KEY RESEARCH FINDINGS
The in-depth environmental scan and Expert Working Group commentary papers conducted by the National Steering Committee produced the most comprehensive and evidence-based analysis of resident duty hours’ impact on Canadian medical education conducted to date. The scan examined how resident duty hours currently operate nationwide, what the scientific evidence says on key issues, and gathered the perspectives and opinions of residents, medical educators and hospital administrators across Canada on resident duty hour issues.
The key research findings from this process centered around four key areas:
Traditional duty periods present risks to the physical, mental, and occupational health of residents. In the past, and in some current situations, residents have been scheduled for duty periods of 24 or more consecutive hours without restorative sleep. At the centre of debate regarding resident duty hours have been concerns regarding the negative implications of such hours worked by residents on their physical, mental, and occupational health.
Fatigue impairs cognitive and behavioural performance. There is wide agreement within sleep science literature that sleep deprivation and fatigue exerts significant impacts on cognitive and behavioural performance. The impact on performance, however, varies according to differences between individuals, their level of fatigue, and numerous other factors.
A tired doctor is not necessarily an unsafe doctor. Patient safety is of prime importance in health care delivery. It is incumbent upon the profession to ensure all providers are capable of maintaining the highest standards of safety in their patient care activities. Sleep deprivation is one of a number of factors that are associated with fatigue and fatigue is one of a number of factors that can affect performance. While it is acknowledged that fatigue has significant impairments for cognitive and behavioural performance, the relationship between fatigue, medical errors and the safety of patient care is unclear. Duty hours cannot be considered in isolation. They must be considered as one factor that impacts fatigue-related risk.
There is no conclusive data to show that restrictions on consecutive resident duty hours are necessary for patient safety. Concerns regarding fatigue’s impact on patient safety have emerged as a key driver for resident duty hour reforms. However, emerging evidence suggests a mixed or inconclusive relationship between duty hour reductions and patient safety, leading to concerns that restrictions on consecutive duty hours have not had the anticipated impact on this crucial outcome as hoped.
Successful efforts to improve patient safety and resident fatigue will need to be comprehensive, involving not only the regulation of resident duty hours alone. Accepting the fact that resident duty hours are not the sole factor impacting fatigue among residents or patient safety, it necessarily follows that initiatives addressing the regulation or restriction of resident duty hours alone are unlikely to lead to improvement in these two domains. Instead, a more comprehensive approach to minimizing fatigue-related risk and optimizing performance is needed.
There is no clear evidence that resident duty hour regulations have had a significant positive or negative impact on academic performance. Resident duty hours are training hours for Canada’s physicians and surgeons in training. On one hand, concerns have been raised about the impact of long hours and fatigue on retention of knowledge. On the other hand, the hours of work spent in training by residents represent significant experience for medical education and opportunities for mentorship and supervision. Skill development requires utilization and practice. Research is not yet conclusive on the overall impact of these two very different factors, and is significantly limited by the fact that medical education outcomes are exceptionally multifactorial. As such, it is unclear whether duty hour restrictions to this point have had a significant impact, positive or negative, on educational outcomes overall.
There is evidence suggesting suboptimal patient care and educational outcomes in surgery resulting from the restriction of resident duty hours. Research related to the impact and regulation of resident duty hours highlights differential, heterogeneous outcomes related to resident duty hours in the surgical disciplines. In particular, concerns regarding patient care and medical education seem to emerge more often in the surgical disciplines, procedural disciplines, and disciplines where patient care acuity is highest. Evidence highlights that more work is needed to develop strategies, different approaches, and new models of surgical care and medical education in the context of evolving work hour regulations.
Resident duty hour regulations necessitate reorganization of health human resources deployment and care delivery models. These changes have the potential for impact on the health care system. As residents function in dual capacity as learners and care providers, there are two complementary but distinct tasks and associated sets of costs and benefits involved in resident duty hours. Changes to the consecutive shift length or total maximum hours of work will necessarily result in the reorganization of health human resources deployment and care delivery models that could result in increased, stable, or decreased fiscal pressures on the health care system. Without careful planning and resource allocations, there is a risk that resident duty hour regulations could inadvertently decrease safety and quality of care through factors such as increased handovers, discontinuity of care and decreased trainee supervision.The final report is a collation of the evidence, findings, recommendations, and suggested metrics reflecting the three project’s phases. Click here to read the final report, Fatigue, Risk and Excellence: Towards a Pan-Canadian Consensus on Resident Duty Hours.