Resident physician extended work hours and burnout

Resident physicians experience an extraordinary amount of stress and pressure, which over time can take a toll on their mental and physical health, education, and provision of quality healthcare. To help protect patients and resident physicians from preventable harm, in 2003, the Accreditation Council for Graduate Medical Education (ACGME) in the United States restricted the time that resident physicians could work to 80 hr per week. Then, based on recommendations from a 2009 Institute of Medicine report “Resident duty hours: Enhancing sleep, supervision and safety” [1] and mounting evidence that extended work hours impair decision making and resident well-being [2–5], in 2011, the ACGME further restricted the duration that a first-year resident physician could work to 16-consecutive hours. However, a debate arose based on claims that patient safety was no worse when work hours were exempted from those limits [6] and the ACGME responded by modifying their policy in July 2017 to allow flexible scheduling and eliminate the 16-consecutive work-hour restriction, again enabling extended shifts up to 28 hr. Whether extended shifts improve or worsen quality of care and resident education remains fiercely debated, but what may get diminished in the argument is how these changes affect the health of physicians themselves. All of this is on a backdrop of greatly increased “burnout” among resident physicians, characterized by feelings of exhaustion, detachment, and ineffectiveness or reduced personal accomplishment [7]. Burnout in physicians stems from overwhelming work demands and often presents during the first two years of training [8, 9], occurring in up to 74 percent of resident physicians [10, 11]. As highlighted in the ACGME Common Program Requirements [12], there are now considerable mounting efforts to assess, avoid, or treat physician burnout across the country. Burnout can be due to many factors, such as increased educational load, increased patient encounters, and inefficiencies in the electronic medical record [13], and we argue that reducing the duration of working shifts may be a necessary first step to help avoid burnout. Thus, we contend that the decision in July 2017 to allow extended work-hours was a regressive step.

It has been well-documented that extended-duration shifts (>80 hr per week) will almost inevitably result in reduced sleep [2–5], and time for rest [6], which are well-known causes of physiological and subjective stress and are potential precursors to burnout [14]. Moreover, disturbed or fragmented sleep is also associated with burnout [14]. Notably, predictors of burnout in resident physicians working within the intensive care unit include the number of night shifts worked per month and if a night shift was worked the day before taking the burnout survey [15]. Conversely, adequate opportunities to sleep between 6 and 8 hr per day and increased number of days off are found to be protective against burnout in a multitude of healthcare workers [16].

Although burnout is usually attributed to demanding workload or job-associated stress, the impact of extended work hours cannot be overlooked. In a survey of 118 residents and interns, those working >80 hr per week had 31 percent higher prevalence of burnout than those working <80 hr per week [17]. Notably, after the 2003 ACGME work-hour restrictions, first-year residents had a 34 percent reduction in burnout compared with first-year residents prior to the implemented restrictions [17]. In a study of surgical residents, a decrease from the 80 hr work week decreased burnout with no measureable difference in quality of patient care [18]. The reduction of duration of shifts will inevitably increase workload during these shifts if no additional resident physicians are hired, which could theoretically cause burnout; yet, there was a nonsignificant trend for decreased incidence of burnout (13% change in burnout, p = 0.07) after implementation of the 2011 work-hour restrictions despite an observed increase in workload [19]. We consider this reduction in burnout as appreciable when considering the increased workload and very high overall rates of burnout in the nonrestricted work schedules (up to 81%). Thus, restricting work durations may be protective of burnout, despite a concurrent increase in workload.

There is a remaining concern that shorter duration shifts may decrease educational opportunities and overall well-being. However, findings have been mixed [20]. In a survey study of first-year residents, those who worked extended shifts reported significantly higher odds of falling asleep while on rounds with attending physicians or during a medical lecture [5], thus affecting their ability to learn. In the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, surgical residents allowed to work more flexible longer duration shifts reported no differences in satisfaction of education quality, a nonsignificant trend for dissatisfaction with their well-being (p = 0.1 for well-being scores, p = 0.06 for comparison of odds ratios between groups), and lower secondary well-being outcomes such as health [6]. More recently, in the randomized-control Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial, it was found that first-year residents in a flexible schedule which allowed for longer working durations had lower satisfaction with their quality of education and well-being when compared with residents in a standard duty-hour rules schedule [21]. It should also be noted that there were no significant differences in burnout between the two groups, though the authors comment on the limitation that they did not measure the actual number of hours worked in each group [21]. Importantly, directors of flexible work-hour units were less likely to report dissatisfaction with resident physician education [21], potentially creating a disconnect between those implementing changes in work hours and those who must undergo extended work-hours.

Untreated burnout can result in substance abuse, depression, and even suicide [22]. Resident physicians have high rates of depression and depression-like symptoms [23]. Moreover, a depressed resident is 6.2 times more likely to make a medication error [11]. With an estimated 28 percent of residents currently depressed or showing symptoms of depression, identified from a pooled prevalence meta-analysis [23], identifying modifiable pathways leading to depression could have implications for both physician and patient health. If left unchecked, burnout can lead to physicians leaving the medical profession [15] and a high rate of physician turnover in the hospital, detrimental to both the hospital [24] and the patient’s experience of care [25].

