Concerns over tired doctors leading to mistakes and patient injuries has led to progressively shorter hours for medical residents in the United States and Europe over the past 20 years. But a review in the British Medical Journal shows that reducing hours has not improved patient safety. An accompanying editorial by Yale researcherLeora Horwitz, M.D., explores some possible reasons why reduced hours have not benefited patients.
"Until now, regulatory agencies and local implementers have focused on hours worked to the exclusion of other concerns," said Horwitz, assistant professor of internal medicine at Yale School of Medicine. "But limiting hours has a number of downstream consequences in addition to reducing fatigue."
Horwitz said there are two possible explanations why fewer hours has not increased safety and reduced mistakes. The first is that to accommodate the rules, house staff are often asked to do the same amount of work in less time.
"A busier, rushed trainee may be more prone to errors, counterbalancing any benefits of a reduction in fatigue," said Horwitz. "Secondly, the decrease in hours worked has led to a substantial increase in discontinuity of care, handovers and transfers to other caregivers. Ample evidence shows that these handovers may result in errors and adverse patient outcomes. These too may counterbalance beneficial effects of reduced fatigue."
Authors on the study reviewed 72 published studies from the U.S. and UK and found that a reduction in working hours to less than 80 a week has had neutral effects on patient safety and has had a limited effect on postgraduate training in the United States.
The study authors say that higher quality studies are urgently needed to evaluate the impact of restricting working hours on objective measures of medical training and patient safety, particularly in the European Union.
In her editorial, Horwitz notes that no one has done a follow-up of trainees who have finished a program with limited working hours. "Without careful and continued attention to these matters, followed by adjustments to regulations and to practice as required, regulation of working hours is unlikely to have the beneficial effects for patients that regulators and the general public had hoped for," she said.