Are Duty-Hour Changes Having Desired Effect?

Give first-year medical residents a few extra hours off work and what do you get? Not much, aside from a bit more anxiety, according to Srijan Sen, M.D., an assistant professor of psychiatry at the University of Michigan.

Aaron Levin

Sen studies the interaction of genes, stress, and depression, so PGY-1s make attractive research targets.

“We’ve been studying interns as a model of stress,” said Sen in an interview with Psychiatric News. “It’s one of those rare situations where relatively happy people are going to be stressed out, and a high percentage will be depressed in a few months.”

With several colleagues, he began tracking interns in 2006 when he was a resident at Yale. His current clinical work includes seeing physicians in training who are struggling with depression.

The researchers so far have recruited more than 4,500 interns and add 800 to 1,000 more each year, collecting DNA in the spring before their internships start. Sen hopes to continue the study for another four or five years to gather sufficient numbers to power observations of what are likely to be small genetic effects.

The current cohort—the seventh so far—served to highlight changes in duty-hour requirements starting in July 2011, as recommended by the Accreditation Council for Graduate Medical Education (ACGME).

About 58 percent of invited medical interns from 22 U.S. institutions agreed to participate in the study. Half were heading into internal medicine, about 10 percent to 15 percent were planning to become psychiatrists, and the rest were from other specialties.

“Reported duty hours decreased from an average of 67.0 hours per week before the new rules to 64.3 hours per week after the new rules were instituted,” the researchers said online March 25 in JAMA Internal Medicine. The reduced duty hours added an insignificant 12 minutes of extra sleep per day and didn’t alter rates of depressive symptoms or measures of well-being for the interns.

“Different strategies for improving resident education and patient care may be necessary to achieve the desired impact of ACGME reforms,” they concluded.

“It’s not clear what those interns were doing with those extra three hours,” Sen told Psychiatric News. “The three-hour drop per week in work hours might not be as much as was hoped for or expected by ACGME.”

However, interns did report a significant increase (from 19.9 percent to 23.3 percent) in concern about making medical errors. “I think this relates to communication problems at handoffs,” said Sen. “With a decrease in shift lengths, interns get more times [at which they] pass off care to the next shift. Now, patients may see two or three interns in their first day in the hospital instead of just one.”

The study recorded the interns’ “concern” about possible errors, not actual charted mistakes. Sen would like to cross-check the two factors in a subsample of a future cohort.

Also, the new ACGME rules cut the maximum shift length but did not restrict the actual work interns need to perform, suggested Sen. “They were expected to do the same work in less time,” he said. “Not only didn’t that reduce stress, it may have increased it.”

However, 2011 was the first year for the new rules, and hospitals may not have fully adjusted work schedules, he said. Outcomes might change as hospitals and senior physicians become accustomed to the new rules.

Aside from that, Sen offers another hypothesis about interns’ response to the new hours. Back in the “bad old days,” interns getting off a 24-hour shift had enough free time to run errands and catch up on sleep before they reported back for duty. “Now work is more intense, and there’s no stress-relieving time,” he suggested. ■