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Association of residency work hour reform with long term quality and costs of care of US physicians: observational study

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4134 (Published 10 July 2019) Cite this as: BMJ 2019;366:l4134

Safe working hours: Better work-life balance and morale for doctors? Yes! Better patient outcome and mortality? Not so sure

Dear Editors

I felt compelled to put in a rapid response to this article as I had read a commentory from an Australian medical tabloid titled "Junior doctor training doesn't suffer with fewer hours", declaring "Shortening junior doctors' working weeks to a mere 80 hours has no impact on the quality of their training, a study suggests." (ref 1)

While noting the conclusion of the BMJ article that "exposure of internists to work hour reforms during their residency was not associated with post-training differences in patient mortality, readmissions, or costs of care", it is obviously very hard to adjust for historical difference between pre- and post-2003 Accreditation Council for Graduate Medical Education (ACGME) reform since evidence-base practice technology and employment practices had changed significantly over time to complete residency particularly when comparing patient care over 12 years. Of significance as well is that we are looking at general internist rather than dedicated proceduralists whose training are far more complex requiring further development in eye-hand coordination, dexterity and other technical skills in addition to communication skills, interpersonal interaction and clinical acumen.

Interestingly there is little evidence to show that another touted benefit of the ACGME reform actually happened: statistics showing improved measurable patient outcome and mortality rates are lacking (Ref 2-3). No doubt morale and job satisfaction is perceived to benefit those residents who experienced the 2003 reform but again, generational expectation, experience and perception is a hard thing to compare.

The article here probably offers no new conclusions since similar results have been published on this issue (Ref 4-6).

Similarly the implementation of the European Working Time Directive (EWTD) in stages since 1996 sees no significance in patient safety and outcome (Ref 6-8), and many supporters struggle to provide concrete evidence that the EWTD actually reduced or stabilised the incidence of occupational hazard, clinical errors or road traffic accidents involving health professionals.

No doubt the EWTD benefited doctors' work-life balances (Ref 9) and I would not want anyone to go back to the "good old days" when 60-80 hour week (including undocumented-hence unpaid overtime) excluding on-call is the norm. However, the price of the EWTD is clear where speciality training duration (formal and informal) is extended for at least 1-3 years depending on speciality.

Of interest while the NHS doctors have the (sometimes symbolic) protection of the EWTD having maximum average 48 hour working week (reduced from 56) and maximum 72 hours’ work in any seven day period (reduced from 91), the ACGME reform for US doctors have a maximum limit of 80 hours work a week, capped shift duration of 16 consecutive hours for interns and 28 hours for other trainees, limited in-hospital call to every third night, and mandated four days off every 28 days (on average one day a week).

So does any bit of this article mean anything to NHS or Australian trainees? Not an iota, in my opinion.

Long term 80 hours week is still potentially dangerous practice for healthcare, but even the South Continent is striking (Ref 9) over outrageous working conditions (ref 10)

References
1. https://www.ausdoc.com.au/news/junior-doctor-training-doesnt-suffer-fewe...
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330189/
3. https://jamanetwork.com/journals/jama/fullarticle/208657
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4269477/
5. https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2014.0318
6. https://www.bmj.com/content/342/bmj.d1580
7. https://www.bmj.com/content/342/bmj.d1200
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990025/
9. https://www.reuters.com/article/india-doctors-strike/indian-doctors-stag...
10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4858461/

Competing interests: No competing interests

12 July 2019
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia