Residents are an essential part of Canada’s 24/7 health system. They are in a unique position, serving as both care givers and physicians-in-training, and they have traditionally worked very long hours. This has led to tremendous national and international debate regarding the regulation of resident work hours. The European Union now limits residents to 52.5 duty hours per week for all member states, while the United States Accreditation Council for Graduate Medical Education (ACGME) has set maximums of approximately 80 hours worked per week. There has been no such unified approach in Canada.
How should we respond? Would a similar “one size fits all” approach to duty hours work for Canada?
Our conclusion — and that of the National Steering Committee on Resident Duty Hours, which just released its pan-Canadian consensus report — is that Canada is best served by adopting national principles and guidelines that can be tailored to produce practical, local solutions to optimize patient care and medical education for the 21st century.
Our health care system is quite unique worldwide. Where in the United States and European Union central authorities and agreements exist to regulate all post-graduate training, in Canada there is no single body with the ability to implement national standards. Regulations are governed by collective agreements negotiated between the hospital or provincial government and the provincial housestaff organizations (PHOs) representing residents. No legislation exists at the federal or provincial level to govern resident duty hours.
Creating a single national standard becomes even more difficult when you consider the wide divergence in resident training needs across disciplines, training sites and stages of training. The on-call roles of Family Medicine residents in a rural region may be very different from those of Cardiology residents in an urban setting, to give but two examples.
Patient care in an extremely acute or surgical care setting presents additional challenges for both education and service delivery. For example, many procedural disciplines require exposure to unusual, infrequent and emergency surgical procedures – ensuring adequate exposure may require some flexibility in scheduling. Optimizing resident training and patient care requires consideration of a many factors unique to each rotation — something that can be better accomplished through tailored solutions.
Meeting the training needs of all residents and the needs of all patients is an extremely difficult task. Factor in the complexity of Canada’s health system and, to date, there is no single “one size fits all” standard that can easily meet the needs of Canadian patients and resident physicians. The recent 16-hour maximum in Quebec has not yet been fully implemented. Evidence is only just emerging, making it far too early to assess all the challenges and benefits. The weekly work limits set by the EU? These have struggled with variability and low levels of compliance. The ACGME standards introduced in 2003 have been criticized for lack of enforcement and evidence to show they had any of the intended impacts. Notably, new standards issued in 2011 allow for more tailored resident duty hours depending on the residents’ level of experience, although it is too soon to evaluate their effectiveness.
There are, of course, valid arguments that have led the ACGME, EU and others to adopt national standards. We are not arguing against change. Rather, that Canada embrace common goals that enable tailored solutions. Australia, for example, has followed a similar approach. The country’s guidelines specifying maximum work hours are not binding. Instead, the Australian Medical Association has promoted a fatigue management plan that encourages avoiding frequent shift changes; when shift changes are needed, going in clockwise rotation (day to evening to night shifts); and minimizing consecutive nights on duty. Each jurisdiction is then able to implement these guidelines and principles in ways that best meet the needs of its residents and patients.
We believe that no “one size fits all” approach exists for Canada and that the new report, Fatigue, Risk and Excellence, offers our best path forward. The status quo on duty hours in Canada is not acceptable and shifts of 24 hours or longer without restorative sleep should be avoided. But successful efforts to improve patient safety and resident fatigue will need to be comprehensive, involving more than the regulation of resident duty hours alone. All provinces and health care institutions should develop comprehensive strategies to mitigate fatigue and fatigue-related risks during residency. Changes to accreditation standards, increased simulation use and new pilot projects to test innovative schedules are also needed.
Naturally, this approach comes with risks. It places the impetus on local residency programs and provincial health jurisdictions, leaving the door open for variability across Canada and potential non-compliance if careful planning is not undertaken. But evidence in the United States and elsewhere reveals these risks also exist when a single, binding national standard is implemented. What’s more, universities and health centres across Canada are already discussing and piloting new approaches. Eschewing a “one size fits all” standard may even encourage participation and innovation precisely because it allows flexibility.
We must find progressive solutions to ensure that physicians are available when Canadians need them, while also ensuring that our system continues to train highly-qualified and healthy physicians. There is no silver bullet or magic number to automatically solve this challenge. But by allowing flexibility and tailored solutions, we recognize the unique organization of Canadian health care, enable new approaches and minimize the chance of unintended consequences to patients. It’s a pivotal first step towards effective, lasting and positive change.
The final report, Fatigue, Risk and Excellence: Towards a Pan-Canadian Consensus is now available at www.residentdutyhours.ca.
The comments section is closed.
The document is outstanding. A few observations if I may:
The implication is that risks are to be avoided . I know you do not mean it that way , but that is how it may/ will be interpreted. Risks can be mitigated but not avoided. Risk is inherent to life and rewards are directly related to risk. If we make residency ” risk free” , it will be sanitized out of useful existence, in my view. I know this is not how you intended the message , in fact it is exceptionally evenhanded and bold in some ways ( I am very impressed in your ability to navigate the shoals of political correctness ) but I am concerned that many will take the document and discussions as being mostly about resident risk ( despite the appropriate disclaimers at the start of the document) . If in fact fatigue is not demonstrably related to worse outcomes, why is it so bad? Fatigue may be necessary to the development of resilience, efficiency , self reliance, altruism, sacrifice. Isn’t that why we became physicians?
