of extended duration in a month while averaging no more than 80 weekly work hours was associated with an 84% increased risk of medical errors (1.84, 1.66 to 2.03), a 51% increased risk of preventable adverse events (1.51, 1.20 to 1.90), and an 85% increased risk of fatal preventable adverse events (1.85, 1.05 to 3.26). Similarly, working one or more shifts of extended duration in a month while averaging no more than 80 weekly work hours also increased the risk of near miss crashes (1.47, 1.32 to 1.63) and occupational exposures (1.17, 1.02 to 1.33).

Conclusions

These results indicate that exceeding 48 weekly work hours or working shifts of extended duration endangers even experienced (ie, PGY2+) resident physicians and their patients. These data suggest that regulatory bodies in the US and elsewhere should consider lowering weekly work hour limits, as the European Union has done, and eliminating shifts of extended duration to protect the more than 150 000 physicians training in the US and their patients.

When policy meets reality: the new 18-hour on-call shift policy and the Israeli anesthesia workforce crisis

BACKGROUND

The Israeli physician workforce faces multiple challenges. These include planned policies reducing physician on-call from 26 to 18 h and, from 2026, allowing only graduates of Ministry of Health approved foreign medical schools to take the Israeli licensing examination and an ongoing physician shortage (2019: Israel had 3.19 physicians/1000 persons vs. OECD average of 3.49 physicians/1000 persons). This study examines the potential impact of these planned policies on the Israeli anesthesiology workforce.

METHODS

Surveys conducted among 34 public and private Israeli hospital anesthesiology department chairs collected data on their department's number of weekday on-call anesthesiologists and current shortage of anesthesiologists. A subsequent survey collected data on each anesthesiologist in the workforce, including the country where they studied medicine.

RESULTS

Each weekday night there were 114 on-call anesthesiologists; 72 residents and 42 attendings. Using productive work coefficients, this translates to 104 resident and 51 attending anesthesiologists. Furthermore, 21 departments had existing anesthesia workforce shortages totaling 110 anesthesiologists. There were 873 anesthesiologists from non-OECD countries whose medical schools are not accredited by the World Federation for Medical Education, of whom 332 were residents (61.9% of residents). Only 20.1% of anesthesiology residents were Israeli medical school graduates.

CONCLUSIONS

Descriptive survey data assessed the immediate and long-term consequences for the healthcare system and anesthesiology workforce of two new Health Ministry policies. Implementing the 18-h policy will immediately remove from the daytime workforce 155 anesthesiologists and who will be unavailable to staff elective surgery operating rooms. This will compound the current national shortage of 110 anesthesiologists. It is unclear how to replace this shortfall since there are no surplus Israeli physicians and very few Israeli graduates choose anesthesiology as a specialty. This situation will be exacerbated after 2026 when graduates of certain foreign medical schools will be unable to enter the medical workforce, further reducing the pool of potential anesthesiology residents. Both policies were promulgated without adequate operational and budgetary planning or fiscal or workforce resources; implementation of the 18-h on-call policy has already been postponed. Therefore, new or updated policies must be accompanied by specific operational plans, budgetary allocations and funds for additional workforce.

Effects of a Designated Note Writing Hour on Pediatric Intern Adherence to Duty Hours

Objectives

Interns spend an inordinate amount of the workday writing notes, leading to less time in direct patient care. Since the introduction of the 80-h workweek, it has been shown that interns spend 12% of the workday in direct patient care, compared to 40% at the computer. A dedicated note-writing hour was introduced into the pediatric intern shift to evaluate its effects on note writing behaviors. Within 1 year of implementation in July 2019, we aimed to establish that 80% of all pediatric intern notes were completed prior to the end of their shift.

Methods

Time stamps from EPIC electronic health record (EHR) database were reviewed for all notes written by pediatric interns during three periods of interest: prior to the implementation of the hour (Jan-May 2019), immediately after implementation (July-Nov 2019), and a year after (May-Aug 2020).

Results

Prior to implementation, 67.9% of notes were completed by sign out. In the period immediately following implementation, and at a year post implementation, percentages increased to 72.5% and 73.5%, respectively. The percentage of notes completed prior to the end of the protected hour improved from 34.0% to 49.5% and 53.7%, respectively. The percentage of notes completed in less than 1 h also increased from 13.9% to 50.6% and 24.9%, respectively.

Conclusion

These results indicate that a designated note writing hour for interns offer an effective intervention to improve note writing efficiency, however, the goal of 80% note completion by sign out was not met.

Current Situation and Demand for Continuing Medical Education (CME) for Obstetricians and Gynecologists

Objective

To explore the needs of obstetricians and gynecologists with different working years for the contents and forms of CME.

Methods

The online questionnaire was distributed on the largest academic training platform for obstetrics and gynecology in China from April 2020 to May 2020. The survey contents mainly included the training forms and training contents of CME, as well as the mastery of diseases by doctors with different working years.

Results

4458 questionnaires were returned, of which 3954 questionnaires were included in the study. There was a significant (p < 0.001) positive correlation between the mastery of 19 diseases by obstetricians and gynecologists with different working years. After adjusting for specialist departments, hospital grades, nature of units and ages, it was found that there was no statistically significant difference between the groups in gynecological endocrine-related diseases, such as precocious puberty/delayed puberty, and there was also no statistically significant difference between the groups of shorter working years in infertility, menopausal syndrome, hyperprolactinemia and premature ovarian failure.

Conclusion

The most popular training content for obstetricians and gynecologists with different working years is common gynecological endocrine diseases, of which abnormal uterine bleeding, menopausal syndrome, polycystic ovarian syndrome and cervical lesions are the most selected diseases, and the most popular form of training is online.