Public Citizen released a report on the results of a new national poll showing that the vast majority of the American public favors restricting medical resident work shifts to no more than 16 straight hours without sleep. The report also summarizes research conducted to date on the dangers of sleep deprivation in residents to both the residents and their patients. The poll comes as the Accreditation Council for Graduate Medical Education (ACGME) is facing intense pressure from dozens of physician organizations to lift the current 16-hour shift cap for first-year medical residents and allow them to work 28 or more hours in a row without sleep.
In 2009, the Institute of Medicine (IOM) issued a comprehensive report documenting the risks to both medical residents (also known as resident physicians or simply residents) and patients when residents work shifts longer than 16 hours and recommended that, among other things, no resident be permitted to work for more than 16 hours straight without sleep.
A national opinion poll conducted in 2009-2010 assessed the public’s attitudes toward the IOM’s recommendations. The overwhelming majority (90%) of the public favored restricting all medical resident work shifts to no more than 16 straight hours without sleep.
In response to the IOM’s report and concomitant public pressure to revise its duty-hour rules, the Accreditation Council for Graduate Medical Education (ACGME) in 2011 restricted first-year residents (interns) to shifts of no more than 16 hours — but allowed all other residents to work shifts of up to 28 straight hours without sleep. The 16-hour work-shift cap for interns was put in place because the ACGME concluded, after an exhaustive evidence review, that interns “make more errors when working longer consecutive hours.”
In recent years, two recent cluster-randomized clinical trials — known as FIRST and iCOMPARE — are purporting to investigate the effect of medical residents’ shift length on patient safety and resident education. The trials randomly assigned resident physicians’ hospitals to either a control arm that was supposed to adhere to the ACGME’s current duty-hour rules, where interns were limited to shifts of no more than 16 hours, or an experimental arm that removed all limits on shift length. These trials are being conducted without the voluntary informed consent of the residents or their patients.
In September 2015, as part of the ACGME’s commitment to review its resident duty-hour restrictions every five years, the ACGME Board of Directors established a task force to develop recommendations for revising these restrictions. Dozens of physician organizations have advocated lifting the 16-hour cap in order to allow interns to work for 28 or more hours in a row without sleep. The ACGME is expected to publicly release a draft proposal for revision of its resident duty-hour limits and solicit comments from stakeholders in the coming months.
New Public Opinion Poll
In July 2016, in response to the potential loosening of the ACGME’s resident duty-hour restrictions, Public Citizen commissioned Lake Research Partners (LRP), an independent public opinion research firm, to conduct a new national opinion poll to assess the public’s current attitudes toward the existing restrictions and proposals to modify them.
On July 20-24, 2016, a randomly identified representative sample of 500 likely voters nationwide participated in a 10-minute telephone survey that was conducted by professional interviewers from LRP. The margin of error for the poll is +/– 4.4%.
Key findings from the poll include the following:
- A total of 86% of respondents opposed a proposal to eliminate the ACGME’s current 16-hour shift limit for first-year residents. This opposition holds across party lines — with 84% of Democrats, 83% of independents, and 88% of Republicans in opposition. Providing respondents with additional information on the reasons to support or oppose the proposal did not affect the level of opposition.
- Most respondents (80%) also supported decreasing the shift limit from 28 hours to a maximum of 16 hours for residents in their second year and above, with Democrats (84%) and Republicans (84%) supporting the measure slightly more than independents (72%).
- Most respondents (77%) said that hospital patients should be informed if a medical resident treating them has been working more than 16 hours without sleep.
- Regarding the iCOMPARE and FIRST trials, 84% of respondents wanted to be informed if they were admitted to an experimental hospital where first-year residents were allowed to work 28 or more consecutive hours without sleep, with 78% “strongly” feeling this way.
Evidence on the Dangers of Long Shifts to Residents and Their Patients
The public’s marked apprehension about resident shifts beyond 16 consecutive hours comports with the evidence on the risks of long resident work shifts without sleep to the safety of both residents themselves and their patients. A substantial body of literature shows that sleep deprivation due to excessively long work shifts increases residents’ risk of motor vehicle accidents, depression, and needle-stick and other injuries that can expose residents to bloodborne pathogens. Depriving medical residents of sleep for more than 16 hours also impairs performance and exposes their patients to an increased risk of medical errors, which can lead to patient injury and death.
One of the primary arguments against reducing the length of residents’ work shifts is that this would increase the number of handoffs necessary to transition patient care from one resident to another and thus interfere with the continuity of care. However, handoffs must occur no matter the length of a resident’s shift, and it is not primarily the number but the quality of handoffs that is crucial in ensuring the safe transfer of patients between physicians. Numerous studies published in recent years point to the potential for implementing standardized handoff systems to minimize errors during the handoff process. Furthermore, all else being equal, a resident handing off a patient after a 16-hour shift will undoubtedly be more alert than will a sleep-deprived resident at the end of a 28-hour or longer shift.
This new poll makes clear that the American public’s opinion on resident duty hours has not changed since a similar poll was conducted in 2009-2010. The public is overwhelmingly opposed to lifting the 16-hour maximum shift length for interns, and favors, by similar margins, the implementation of a new similar cap for all other medical residents. The public strongly feels that patients should be informed if the doctor treating them has worked for more than 16 hours in a row. Similarly, members of the public would want to be informed were they admitted to an experimental-arm hospital in the FIRST or iCOMPARE clinical trials where interns are allowed to work shifts of 28 hours or longer. The results were bipartisan across the board, with Democrats and Republicans expressing nearly identical preferences in response to all questions. Thus, this is not a partisan political issue, but one of public safety.
As detailed in this report, the science is clear: Residents, like any other human beings, are unable to avoid the cognitive and motor limitations that inevitably accompany prolonged sleeplessness, and both residents and their patients are put at risk once residents’ shifts exceed the 16-hour mark. Furthermore, 16-hour or shorter shifts are feasible and have already been implemented, in some cases for all residents, through the night float systems adopted by many residency programs across the country. The ACGME acted counter to public opinion when it allowed second-year-and-above residents to work 28 hours consecutively without sleep in its 2011 rules, and it risks continuing to do so should it disregard the latest poll’s results.