The Orthopaedic Trauma Association (OTA) is a professional organization, composed primarily of orthopaedic trauma surgeons, with the mission of promoting excellence in the care of injured patients through education, research, and advocacy. The majority of our membership is from the United States and is involved in training orthopaedic residents. We read with great concern the prepublication draft of the recent report by the Institute of Medicine (IOM) entitled "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety."1 We believe that if the recommendations of this IOM committee were adopted by the Accreditation Council for Graduate Medical Education (ACGME), the result would be detrimental to the care of trauma patients and the training of orthopaedic residents in the United States.
While it may seem intuitively logical that sleep deprivation and excessive fatigue might lead to the commission of medical errors by resident physicians and resultant patient injury, there is no evidence that this is actually occurring or has occurred to a substantial degree in the current training environment. The IOM report acknowledges this lack of evidence in the summary section of Chapter 6, in which they note that the "data are too limited" to determine what proportion of errors or adverse events are even attributable to residents, much less to resident fatigue (page 6-23). The report notes that it is "not possible" to determine the extent of patient risk from resident fatigue or whether further reduction in resident duty hours would improve patient safety (page 6-24). While this lack of evidence may be due to inadequate study, we believe it is also true that the current system of supervision and oversight limits the likelihood of patient injury from resident error.
We agree with the committee that there has been inadequate time and effort to study the effects of the introduction of the eighty-hour workweek restrictions instituted in 2003. The report notes that there has been a "lack of any comprehensive attempt to document changes … and their impact, if any, on … patient safety" (page S-15) and "the full effects" of the 2003 duty-hour regulations remain unclear (page 4-19)1. Nonetheless, they go on to recommend further restriction of resident duty hours. We believe that it is dangerous and imprudent to make disruptive, expensive, and potentially harmful regulatory changes to correct a problem that is not documented to exist, particularly without adequate study of the effects of duty hours on patient safety and educational efficacy. Changes in resident duty-hour regulations should be based on the results of such research, in the same manner that changes in medical care should be based clearly on scientific evidence.
We believe the proposed changes would be detrimental for the following reasons:All regulatory changes involve unintended and unexpected consequences. There are many possible ways in which increased duty-hour restrictions may actually increase medical errors and worsen patient safety. Other factors in resident-associated medical errors include faulty handover of care, high patient loads, and cross-covering large numbers of patients2. All of these are likely to be worsened, at least in the short term, by the proposed changes. This is acknowledged in the report when they state "All … agreed that shorter duty hours have resulted in more handovers of care, which have been associated with increased risks to patient safety"1 (page 1-11). In addition, further limitation of duty hours may reduce the number of residents on duty in some hospitals at one time, reducing resident-resident supervision and backup. Further study is warranted to ensure that the increased duty-hour restrictions do not result in more patient harm and to quantify the associated risk.As detailed in the 2006 IOM report "Hospital-Based Emergency Care: At the Breaking Point,"3 America's trauma centers are in a crisis state. Many or most trauma centers are affiliated with teaching institutions and rely on resident care to keep up with the ever-increasing load of emergency patients. As trauma surgeons, we are acutely aware of this problem on a daily basis. Further restriction of resident duty hours may cripple trauma centers by forcing perfectly capable, well-trained, and eager surgical residents to sit on the sidelines, while manpower shortages result in decreased access for patients.Further limitation of resident duty hours will necessarily result in reduced resident experience in patient care. This will produce residents with a lower level of surgical skill and immature ability for independent decision-making. These less skillful, less experienced graduates may place subsequent patients at risk for errors committed when the surgeons are in independent practice, without the protective backup of experienced faculty surgeons. Some effort to study and estimate this risk should be performed prior to instituting any changes, in order to compare with the potential risks of the current system. Alternatively, the duration of surgical training programs may need to be lengthened to achieve adequate experience and skill, which would worsen the projected manpower shortages in surgical specialties and reduce patient access to care.While studies have documented that the eighty-hour workweek has resulted in improvements in self-reported quality of life for residents, they have also documented a reduction in the same measures for faculty4,5. Academic physicians, particularly orthopaedic trauma surgeons, are a group at high risk for career burnout. Any changes that increase faculty stress and decrease quality of life will adversely affect our ability to recruit and retain the experienced surgical teachers who provide the final firewall of patient protection through oversight and supervision.The economic burden of these proposed changes, which is estimated to be $1.7 billion1 (page S-14), will drain resources from teaching programs and/or from patient care. Although the committee has called on Congress and "all potential funding sources" to consider mechanisms for support, it is unclear where this money could be found in the current federal budget. We agree with the authors of the report that "without the necessary restructuring in resource allocation, attempts to implement the recommendations will fail to have the desired benefits and could even reduce patient safety"1 (page S-5). To make any such sweeping changes before the funding mechanism is firmly in place could be disastrous.The infrastructure and mechanisms for monitoring compliance with some of these recommendations, particularly the five-hour protected sleep period between 10 p.m. and 8 a.m. ("nap time"), do not exist and would necessitate a dramatic expansion of the surveillance activities of residency programs. It is not clear who would be performing bed checks and whether that cost is included in the above estimate of resources required.
