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.