New recommendations for Canadian doctors-in-training focus on fatigue
After finishing medical school, new doctors go through several years of post-graduate, on-the-job training – known as residency – in order to become licensed to practice independently.
Historically, residency has involved very long hours spent in hospital, so that residents see a high volume of diverse cases as well as provide patient care.
As part of their training, residents provide a large amount over-night hospital care, known as “call”. It is not uncommon for residents “on call” to work through the night, with little or no sleep for 26 hours or longer.
However, since the 1984 death of Libby Zion in a New York hospital, there has been growing concern that the long hours worked by residents – especially overnight – may pose risks for patients as well as the residents themselves.
Zion died from a medical error that was attributed in part to overwork and exhaustion on the part of the residents who treated her. Her case sparked a re-evaluation of residency training in the United States, and ultimately led to a limit on the hours that can be worked continuously by residents there to 24 per shift and 80 per week.
In Canada, limits on resident duty hours are established by labour agreements negotiated between residents’ professional associations and provincial governments, health authorities or hospitals. In most provinces, there is a limit of 24 hours for a single call shift and no more than seven call shifts every 28 days. The exception is Quebec, where call shifts are limited to 16 hours following an arbitration decision in 2011.
Today, after more than a year of study and deliberation, Canada’s National Steering Committee on Resident Duty Hours released its recommendations for a pan-Canadian approach to resident duty hour reform.
As part of its work, the National Steering Committee reviewed existing evidence of the effect of resident duty hours on patient safety, resident health and quality of resident education. It concluded that the status quo in most of Canada of 24 or more hours without restorative sleep should be avoided and that new accreditation standards for Canadian training programs should be put in place to ensure they develop and implement fatigue management plans for their residents.
Restricting resident duty hours has had little impact on patient safety
Patient safety is at the heart of concern over resident duty hours. Yet the evidence about the effect of restricting resident on patient safety reveals a “paradox”, says Kevin Imrie, co-chair of the National Steering Committee.
“We know from the sleep science literature that sleep deprivation leads to fatigue, and that fatigue impacts on performance. There’s really no question about that,” he explains. “When we take it one step further and ask ‘what’s the evidence fatigue leads to errors’ – the evidence is a little weaker. There’s some, but it’s not so conclusive. But when you take a further step and ask ‘does fatigue lead to errors that affect patient care’ – when you look at overall patient outcomes – there isn’t any evidence of impact,” he says.
The Steering Committee reviewed studies from every country that had restricted the hours residents worked, yet could find no clear evidence that patient safety had improved in these countries. “There were even small signals that in some areas – particularly surgery – things may have gotten worse,” says Imrie.
Why is this? Imrie says the exact reason for the lack of improvement is not known, but there are several theories.
One of these is that in many countries with limits on resident duty hours, the duty hour restrictions are quite modest. In these jurisdictions, residents could still be working very long hours, so the restrictions may not have been large enough. In addition, even in countries with meaningful restrictions, compliance rates are not always high.
But Imrie believes the cause lies elsewhere. “Long hours and fatigue are only one cause of errors. If you just restrict duty hours, you can create unintended consequences – particularly increased handovers,” he says. (Handovers are when care is transferred between residents at the end of a shift.)
“Handovers involve one of the greatest risks of error in health care,” explains Imrie, “a lot of important information can get lost as care is transferred.” If resident call shifts are shortened so that the number of handovers is increased, any benefits to patient safety from reduced fatigue may be offset by increased errors resulting from more handovers.
These findings led the Steering Committee to look beyond just duty hours, to consider the broader impact of fatigue – and the strategies used to manage it – on the safety of both patients and residents.
Traditional duty hours present risks to the physical, mental and occupational health of residents
Where the evidence is much clearer is on the impact of traditional duty hour models on the health and safety of residents, according to the Steering Committee’s report.
But perhaps most alarming is the risk to personal safety posed by extended work hours. Evidence indicates that residents who work longer hours experience much greater risk of being in a motor vehicle accident. Residents who have worked extended hours are also at higher risk of needle stick injuries, which can expose them to blood-borne diseases such as HIV and Hepatitis.
These risks to the health and well-being of residents have begun to be recognized outside of the medical profession. In Quebec, they were cited by the arbitrator in the decision that call shifts should be limited to no more than 16 hours, explains Caroline Lacroix, President of Fédération médecins résidents Québec, which represents Quebec’s medical residents. Lacroix notes that the effects on resident health and safety were deemed by the arbitrator to “violate both the Canadian Charter of Rights and Freedoms and Quebec’s Charte des droits et libertés de la personne.”
A fine balance: maintaining high quality medical education while reducing hours
The other essential dimension of reforming resident duty hours is the potential effect on the quality of medical education. “We have to look both at the safety of the patients these residents are caring for now, as well as the safety of the patients they will be caring for in the future. We have to make sure we’re training the most skilled physicians that we can,” says Imrie.
One of the chief reasons residents work such long hours is for them to gain experience by seeing a many diverse cases. Reducing the number hours worked by residents runs the risk of producing less experienced doctors, who may not be ready for independent practice at the end of residency.