I am very concerned about the emphasis on resident comfort which risks crowding out other values that are in my opinion more important.
Do we as a community think the current generation of physicians are defective in some way? Or their health is at risk? In fact MDs have much better health status as I understand it, better than expected from high income and social status alone, despite the fact that all of us trained in an era with much tougher duty hours and circumstances.
I also pity all program directors in the quest to establish ” fatigue mitigation” strategies. Inherently reasonable, but it will come at an expense and I fear the expense side of the ledger will not be viewed with sympathy by accreditors. Are the residents really as fragile as the zeitgeist assumes? If yes, we have I would think a much bigger problem than fatigue alone.
In sum, if I may, %featured%the road to hell is paved with good intentions. The content of the document and the discussions are salutary and necessary, but I fear may contribute to a general erosion of 18 th century ( 14 th century?) virtues : Self sacrifice, loyalty, selflessness, modesty…%featured%
I would be interested in pursuing these themes at any time. We have a responsibility it seems to me not to leave these worries dangling. I may be totally wrong of course.
Paul
Hi Paul,
Two thoughts on what you have said:
– I don’t think it’s entirely fair to say the report focuses on resident “comfort”. It focuses on resident “health”. To me there is a big difference. Sleep deprivation is linked to a number of mental and physical health conditions, which are well established by the evidence cited in the report – it’s worth reviewing. Also, there is the issue of personal safety, specifically the increased risk of motor vehicle accidents (and death) post-call. I worry describing these as resident “comfort” glosses over the evidence about the real negative impacts on resident health associated with fatigue. Perhaps there are other ways to address these, but they are more serious issues than you suggest.
– You are mistaken that MDs have much better health status than income and social status would indicate. It is in fact the opposite. This is especially true of mental health. International studies place the suicide rate of physicians at double to quadruple national rates (matched for socioeconomic status, gender, etc). Depression is also alarmingly common among physicians, especially during the training stages of their career. Physicians also appear to be at greater risk than the general population for prescription drug abuse. Divorce rates are also higher for physicians than the general population.
%featured%Somehow the myth that physicians are invulnerable has been perpetuated within the culture of medicine. Sadly, the evidence indicates otherwise.%featured%
What you say about physician mental health is probably true, Jeremy, but Paul’s point that physicians have good health status and better life expectancy than other professionals is also true.
See http://www.ncbi.nlm.nih.gov/pubmed/11020591 for example.
Fair enough – I should have limited my comments only to mental health and personal safety (the study you site shows higher physician mortality for both accidents and suicide). A pretty good (though old now) overview of some of the literature: http://www.medscape.com/viewarticle/410643
Thank you Paul for your thoughtful comments. I do believe that the balance between wellness and presence (in the clinical setting) is going to be difficult to determine. We have to acknowledge that residency is primarily a period of intense training and professionalization and that there will some fatigue associated with achieving these objectives, particularly if the end goal is excellence, and not simply competence. It is worth noting that fatigue does not magically disappear once residency is completed, as our obligations to our patients continue until we retire. There risks posed to resident health must be carefully measured and any changes in residency training structures, measured against these metrics. Shift work for example, is probably not better than extended shifts and shift work is recognized by the WHO as a Class 1 carcinogen. However thare are improvements that can and should be made. We must do a better job of protecting resident sleep at night. Interupptions related to non urgent issues should be curtailed. In addition, we must consider the “jobs” that residents do, and sift throught what tasks are medically necessary for our patients, and important for their learning and training, and minimize the rest. These additional service needs, contribute to their sense of fatigue. We will have to grapple with the risk of driving when fatigued – this could include interventions such as education, mandated naps in hospital before driving and taxis after extended periods of wakefulness. I am sure there are others. The mental health risks of fatigue and burnout should be acknowledged and residents should be better supported by interventions such as ready access to wellness professionals as a means to decrease these risks. This dialogue is an important one, and i think it is up to us to define the boundaries. One size does not fit all and fatigue in fact is part of life (parenthood, writing a thesis . . . ). We need to develop strategies that will help all of us develop resilience and identify when it might be better for the individual physician to take a break. All of these comments must be considerred in light of the facts that 1. Canada has long been recognized as training among the best physicans in the world and 2. true expertise comes only from experiential learning in a mentored environment.
happy to keep talking
I love your comment and share many of the same concerns.
However, I also realize that there has been quite a large yet gradual paradigm shift from medicine practiced in the Golden days to now.
Residency has devolved from the in-the-trenches hard-core training method of novice physicians to a cheap never-ending source of highly-educated hospital-based physicians. Such a transformation has made the resident less of a professional who hones his skills like an apprentice would, and more of an employee whose purpose is to keep the hospital in-budget. Who he serves is not the patient, but the hospital system. The mindset therefore changes from that of the professional to that of the employee.
Also of note is that the medical knowledge has exploded over the last few decades, making practice all the more challenging. Couple that with the ever-increasing risks of litigation and presence of preposterous external regulations, and what you have is a field that requires a sound, rested mind to perform safely and correctly.
Very little work has been done regarding how residents spend their time in hospitals, and how that could be made more efficient. I recall most of my time in residency was spent doing paperwork that nurses, ward clerks and social workers should have been doing.