The 2017 ACGME Common Work Hour Standards: Promoting Physician Learning and Professional Development in a Safe, Humane Environment

Sleep, Well-Being, and Cognition in Medical Interns on a Float or Overnight Call Schedule

Importance

Extended work hours and night shifts are essential in health care, but negatively affect physician sleep, well-being, and patient care. Alternative schedules with shorter work hours and/or reduced irregularity might mitigate these issues.

Objective

To compare sleep, well-being, and cognition between interns working irregular, extended shifts (call schedule), and those working a more regular schedule with restricted hours (float schedule).

Design, Setting, and Participants

In this observational longitudinal cohort study, interns in a Singapore-based teaching hospital were studied for 8 weeks from January 2022 to July 2023. Data were analyzed from July 2023 to July 2024.

Exposure

Participants worked either regular approximately 10-hour workdays, interspersed with 24 hour or more overnight calls 4 to 5 times a month, or a float schedule, which included regular approximately 10-hour workdays, and 5 to 7 consecutive approximately 12-hour night shifts every 2 months. Exposure was based on departmental training and operational needs.

Main Outcomes and Measures

Sleep was measured with wearable sleep trackers and an electronic diary. Day-to-day well-being and cognitive assessments were collected through a smartphone application. Assessments included the Sleep Regularity Index (SRI; determines the probability of an individual being in the same state [sleep or wake] at any 2 time points 24 hours apart, with 0 indicating highly random sleep patterns and 100 denoting perfect regularity) and Pittsburgh Sleep Quality Inventory (PSQI; scores ranges from 0 to 21, with higher scores indicating poorer sleep; a score greater than 5 suggests significant sleep difficulties).

Results

Participants (mean [SD] age, 24.7 [1.1] years; 57 female participants [59.4%]; 41 on call schedule [42.7%]; 55 on float schedule [57.3%]) provided 4808 nights of sleep (84.2%) and 3390 days (59.3%) of well-being and cognition assessments. Participants on a float schedule had higher SRI scores (mean [SD] score, 69.4 [6.16]) and had better quality sleep (PSQI mean [SD] score, 5.4 [2.3]), than participants on call schedules (SRI mean [SD] score, 56.1 [11.3]; t91 = 6.81; mean difference, 13.3; 95% CI, 9.40 to 17.22; P < .001; PSQI mean [SD] score, 6.5 [2.3]; t79 = 2.16; 95% CI, 0.09 to 2.15; P = .03). Overnight call shifts, but not night float shifts, were associated with poorer mood (-13%; β = -6.79; 95% CI, -9.32 to -4.27; P < .001), motivation (-21%; β = -10.09; 95% CI, -12.55 to -7.63; P < .001), and sleepiness ratings (29%; β = 15.96; 95% CI, 13.01 to 18.90; P < .001) and impaired vigilance (21 ms slower; β = 20.68; 95% CI, 15.89 to 25.47; P < .001) compared with regular day shifts. Night shifts with naps were associated with better vigilance (16 ms faster; β = -15.72; 95% CI, -28.27 to -3.17; P = .01) than nights without naps.

Conclusions and relevance

In this cohort study, 24-hour call schedules were associated with poorer sleep, well-being, and cognition outcomes than float schedules. Naps during night shifts benefited vigilance in both schedules.

Impact of Burnout on Anaesthesiologists

Professional burnout syndrome (PBS) is an issue affecting individuals and organizations alike, characterized by emotional exhaustion and reduced effectiveness resulting from overwhelming work demands. Root causes include excessive workload, unrealistic expectations, and blurred work-life boundaries, which are often intensified by organizational culture and inadequate support systems. The consequences range from decreased productivity and creativity to high turnover rates and financial strain on organizations. Mitigating PBS requires a comprehensive approach that addresses both individual and organizational levels. Individually, stress management techniques and self-care practices are crucial for building resilience and coping with work-related stressors. Organizations play a vital role in promoting employee well-being by fostering a supportive work environment, promoting work-life balance and providing access to support systems such as counseling and mentorship programs. Leadership is key in creating a culture that values employee health and prioritizes open communication and empathy. Policy interventions can further support efforts to combat PBS by enforcing labor laws that protect employee rights, such as setting limits on working hours and ensuring access to mental health services. Additionally, incentivise organizations to prioritize employee well-being through tax incentives or certification programs can encourage proactive measures against burnout. The aim of this review is to provide a comprehensive exploration of PBS, examining its causes, consequences, and potential mitigation strategies in individuals and organizations, with a focus on anaesthesiology.

