Reduced work hours: who benefits?

Many countries in the Western hemisphere now impose limitations on hours of work on medical staff. In the United States, a change resulted from the investigations that followed the death of Libby Zion in 1984, an 18-year-old daughter of an attorney and journalist in a New York hospital.3 Although an investigating committee found no doctor directly liable, they thought that resident’s deprivation of sleep was a contributing factor. In response, the New York State Department of Health introduced a mandate in 1989 limiting on-duty time to 80 hours per week, with no more than 24 hours worked consecutively and with one 24-hour period off work per week.25 In 2003, this limitation was enforced nationwide when the Accreditation Committee for Graduate Medical Education (ACGME), perhaps in an effort to preempt government legislation, introduced a compulsory restriction to 80 hours per week for all residency training programs.1,2 Again, duration of on-call duty was restricted to 24 hours, resident on-call to no more than every 3rd night, and 1 day in 7 days free from patient care responsibility. All work hours were to be averaged during a 4-week period. The introduction of such requirements was based on the assumption that sleep deprivation impaired performance. But, what evidence supports this? Friedman et al.13 recently reviewed studies that examined the relationship between a doctor’s performance and deprivation of sleep. Of 13 studies reporting the effect on manual tasks, such as surgical performance, suture placement, and performance on a surgical stimulator, only 7 found a significant relationship. Similarly, of 27 studies reporting the effect of sleep deprivation on cognitive tasks including chest x-ray and ECG interpretation, 17 found a positive link. Therefore, the evidence is conflicting, but the fact that the majority of studies did find an effect is sufficient to ensure that these work hour restrictions will continue. How have neurosurgical residents and program directors responded? Cohen-Gadol et al.7 conducted a survey of 93 program directors and 617 residents; 45 and 20%, respectively, replied. A minority of residents and even fewer program directors thought that the reduction in hours carried positive aspects, such as potential improvement in examination scores, improved attendance at educational meetings, and a potential increase in research publications, whereas 60% of residents and 78% of program directors thought that reduced hours would have negative effect on various aspects of training. In 1990, in the United Kingdom, a committee of junior hospital doctors negotiated a “New Deal” with the government on hours of work, whereby on-call rotas would be limited to 83 hours per week and would carry minimal periods of compensatory rest; from 1994 this would fall to 72 hours per week.24 Only 56 of these hours could constitute actual work. If valid educational reasons existed, the hours could be increased to 83 hours per week (the English Clause).10 Any difficulties and concerns regarding the enforced reduction to these hours pales into insignificance with the introduction in August 2004 of the European Working Time Directive, legislation applying to all countries within the European Union.8,9 This directive restricts work to 58 hours per week from August 2004, falling to 56 hours per week from August 2007, then to 48 hours per week from August 2009. Requirements for compensatory rest include 11 hours of continuous rest within any 24 hours and a minimum of 20 minutes of break every 6 hours. The European Court of Justice further ruled that time spent as a resident on-call (i.e., resident within the hospital) must be regarded in its entirety as working time, even if the doctor remained asleep, undisturbed for many hours (the SiMAP ruling),11 and that compensatory rest must be taken as soon as possible after the working shift, thus, preventing the accumulation of rest periods (the Jaeger Ruling).12 At present, staff have the right to sign a waiver to “opt out” of the requirements, provided that this is entirely voluntary. The European Commission plans to discontinue this option, a move currently resisted by the UK government. Current working time regulations recently imposed in the United States are approximately equivalent to the United Kingdom restrictions from 1990 to 2004. Has it been possible to train neurosurgical registrars (residents) within these restricted hours of work? If so, is the training equivalent to that in the United States?