A well written article that addresses the impact of duty hour restrictions in residency. Hoping to have a review of the new article that is cited shortly.

3 thoughts on “

  1. Hey AP:
    Great blog – I couldn’t resist procrastinating a bit over this posting (after this, it’s back to studying neuro for the dreaded exam).

    Had a rabid debate about this article recently with a few other residents… Well written, but some problems with the content and maybe a bit over-reaching for the conclusions.

    Here is a synthesis to our discussion/critiques:
    An example of a retrospective survey study that probably doesn’t truly capture the essence or improvements…

    Point #1: Every group is going to map to their own norms (pre-/post- changes).
    Taking the literature around self-awareness/self-perception of physicians, a retrospective survey of residents would be the least methodoligcally sound way to investigate this problem. Historically, the big med ed researchers have found time and time again that residents are their own worst critics. Those that are good think they’re horrible (i.e. more likely to notice and report error) and those that are bad think they’re hot shit (i.e. will not notice or not report error).

    Point #2: Are people reporting everything? Are there unconscious biases?
    Beyond this the stigma of mental health is high in our profession – and the attitude of ‘suck it up’ prevents many of those with depression from self-identifying it.

    Point #3:
    To truly measure medical errors would require actually *accurately* measuring medical errors – something that we have not yet mastered – And this would need to be in a validated way – pre/post intervention. Self report is not sufficient…

    One might imagine that by increasing sleep and daytime work hours, residents are now:
    – less sleep deprived (can notice, realize, remember mistakes)
    – more supervised (less post-call = more day-time work hours with attendings watching them and pointing out mistakes).

    Both are plausible confounding variables.

    Point #4: The Hawthorn effect
    By creating a survey and then repeating the survey, have you already impacted a change in the culture around error reporting? In the three years between the pre- and the post-survey, what was the effect of the survey itself? By looking and having this big survey about error, have you introduced a bit wave of self-awareness? Can’t answer this without a controlled study (might have used Canada or something as the control cohort)

    In the time of introducing to the time of surveying, you had two groups of interns that became seniors/chiefs now more educated (possibly by the study survey itself) re: error/safety issues…. In the 3 years from start to finish, people were vastly more attuned to medical error – especially in the setting of work hours debate etc..

    I would posit that actually there are many confounding variables – specifically re: work hours and the cultural milleu around error that changed between 2009-2011…

    I’m not saying that duty reforms are correct or incorrect, beneficial or not … But this study raises but a hypothesis that duty hour reforms may not be beneficial – and that more prospective research is needed to discuss this? This study shouldn’t be taken as *proof positive* of the failure or detriment of work hours reform.

    PGY5 Emerg Med

    • Thanks very much for the well written post! Always great to have people commenting on the blog especially for such controversial issues as duty hour reform!

      I agree, this study probably doesn’t answer the question about error. I think the numbers regarding sleep are interesting as are the numbers of hours worked. I buy the data…seems reasonable. Interesting that there was only a decrease in 3 hours post-duty hour reform. From the data, it’s difficult to know exactly what the effect on work hours as the standard deviation from the mean increased post-duty hour reform. Its not surprising there was no change in sleep hours because work isn’t the only thing that might prevent residents from sleeping. Maybe less work means they party more?

      As you’ve mentioned the self-reported errors is very challenging to interpret. I’m not sure I buy that there was much Hawthorne effect from the study itself though I will acknowledge that perhaps reporting changed simply to due general awareness as duty hours became a popular topic of conversation and in the media.

      It is interesting that interns are now reporting more errors. This fact, regardless of whether duty hour reform had occurred raises interesting questions about the possible change in culture of error within medicine. Are we more aware of errors? Have systems been implemented to make us aware or maybe we’re just more open to talking about error. It does remain a hypothesis generating study rather than a hypothesis proving study. Though the authors do argue strongly in favor of their conclusions by trying to prove through the limitations section how little these issues impacted the data (I don’t buy it).

  2. Pingback: Residency Workload | medaholic

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