Hip Fracture Repair by the Post-Call Surgeon: A Multicenter Retrospective Review

INTRODUCTION

The purpose of this study was to evaluate surgeons' ability to perform or supervise a standard operation with agreed-upon radiologic parameters after being on call.

METHODS

We reviewed a consecutive series of patients with intertrochanteric hip fractures treated with a fixed angle device at 9 centers and compared corrected tip-apex distance and reduction quality for post-call surgeons versus those who were not. Subgroup analyses included surgeons who operated the night before versus not and attending-only versus resident involved cases. Secondary outcomes included union and perioperative complications.

RESULTS

One thousand seven hundred fourteen patients were of average age 77 years. Post-call surgeons treated 823 patients and control surgeons treated 891. Surgical corrected tip-apex distance did not differ between groups: on-call 18 mm versus control 18 mm (P = 0.59). The Garden indices were 160° on the AP and 179° on the lateral in both groups. In 66 cases performed by surgeons who operated the night before, the TAD was 17 mm. No difference was noted in corrected tip-apex distance with and without resident involvement (P = 0.101). No difference was observed in pooled fracture-related complications (P = 0.23).

CONCLUSION

Post-call surgeons demonstrated no difference in quality and no increase in complications when performing hip fracture repair the next day compared with surgeons who were not on call.

The effects of resident work hours on well-being, performance, and education: A review from a Japanese perspective

This article examines the impact of working-hour restrictions on the well-being, performance, and education of medical residents in Japan. Despite Japan's plan to introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the 80-hour-per-week regulation in the United States and the 48-h-per-week regulation in the European Union influencing other regions. The article also discusses the effectiveness of working-hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety and resident education are mixed, and further reduction in working hours must be carefully considered to avoid adverse effects. The planned changes to working-hour limits for residents in Japan offer a unique opportunity to gain new evidence on the impact of such regulations, which will be of interest to policymakers and researchers worldwide.

Work like a Doc: A comparison of regulations on residents' working hours in 14 high-income countries

BACKGROUND

Medical residents work long, continuous hours. Working in conditions of extreme fatigue has adverse effects on the quality and safety of care, and on residents' quality of life. Many countries have attempted to regulate residents' work hours.

OBJECTIVES

We aimed to review residents' work hours regulations in different countries with an emphasis on night shifts.

METHODS

Standardized qualitative data on residents' working hours were collected with the assistance of experts from 14 high-income countries through a questionnaire. An international comparative analysis was performed.

RESULTS

All countries reviewed limit the weekly working hours; North-American countries limit to 60-80 h, European countries limit to 48 h. In most countries, residents work 24 or 26 consecutive hours, but the number of long overnight shifts varies, ranging from two to ten. Many European countries face difficulties in complying with the weekly hour limit and allow opt-out contracts to exceed it.

CONCLUSIONS

In the countries analyzed, residents still work long hours. Attempts to limit the shift length or the weekly working hours resulted in modest improvements in residents' quality of life with mixed effects on quality of care and residents' education.

Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector

BACKGROUND

The services of Healthcare and Social Assistance (HCSA) workers are needed by society around the clock. As a result, these workers are exposed to shift work and long work hours. The combination of demanding work schedules and other hazards in the HCSA work environment increases the health and safety risks to these workers, as well as to their patients/clients and the public.

METHODS

This paper has three aims: (1) provide an overview of the burden of shift work, long hours, and related sleep and fatigue problems in this sector; (2) suggest research priorities that would improve these; and (3) discuss potential positive impacts of addressing these research priorities for the health and safety of workers and the public. The authors used a modified Delphi approach to anonymously rank-order priorities for improving HCSA worker health and safety and public safety. Input was also obtained from attendees at the 2019 National Institute for Occupational Safety and Health (NIOSH) Work Hours, Sleep, and Fatigue Forum.

