Internal medicine and surgery residents’ views of duty hour restrictions and causes of medical errors

Volpp KG, Shea JA, Borman KR, Jones AT, Weissman A, McKinney S, Biester TW, Itani KM. Internal medicine and surgery residents’ views of duty hour restrictions and causes of medical errors. Paper presented at: Society of General Internal Medicine Annual Meeting; 2011 May 5; Phoenix, AZ.

BACKGROUND: Duty hour regulations, initially introduced in 2003 with further restrictions scheduled for release in 2011, were intended to improve patient safety and resident well-being. Surveys that have examined residents' perceptions of and experiences with the 2003 duty hours standards have generally reported that a more regulated work life is associated with improved training morale and a better work-life balance, but also reflect widespread concerns regarding sufficient time for educational opportunities and continuity of care. Many of the early reports were limited to a single or a small number of programs and had low response rates. We assessed the potential impact of regulations debated as part of the proposed 2011ACGME duty hours by investigating internal medicine and surgery residents' perceptions of key elements of the proposed duty hour standards on quality of care as well as causes of medical errors. METHODS: A voluntary resident questionnaire was administered following the October 2009 Internal Medicine In-Training (IM-ITE) and Winter 2010 Surgery in-training examinations (ABSITE). RESULTS: Responses were obtained from 18,272 (82%) internal medicine trainees, 3,710 (99.3%) senior-level surgery trainees and 3,878 (99.1%) junior-level surgery trainees. In general, surgical trainees thought that the 2011 ACGME changes would have little impact on the quality of patient care. The majority of senior and junior surgery trainees selected "not at all" or "to a small extent" the impact on quality of care on the following measures: reducing the cap from 80 hours per week (85% seniors, 79% juniors), limiting shift length to 16 hours (75% seniors, 63% juniors), requiring naps during 30 hour shifts (77%seniors, 64% juniors), enforcing the 80 hour rule each week instead of averaging over 4 weeks (74% seniors, 65% juniors), and increasing hours off after nights and extended shifts (66% seniors, 51% juniors ). In contrast, the majority of the medicine trainees thought that most of these measures would "usually" or "always" impact patient care, for example increase hours off after nights and extended shifts (57%), limit shift length to 16 hours (53%), and require naps during 30 hour shifts (51%). More than half of the internal medicine trainees thought errors were "occasionally" or more often caused by: excessive workload (69%), resident fatigue (67%), inexperience or lack of knowledge (62%), incomplete handoffs (60%), and insufficient ancillary staff (54%). The majority of surgery trainees pointed to inexperience/ lack of knowledge and incomplete handoffs as the cause of adverse events. Inadequate supervision was "never" or "rarely" the cause of medical errors involving residents (72% surgery juniors, 74% surgery seniors, 56% internal medicine), nor was fatigue among surgical trainees (73% for surgery seniors, 60% for surgery juniors). CONCLUSION: A survey among a national sample of surgical and internal medicine trainees with an extremely high response rate revealed that most surgical residents do not expect further restrictions on duty hours would have beneficial effects on quality of care while internal medicine residents were generally more favorable to these changes. These perceptions among trainees of surgical and medical specialties and their impact on training and quality of care should be taken into consideration when adjusting work hour regulations. Among surgical residents, the lack of a perceived relationship between fatigue and medical errors may help explain why they think duty hour restrictions are unlikely to improve quality of care.