One of the strategies to help combat poor well-being outlined in ACGME Common Program Requirements is to promote self-care and recognition of symptoms of burnout and depression [12]. Short-sleep schedules may actually negatively affect the ability of the resident to do so. It has been well-established that a sleep-deprived individual is unable to perceive and accurately track their level of sleepiness [26] and may also impair the ability to subjectively recognize other objective performance outcomes. It would thus not be surprising if a sleep-deprived resident would be unable to accurately track their own health status.

The balance between duration of shifts and resident physician health is a multifaceted problem. Concerns over reducing the educational opportunities and increasing the workload in a shortened shift scenario are common. Financial issues arise as reducing the maximal duration of work per week per resident physician requires that teaching hospitals either employ additional physicians at their own expense [27] or increase the workload of the current residents and risk of errors due to understaffing, or shift some tasks to other physicians or even nonphysician healthcare workers. In hospitals with an insufficient number of resident physicians, it may be possible to “paper over the cracks” by increasing the number of patients assigned to highly motivated trainees who are “running on adrenaline,” but only by increasing the risk of burnout. Removing the 2011 ACGME work-hour limits, as occurred in July 2017 in the United States, has the potential of putting resident physicians at higher risk for burnout and depressive symptoms. How can we improve the current situation? The current policy is designed to train physicians to become better adept at self-evaluation of the symptoms and to try to treat burnout and depression after they manifest. On the other hand, we contend that this policy is simply a recognition of the underlying problem, and it is better to try to avoid such problems by reducing the duration of shifts.

Resources to implement interventions to help combat burnout, such as reducing both work hours and workload to manageable levels, are needed. At Oregon Health and Science University, a survey of over 2200 residents over 10 years revealed that those who participated in a program with counseling geared towards improving wellness, resilience, and preventing burnout [28] tended to have higher levels of career satisfaction [29]. In that same survey, healthcare professionals who also had time to focus on personal needs reported lower levels of stress and burnout [29]. Further work is needed on individual and organizational strategies, particularly with the potential disconnect between directors of flexible programs and their resident physicians [21], to determine which interventions lessen burnout.

Although the debate continues regarding the pros and cons of extended work hours for provision of optimal healthcare, we surely all can agree that the health of the physicians themselves is an essential factor.

Funding

Dr. McHill is supported by NIH KL2TR002370. Dr. Shea is supported by the Oregon Institute of Occupational Health Sciences at Oregon Health & Science University via funds from the Division of Consumer and Business Services of the State of Oregon. Outside of the current work, Dr. Shea also receives support from National Institutes of Health (NIH) grants R01 HL142064, R01 HL125893, HL125893-03S1, and R01 HL140577 (to S.A. Shea), DoD grant PT150133 (to L. Hammer), and CDC grant U19 OH010154 (to W.K. Anger). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Notes

Conflict of interest statement. A.W.M. and S.A.S have nothing to disclose; C.A.C. has received consulting fees from or served as a paid member of scientific advisory boards for the following: Columbia River Bar Pilots; Ganésco Inc.; Institute of Digital Media and Child Development; Klarman Family Foundation; Samsung Electronics; Vanda Pharmaceuticals; Washington State Board of Pilotage Commissioners; and Zurich Insurance Company, Ltd. C.A.C. has also received education/research support from Optum, Philips Respironics, Inc., San Francisco Bar Pilots, Schneider Inc., Sysco, and Vanda Pharmaceuticals. The Sleep and Health Education Program of the Harvard Medical School Division of Sleep Medicine, and the Sleep Matters Initiative (which C.A.C. directs) have received funding for educational activities from Cephalon, Inc., Jazz Pharmaceuticals, ResMed, Takeda Pharmaceuticals, Teva Pharmaceuticals Industries Ltd., Sanofi-Aventis, Inc., Sepracor, Inc., Wake Up Narcolepsy, and Mary Ann & Stanley Snider via Combined Jewish Philanthropies. C.A.C. is the incumbent of an endowed professorship provided to Harvard University by Cephalon, Inc. and holds a number of process patents in the field of sleep/circadian rhythms (e.g. photic resetting of the human circadian pacemaker). Since 1985, C.A.C. has also served as an expert on various legal and technical cases related to sleep and/or circadian rhythms including those involving the following commercial entities: Complete General Construction Company, FedEx, Greyhound, HG Energy LLC, South Carolina Central Railroad Co., Stric-Lan Companies LLC, and United Parcel Service (UPS). C.A.C. owns or owned an equity interest in Vanda Pharmaceuticals. He received royalties from Houghton Mifflin Harcourt/Penguin, McGraw Hill, and Koninklijke Philips Electronics, N.V. for the Actiwatch-2 and Actiwatch-Spectrum devices. Dr. Czeisler’s interests were reviewed and managed by Brigham and Women’s Hospital and Partners HealthCare in accordance with their conflict of interest policies.

Work Performed: Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239