RESULTS

The highest rated research priorities were developing better designs for work schedules, and improving the HCSA culture and leadership approaches to shift work and long work hours. Additional priorities are identified.

CONCLUSION

Research in these priority areas has the potential to benefit HCSA workers as well as their patients/clients, employers, and society.

[Safer anesthesia and duty hour limits: are handovers of personnel allowed?]

Restrictions of duty hours in medicine are an ambivalent matter with respect to patient safety. Continuity of treatment carries the risk of medical errors from declining performance capability and must be balanced against the risk of communication failure and information loss due to personnel changes. Complete intraoperative changes of anesthetists are frequently carried out in the clinical routine but possibly have the potential to negatively influence the postoperative morbidity and mortality. The relevance of anesthesiological care for the perioperative outcome also seems to vary depending on the specialist discipline involved. While standardized handover protocols seem to be only of limited effectiveness for the improvement of transfer of information, they are nevertheless a reasonable approach for optimization of interprofessional communication and reduction of treatment errors.

Sleepy Psychotherapists: How Clinicians' Biological Factors May Affect the Conduct of Psychotherapy

OBJECTIVE

Numerous therapist variables and cognitive biases can affect the quality of the therapeutic alliance and the conduct and outcomes of psychotherapy. This article aims to examine factors that potentially affect clinician performance, including chronobiological variables of clinicians and patients.

METHODS

The author reviewed literature pertaining to biological influences on human cognitive performance and considered how these factors may apply to the practice of psychotherapy.

RESULTS

Biological factors potentially affecting the conduct and quality of psychotherapy were identified. These factors include decision fatigue, hunger, sleep deficit, shift work, and several chronobiological issues related to circadian rhythms and episodic ultradian rhythms. In addition, misaligned scheduling of psychotherapy sessions in relation to therapist and patient evening-morning chronotypes may impede the effectiveness of psychotherapy.

CONCLUSIONS

The practice of psychotherapy is cognitively demanding, requiring that clinicians remain constantly alert and in command of their executive functions. Decreases in clinician alertness resulting from homeostatic depletion, chronobiologically misaligned schedules, and illness-associated factors may reduce the quality and benefit of psychotherapy sessions. Mitigation strategies are available. Investigations of these factors are needed.

Hilaire MA, O’Brien CS, Stone KL, Phillips AJ, Klerman EB, Qadri S, Wright KP, Halbower AC, Segar JL, McGuire JK, Vitiello MV, de la Iglesia HO, Poynter SE, Yu PL, Sanderson AL, Zee PC, Landrigan CP, Czeisler CA, Lockley SW. Extended Work Shifts and Neurobehavioral Performance in Resident-Physicians

OBJECTIVES

Extended-duration work rosters (EDWRs) with shifts of 24+ hours impair performance compared with rapid cycling work rosters (RCWRs) that limit shifts to 16 hours in postgraduate year (PGY) 1 resident-physicians. We examined the impact of a RCWR on PGY 2 and PGY 3 resident-physicians.

METHODS

Data from 294 resident-physicians were analyzed from a multicenter clinical trial of 6 US PICUs. Resident-physicians worked 4-week EDWRs with shifts of 24+ hours every third or fourth shift, or an RCWR in which most shifts were ≤16 consecutive hours. Participants completed a daily sleep and work log and the 10-minute Psychomotor Vigilance Task and Karolinska Sleepiness Scale 2 to 5 times per shift approximately once per week as operational demands allowed.

RESULTS

Overall, the mean (± SE) number of attentional failures was significantly higher (P =.01) on the EDWR (6.8 ± 1.0) compared with RCWR (2.9 ± 0.7). Reaction time and subjective alertness were also significantly higher, by ∼18% and ∼9%, respectively (both P <.0001). These differences were sustained across the 4-week rotation. Moreover, attentional failures were associated with resident-physician-related serious medical errors (SMEs) (P =.04). Although a higher rate of SMEs was observed under the RCWR, after adjusting for workload, RCWR had a protective effect on the rate of SMEs (rate ratio 0.48 [95% confidence interval: 0.30-0.77]).

