Resident Duty Hours, Unintended Consequences, and the 10,000-Hour Rule

The medical community has debated the value of sleep versus continuity of care since 2003, when the Accreditation Council for Graduate Medical Education limited the number of consecutive hours medical residents may be on duty. (Organizations are required to comply with the duty hour standard to retain ACGME accreditation.) Research, however, has shown that making sure resident physicians get enough rest doesn’t insure safer care for patients, which was the main driver of the standard. Whether or not limiting duty hours has improved patient safety has been the subject of many studies, which have yielded mixed results. In “Why Doesn’t Medical Care Get Better When Doctors Rest More?,” Lisa Rosenbaum, MD, investigates some of the assumptions and dynamics that make this such a difficult problem to understand and solve.

This, of course, is not the only tough patient safety problem that remains unsolved despite years of attention and intervention. It’s a good example of how complexity—circumstances that are complex and dynamic—continues to raise the bar even as we are engaged in solving a problem. Just when we think we’ve found a solution, we discover a new problem the solution creates and perhaps a new wrinkle in the original problem, which has continued to evolve as only one piece of a much larger, evolving system. As Woods et al., (2010) point out, “…the enemy of safety is complexity. Progress is learning how to tame the complexity that arises from achieving higher levels of capability in the face of resource pressures. This directs us to look at sources of complexity…and leads to the recognition that tradeoffs are at the core of safety.” Those resource pressures include humans, who continually, simultaneously make systems safer and less safe. To overcome this conundrum, we must embrace the complexity and learn to work with it, not against it, and learn to work with adjustments—tradeoffs—as part of the continuum. Which brings me back to the problem of sleep-deprived resident physicians.

That we all need a good night’s sleep to do our “best” is common sense wisdom most of us heard first as toddlers. While many of us take pride in our ability to dig deeper and perform well despite fatigue, recent research finds that 80% of U.S. citizens would prefer to be treated by someone else if they knew their doctor had been awake and working for the prior 24 hours. Other research shows that residents who drive home at the end of very long on-duty shifts are more likely to have automobile accidents, with increased potential for causing injury to themselves and others.

Rosenbaum points out two problems with limiting residents’ duty hours: 1) becoming an accomplished physician requires many, many hours of practice in many, many different situations (which are limited by the duty-hours standard), and 2) increasing the number of times physicians “hand off” their patients to other physicians increases opportunities for error. Never mind how tired everyone is, if crucial information goes missing in the hand-off, everyone is at risk. This unintended consequence—more hand-offs because residents must go off duty—may be just as hazardous as the original problem, exhaustion.

Because risk associated with hand-offs is a well-known and studied (and persistant) safety problem, it seems reasonable to continue to emphasize the importance of sleep while redoubling our efforts to improve communications around hand-offs. When we improve the hand-off process, we improve our chances of avoiding harm due to human error, regardless of what causes the error.

In thinking about the problem of shorter clinical shifts and more hand-offs, Rosenbaum goes beyond the obvious challenge of clinical data exchange and observes that something more subtle may also be lost: “The stories of our patients, which we used to own, now come it fits and starts.” That is a harder problem to solve and to measure. She identifies another danger, that of focusing our efforts on the problems that can most easily be measured. Safety and quality experts often comment, “if you can’t measure it, you can’t improve it.” While there is truth in that statement, it should not be used as a limiting factor. Rosenbaum is concerned about how young physicians develop their sense of “what it means to be a doctor” and the way that limiting duty hours may fragment their clinical experiences and relationships with patients—neither impossible nor easy to measure.

Another New Yorker writer, Malcolm Gladwell, has explored the roles of talent and practice in the development of expertise in a way that may also inform our understanding of the duty-hours problem. In “Complexity and the Ten-Thousand-Hour Rule,” Gladwell reiterates the equation he first discussed in his book Outliers: Achievement = talent + preparation. He explains further that something referred to as the “10,000-hour rule” comes from a 40-year-old study of expertise that found that becoming a grandmaster in chess requires roughly 10,000 to 50,000 hours of practice (or “preparation”).

Gladwell observes that each individual who aims for high levels of achievement—becoming an expert physician, for example—brings a personal approach to all those hours of practice and achieves a unique result. Individuals vary in the amount and quality of attention, commitment, curiosity, and creativity they are able to apply as they develop their expertise. Gladwell describes the results of recent study of athletes that found “what separated the best from the rest was how long and how intently they worked [practiced].” How might that relate to medical education? How does the ACGME’s duty-hours standard affect the quality of residents’ practice experiences? What about the affect of more sleep?

The debate about duty-hours for resident physicians, no doubt, will continue.