Shorter shifts don't help medical residents or patients

The notorious 24- or even 36-hour shifts that medical residents work in hospitals around the world have been widely criticized for leading to medical errors and poor patient outcomes.

This led to a slew of legislation limiting on-call hours.

But new research prepared by a trauma surgeon at St. Michael’s Hospital shows that shorter shifts don’t improve patient care and can actually worsen residents’ exam scores.

What seems a counterintuitive result makes sense when you think about residency as specialized training that involves thousands of hours of observation and requires people to be able to work when fatigued and under pressure, said the report’s author, Dr. Najma Ahmed.

“Residency is an immersive experience,” said Ahmed, a trauma surgeon at St. Mike’s and director of the residency program at the University of Toronto medical school.

“You just have to be around enough to have seen enough of everything, so that when you go into independent practice, you can draw on your experience.”

While conceding that fatigue is an issue, Ahmed says following a patient’s journey from admission with a symptom through analysis, treatment, surgery and recovery takes time.

“That can’t be done in an eight- or 10-hour shift,” she said.

Currently, medical residents across Canada have their shifts capped at 24 hours. But in 2011, a Quebec arbitrator limited on-call shifts to 16 hours, saying that a round-the-clock shift posed a danger to residents’ health and violated that province’s Charter of Rights.

In reaction to the ruling, a National Steering Committee on Resident Duty Hours was put together to study the issue, and determined that shifts of 24 hours or longer without sleep should be avoided. It urged all provinces and health-care institutions to develop strategies to minimize fatigue.

Now in Ontario, residents do 24-hour shifts only every third or fourth shift, and work for 10 or 12 hours during the shifts in between. More importantly, Ahmed said, residents must be allowed time to rest or sleep during their 24-hour shift, and strategies are being developed to make that sleep as effective as possible.

“We’re trying to figure out a way that it respects the circadian rhythms,” she said.

Ahmed’s research analyzed 135 articles on the impact of resident duty hours on clinical and educational outcomes in surgery, and determined that mortality did not drop when surgery residents worked shorter shifts. What’s more, residents who worked for less time fared worse on certification exams.

“Medicine is the development of expertise. You can only shave off so much experience time before you lose some of the value of the training,” she said. “Trainees need to be around enough to know what’s normal … You need to see 100 normals to understand what’s not normal.”

It’s also a question of training your body, she said, so you’re ready for incidents with multiple patients who need surgery immediately.

“We’re not training airline pilots, we’re training fighter pilots,” she said. “You can’t just be OK; you must be excellent.”