CONCLUSIONS

Performance impairment due to EDWR is improved by limiting shift duration. These data and their correlation with SME rates highlight the impairment of neurobehavioral performance due to extended-duration shifts and have important implications for patient safety.

Sleep-deprived residents and rapid picture naming performance using the Mobile Universal Lexicon Evaluation System (MULES) test

Objective

The Mobile Universal Lexicon Evaluation System (MULES) is a rapid picture naming task that captures extensive brain networks involving neurocognitive, afferent/efferent visual, and language pathways. Many of the factors captured by MULES may be abnormal in sleep-deprived residents. This study investigates the effect of sleep deprivation in post-call residents on MULES performance.

Methods

MULES, consisting of 54 color photographs, was administered to a cohort of neurology residents taking 24-hour in-hospital call (n = 18) and a group of similar-aged controls not taking call (n = 18). Differences in times between baseline and follow-up MULES scores were compared between the two groups.

Results

MULES time change in call residents was significantly worse (slower) from baseline (mean 1.2 s slower) compared to non-call controls (mean 11.2 s faster) (P < 0.001, Wilcoxon rank sum test). The change in MULES time from baseline was significantly correlated to the change in subjective level of sleepiness for call residents and to the amount of sleep obtained in the 24 h prior to follow-up testing for the entire cohort. For call residents, the duration of sleep obtained during call did not significantly correlate with change in MULES scores. There was no significant correlation between MULES change and sleep quality questionnaire score for the entire cohort.

Conclusion

The MULES is a novel test for effects of sleep deprivation on neurocognition and vision pathways. Sleep deprivation significantly worsens MULES performance. Subjective sleepiness may also affect MULES performance. MULES may serve as a useful performance assessment tool for sleep deprivation in residents.

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MULES is a rapid picture naming test that captures extensive brain networks.

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MULES performance is impaired in sleep deprived residents.

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Subjective sleepiness may also affect MULES performance.

•

MULES may serve as an assessment tool for sleep deprivation in residents.

Does Increased Schedule Flexibility Lead to Change? A National Survey of Program Directors on 2017 Work Hours Requirements

BACKGROUND

The learning and working environment for resident physicians shifted dramatically over the past two decades, with increased focus on work hours, resident wellness, and patient safety. Following two multi-center randomized trials comparing 16-h work limits for PGY-1 trainees to more flexible rules, the ACGME implemented new flexible work hours standards in 2017.

OBJECTIVE

We sought to determine program directors' (PDs) support for the work hour changes and programmatic response.

DESIGN

In 2017, US Internal Medicine PDs were surveyed about their degree of support for extension of PGY-1 work hour limits, whether they adopted the new maximum continuous work hours permitted, and reasons for their decisions.

KEY RESULTS

The response rate was 70% (266/379). Fifty-seven percent of PDs (n = 151) somewhat/strongly support the new work hour rules for PGY-1 residents, while only 25% of programs (N = 66) introduced work periods greater than 16-h on any rotation. Higher rates of adopting change were seen in PDs who strongly/somewhat supported the change (56/151 [37%], P < 0.001), had tenure of 6+ years (33/93 [35%], P = 0.005), were of non-general internal medicine subspecialty (30/80 [38%], P = 0.003), at university-based programs (35/101 [35%], P = 0.009), and with increasing number of approved positions (< 38, 10/63 [16%]; 38-58, 13/69 [19%]; 59-100, 15/64 [23%]; > 100, 28/68 [41%], P = 0.005). Areas with the greatest influence for PDs not extending work hours were the 16-h rule working well (56%) and risk to PGY1 well-being (47%).

CONCLUSIONS

Although the majority of PDs support the ACGME 2017 work hours rules, only 25% of programs made immediate changes to extend hours. These data reveal that complex, often competing, forces influence PDs' decisions to change trainee schedules.

Is Patient Advocacy the Solution to Physician Burnout?

Physician burnout has been on the rise over the last several decades in a variety of specialties, leading to high rates of physician suicide and poor health outcomes for patients. As leaders in healthcare attempt to combat this issue through mental health initiatives and changes in medical training policies, we propose patient advocacy as a powerful technique to combat physician burnout and restore autonomy, purpose, and meaning into physicians' lives.