All regulatory changes involve unintended and unexpected consequences. There are many possible ways in which increased duty-hour restrictions may actually increase medical errors and worsen patient safety. Other factors in resident-associated medical errors include faulty handover of care, high patient loads, and cross-covering large numbers of patients2. All of these are likely to be worsened, at least in the short term, by the proposed changes. This is acknowledged in the report when they state "All … agreed that shorter duty hours have resulted in more handovers of care, which have been associated with increased risks to patient safety"1 (page 1-11). In addition, further limitation of duty hours may reduce the number of residents on duty in some hospitals at one time, reducing resident-resident supervision and backup. Further study is warranted to ensure that the increased duty-hour restrictions do not result in more patient harm and to quantify the associated risk.
As detailed in the 2006 IOM report "Hospital-Based Emergency Care: At the Breaking Point,"3 America's trauma centers are in a crisis state. Many or most trauma centers are affiliated with teaching institutions and rely on resident care to keep up with the ever-increasing load of emergency patients. As trauma surgeons, we are acutely aware of this problem on a daily basis. Further restriction of resident duty hours may cripple trauma centers by forcing perfectly capable, well-trained, and eager surgical residents to sit on the sidelines, while manpower shortages result in decreased access for patients.
Further limitation of resident duty hours will necessarily result in reduced resident experience in patient care. This will produce residents with a lower level of surgical skill and immature ability for independent decision-making. These less skillful, less experienced graduates may place subsequent patients at risk for errors committed when the surgeons are in independent practice, without the protective backup of experienced faculty surgeons. Some effort to study and estimate this risk should be performed prior to instituting any changes, in order to compare with the potential risks of the current system. Alternatively, the duration of surgical training programs may need to be lengthened to achieve adequate experience and skill, which would worsen the projected manpower shortages in surgical specialties and reduce patient access to care.
While studies have documented that the eighty-hour workweek has resulted in improvements in self-reported quality of life for residents, they have also documented a reduction in the same measures for faculty4,5. Academic physicians, particularly orthopaedic trauma surgeons, are a group at high risk for career burnout. Any changes that increase faculty stress and decrease quality of life will adversely affect our ability to recruit and retain the experienced surgical teachers who provide the final firewall of patient protection through oversight and supervision.
The economic burden of these proposed changes, which is estimated to be $1.7 billion1 (page S-14), will drain resources from teaching programs and/or from patient care. Although the committee has called on Congress and "all potential funding sources" to consider mechanisms for support, it is unclear where this money could be found in the current federal budget. We agree with the authors of the report that "without the necessary restructuring in resource allocation, attempts to implement the recommendations will fail to have the desired benefits and could even reduce patient safety"1 (page S-5). To make any such sweeping changes before the funding mechanism is firmly in place could be disastrous.
The infrastructure and mechanisms for monitoring compliance with some of these recommendations, particularly the five-hour protected sleep period between 10 p.m. and 8 a.m. ("nap time"), do not exist and would necessitate a dramatic expansion of the surveillance activities of residency programs. It is not clear who would be performing bed checks and whether that cost is included in the above estimate of resources required.
In addition to the reasons we have listed, we have more general and philosophical concerns with the culture that may be promoted by the recommendations in this report—that is, a culture in which the needs of the patient are no longer the primary concern of the physician but take a secondary role to the personal comfort of the physician. This trend would seem to erode the basis of professionalism underlying the practice of specialty surgery in the U.S. Although some medical specialties, because of the nature of their practice, can adopt a "shift work" approach with no reduction in quality of patient care, we do not believe that is true for orthopaedics nor for the subspecialty of orthopaedic traumatology. Ours is a challenging profession, in which working long hours and functioning while fatigued are sometimes necessary for successful outcomes. As the report states, "many physicians work long and unpredictable hours around the clock once they finish their graduate medical training—longer hours than most other workers in the United States"1 (page 1-8). If potential orthopaedic surgeons do not learn how to recognize, accommodate to, and work through some level of fatigue within the relatively protected environment of residency, then they will have to learn it later, after residency, possibly at great cost to their patients. There should be some recognition in the regulations for the differences between the specialties. One set of rigid rules does not fit all specialties and could do a disservice to the public by producing physicians who may be ill-suited for their chosen specialty.
We strongly urge the ACGME not to adopt any of the proposed changes contained in the IOM report unless and until further study documents the need for change and a favorable risk-benefit ratio for the proposed restrictions and certainly not until adequate funding mechanisms are solidly in place. 