Duty Hour Reform: Only a Small Piece of a Larger Problem—Reply

Abstract

We agree with Dr. Runyan that addressing inter-professional communication and handoff training are critical factors in achieving meaningful improvement in both the quality of care that residents provide and the quality of life that they enjoy. Evidence from multiple studies indicate that the most recent set of ACGME duty hour reforms, which focused almost exclusively on reducing maximum shift length, have not achieved the intended improvements in quality of care or quality of life (1–3). If this experience with interns is instructive, then extending work hour limits to all residents, without address the additional factors raised be Dr. Runyan, will likely be ineffective. In addition to communication training, an essential piece of the puzzle not addressed by existing duty hour reforms is work compression. House officers now spend fewer hours in the hospital but their clinical workload and educational requirements have not decreased proportionally, resulting in an even more frenetic pace of work — a phenomenon known as “work compression” (4). In 2000 a typical call day lasted 36 hours. This was specifically reduced for interns from 36 hours to 30 hours in 2004 and to 16 hours with the latest duty hour changes. As a result, current interns have fewer hours to complete their work and engage in learning and team building experiences. This leaves the new intern generation in a frustrating situation where they are often criticized or chided for having less work when, in many cases, they are simply given less time to complete it. If we know that timed tests result in more errors than untimed ones, we should not be surprised that giving interns less time to complete the same amount of work would adversely affect their patient care. Paradoxically, with the addition of new, often untested, educational curriculum in communication skills and systems of care to traditional clinical topics, interns are also being asked to learn more in less time. Collectively, these changes often result in reduced opportunities to double-check orders, follow a disease course, spend time at the patient’s bedside, teach students or share a meal with their team. Incorporating solutions that address the problems associated with work compression are needed to fully achieve the goals of residency duty hour reform.