Reflections on Learning to Heal, Time to Heal, and Let Me Heal

In this Invited Commentary, the author reflects on the contributions, influence, and continued relevance of his 3 books on American medical education: Learning to Heal, Time to Heal, and Let Me Heal. Collectively, the books provide a panoramic view of U.S. medical education spanning 2 centuries, and they cover virtually every topic and consideration pertinent to the enterprise. They are works of education as well as works of history, and as such, they identify the timeless principles and values-maintaining rigorous academic standards and serving as a public trust-that need to be protected at all costs if medical education in the United States is to retain its tradition of excellence and leadership. Learning to Heal describes the creation and maturation of the U.S. system of medical education, focusing on its cultural as well as its scientific roots; the book also defined the educational meaning and significance of these changes. Time to Heal introduced the term "learning environment" into the lexicon of medical education; it also inspired a number of notable experiments in undergraduate and graduate medical education. Let Me Heal provided the intellectual foundation for the 2017 version of Section VI of the Common Program Requirements of the Accreditation Council for Graduate Medical Education. However, the most notable contribution of these books is their analysis of medical education's ongoing challenges and opportunities; thus, they provide a framework for improving medical education and health care delivery in the United States today.

Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing

OBJECTIVES

To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model.

DESIGN

Prospective observational study.

SETTING

Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing.

PATIENTS

Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012.

INTERVENTIONS

As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily.

MEASUREMENTS AND MAIN RESULTS

Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model.

CONCLUSIONS

Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.

Factors related to burnout in resident physicians in Japan

OBJECTIVES

We explore the prevalence and characteristics of burnout among Japanese resident physicians and identifies factors associated with burnout.

METHODS

A cross-sectional study was conducted three times between April 2017 and March 2018 at a Japanese teaching hospital. Resident physicians were invited to answer an online survey that included existing valid instruments related to burnout, depression, and empathy. Demographic, background, occupational, and socioeconomic data were also collected. Participants were prompted to report the average daily work hours and the specialty they wish to pursue.

RESULTS

Overall, 39/76 (51%), 27/76 (36%), and 21/76 (28%) resident physicians responded to surveys in April 2017, October 2017, and March 2018, respectively. The percentages of participants with burnout for surveys in April 2017, October 2017, and March 2018 were 7/39 (18%), 6/27 (22%), and 7/21 (33.3%). Emotional exhaustion (EE) was the only burnout component strongly correlated with the severity of depression (r = .615, p < .001; r = .706, p < .001; r = .601, p < .01). EE and depersonalization (DP) had no significant correlation with average daily working hours (β = .156, p = .343 for EE; β = .061, p = .711 for DP).

CONCLUSIONS

The results suggest that capping working hours alone may not be effective in reducing burnout in Japanese resident physicians. Medical educators might need to consider not only working hours but also individual job quality and satisfaction to address burnout. Future studies may need to incorporate qualitative methods to explore the characteristics of burnout.

Pathways to Independent Primary Care Clinical Practice: How Tall Is the Shortest Giant?

Patients can be treated by a physician, a nurse practitioner (NP), or a physician assistant (PA) despite marked differences in the education and training for these three professions. This natural experiment allows examination of a critical question: What is the minimum education and training required to practice primary care? In other words, how tall is the shortest giant? State licensing requirements, not educational bodies, legislate minimum training. The current minimum is 6 years, which includes 27.5 weeks of supervised clinical experience (SCE), for NPs. In comparison, PAs train for 6 years with 45 weeks of SCE, and physicians for at least 8 years with 110 weeks of SCE. Initial, flawed studies show equivalent patient outcomes among the professions. If rigorous follow-up studies confirm equivalence, the content and length of medical education for primary care physicians should be reconsidered. Unmatched medical school graduates, with 7 years of training and 65 weeks of SCE, more than the required minimum for NPs, deserve to practice independently. So do PAs. If equivalence is not confirmed, the minimum requirements for NPs and/or PAs should be raised, including considering a required residency (currently optional). Alternatively, the scope of practice for the three professions could be defined to reflect differences in training. There is an urgent need to set aside preconceived notions and turf battles, conduct rigorous independent studies, and generate meaningful data on practice patterns and patient outcomes. This should inform optimal training, scope of practice, and workforce development for each invaluable primary care clinical practitioner.