These concerns are particularly strong in surgery and other procedural specialties. This is because procedural specialties involve mastering mechanical skills. “People often quote the 10,000 hour rule,” says Najma Ahmed, a Toronto trauma surgeon who sat on the National Steering Committee. “It takes roughly 10,000 hours to master any mechanical skill. Whatever approach is taken to manage resident fatigue needs to take this into account,” she says.
This leads some to worry that restricting duty hours could lead to longer residencies.
“That would be unacceptable,” says Richard Reznick, Dean of Medicine at QueensUniversity, “adding another year of residency would be criminal.”
These concerns are not without basis. In Europe, where resident hours are restricted to 14 hour shifts and no more than 48 hours per week, training is significantly longer than in Canada. “In Canada, most residencies are no more than five years,” says Imrie, “in Europe, medical graduates do a two year internship before even beginning residency, which tend to be five to seven years and may go on longer.”
Instead of adding to the length of residencies or bemoaning reductions in resident duty hours, Reznick believes that educators need to “stop whining” and “get on with the job of optimizing the time we’re given with our trainees.” He thinks this could be accomplished in part by teaching residents procedural skills much earlier in residency.
A line in the sand: the status quo of 24 or more consecutive hours without restorative sleep should be avoided
“We spent a lot of time debating whether there’s a ‘magic number’ that applies in all specialties,” says Imrie, “but it’s not ‘one size fits all’. However, we did agree that the current state in provinces other than Quebec – 24 hours without restorative sleep – is not ideal.”
“We’re very happy with the result,” says Mathieu Dufour, a psychiatry resident who represented the Canadian Association of Interns and Residents on the committee. “It’s very important that there’s a recognition that the current situation in most of Canada is not good for patients or residents,” he says.
This consensus represents a clear line in the sand, but it simultaneously gives educational programs a lot of flexibility. This is because it shifts the focus from restricting duty hours to managing fatigue. As a result, educational programs could in theory still have 24 hour call shifts, so long as they find a way to provide residents with restorative sleep during that period in order to effectively manage their fatigue.
“The flexibility is important for surgery and other procedural specialties,” says Ahmed. “There are a lot of approaches that we can use, such as strategic napping and more undisturbed periods of sleep while on call.”
Alternative call model already in place in Calgary
Some regions in Canada have already begun to experiment with alternative call schedules. The internal medicine service at the University of Calgary, for example, moved in 2011 to a “night float” system, similar to what is used throughout the United States.
Under the float system, residents on call work 12 hour night shifts (8pm to 8am), instead of traditional 24 hour shifts, explain Stacey Hall and Ryan Lenz, the residents who run the float system. Also, instead of having their call shifts spread out over a month, call shifts for junior residents are grouped into blocks of five days. In order to ensure residents don’t become fatigued, they get a pre-call day to sleep and get ready for their block of night shifts. “Typically I’m able to sleep-in the day before my float begins,” says Lenz, “and then have a big nap in the afternoon – it definitely helps me feel more alert once the call shift begins.”
“The system is currently under evaluation,” says Hall, “and we’re open to continuing to adjust it as we receive feedback.” Lenz notes for example that junior residents felt the five day block was a little too long, and so they are looking at the possibility of shortening the blocks by a day.
It will also be important to determine the effect of the new system on overall resident fatigue, since it involves shorter hours, but a higher workload. “We now have two residents covering what used to be covered by three residents,” says Hall. “The rationale is that two well-slept residents can do as much as three fatigued residents,” but she notes that the overall effect on resident fatigue of shorter hours versus increased workload under the new float system has not yet been fully evaluated.
Fatigue management to be incorporated into residency program accreditation standards
“What’s really important about the recommendations,” says Dufour, “is that they put the emphasis on fatigue and risk, rather than duty hours.”
Rather than cap hours, the primary recommendation from the National Steering Committee is that every residency training program in Canada be required to develop, implement and monitor its own comprehensive fatigue management strategy. These strategies must recognize that fatigue is multi-faceted, and thus must go beyond duty hours to consider workload, individual physiology and needs, supervision and support.
“These strategies need to teach our residents how to assess their fatigue and how it’s affecting their performance,” says Imrie, “they need to mitigate and manage fatigue whether it comes from long hours, workload or stress outside the workplace.” He adds that in order for this approach to be successful in improving patient safety as well as resident health, Canadian programs needs to learn from the experience of other countries, such as by training residents in improved handover protocols.
To give these recommendations teeth, the requirement to develop, implement and monitor fatigue management strategies is to be built into the accreditation standards of the three colleges that certify doctors: the Royal College of Physicians and Surgeons, the College of Family Physicians of Canada and Collège des médecins du Québec. Thus residency programs that fail to take resident fatigue seriously will risk losing their accreditation.
To support residency programs in developing fatigue management strategies, the Steering Committee also recommends that a pan-Canadian consortium be established as a means to evaluate and share the effectiveness of various strategies.
Beyond resident and patient safety there will be a number of important areas to evaluate, including the impact on education, cost, and other team members including the supervising physician.
A new era for Canadian medical education
While the National Steering Committee avoided recommending a ‘one size fits all’ approach for Canada, there is no doubt that the country’s residency programs are in for significant change in coming years.
Canada’s focus on fatigue from all sources, rather than just duty hours, is distinct from the approaches that have been taken to date in the United States and Europe. It remains to be seen whether this new approach will finally produce the gains in patient safety that have proved elusive in other jurisdictions.