Measurement of resident fatigue using rapid number naming

OBJECTIVE

Sleep deprivation has a negative effect on neurocognitive performance. The King-Devick test (KDT), which tests speed and accuracy of number-reading, requires integrity of saccades, visual processing, and cognition. This study investigated effects of sleep deprivation in on-call residents using KDT.

METHODS

A prospective cohort study was conducted among 80 residents. KDT was performed at the beginning and end of an overnight call shift for the residents in the experimental group. A control group was tested at the beginning of 2 consecutive day shifts. Estimates of hours of sleep, Karolinska Sleepiness Scale (KSS)(1 = extremely alert, 9 = extremely sleepy), and time and accuracy of KDT were recorded.

RESULTS

42 residents were tested before and after overnight call shifts and 38 served as controls. Change in test time differed between the groups, with the experimental group performing 0.54(SD = 4.0) seconds slower after their night on call and the control group performing 2.32(SD = 3.0) seconds faster on the second day, p < 0.001. This difference was larger in surgical compared to medical residents.

CONCLUSIONS

Sleep deprivation was inversely correlated with neurocognitive performance as measured by KDT, with more effect on surgical than medical residents. Further research could investigate whether this test could help determine fatigue level and ability to continue working after a long shift.

Preventing incremental drift away from professionalism in graduate medical education

Professionalism is a core competency of graduate medical education programs, stipulated by the Accreditation Council for Graduate Medical Education. We identify an underappreciated challenge to professionalism in residency training, the risk of incremental drift from professionalism, and a preventive ethics response, which can occur in residency programs in countries with oversight similar to that of the Accreditation Council for Graduate Medical Education. Two major, welcome changes in graduate medical education-required duty hours and increased attending supervision-create incentives for drift from professionalism. This article analyzes these incentives based on the ethical concept of medicine as a profession, introduced into the history of medical ethics in late 18th century Britain. This concept calls for physicians to make 3 commitments: to scientific and clinical competence; to the protection and promotion of the patient's health-related interests; and to keeping individual and group self-interest systematically secondary. Some responses of programs and residents to these incentives can undermine professionalism, creating a subtle and therefore hard-to-detect drift away from professionalism that in its worst form results in infantilization of residents. Program directors and educators should prevent this drift from professionalism by implementing practices that promote professionally responsible responses to the incentives created by required duty hours and increased attending supervision.

A 3-Year Study of Resident Reaction to 2011 ACGME Work Hour Rules in a Family Medicine Residency

INTRODUCTION

2011 Accreditation Council for Graduate Medical Education (ACGME) work hour rules prompted concerns regarding potential negative impacts on patient care and resident education. We were interested in resident reaction to call restructuring and night oat (NF) in a family medicine residency over 3 years following implementation of the 2011 rules.

METHODS

We conducted structured interviews of residents from 2011-2012 through 2013-2014. Interviews were recorded, transcribed, and analyzed for themes.

RESULTS

Fifty-eight interviews were conducted, including 18/18 residents in 2011-2012 (100%), 18/20 residents in 2012-2013 (90%), and 22/22 residents in 2013-2014 (100%). Following introduction of the 24-hour work limit, upper year residents reported significantly less fatigue and improved personal lives, patient care, and educational experience. Reactions to NF varied with length and intensity of the NF rotation; most PGY-1 residents reported increased fatigue, more burnout, and worse personal lives on NF. Most residents felt patient care quality on NF did not differ from non-NF rotations because improved inpatient nighttime continuity mitigated effects of fatigue and increased care transitions. Reactions regarding educational experience on NF were initially negative, but improved over time.

CONCLUSIONS

Residents' reactions to 2011 ACGME work hour rules suggest the rules improved resident well-being, except on NF. Negative effects of NF may be minimized by limiting NF rotations to 5 nights/week for 2 consecutive weeks, and 1 month total per academic year.