Twenty-four-hour shifts for residents

This month we present a debate on the 24-hour shifts that were until recently imposed on residents in training in Quebec medical institutions. Dr Jonathan Cools-Lartigue, a surgical resident, argues in favour of them (page 133),¹ while Dr Marie-Renée B-Lajoie, a practising family physician, argues against them (page 132).²

In the debate, Dr B-Lajoie cites the following troubling facts: “‘They [residents] make 36% more serious medical mistakes … they are nearly 6 times more likely to make serious diagnostic errors … and they are 2.3 times more likely to be involved in a car accident after a 24-hour institutional on-call.’”² And as if that were not enough, she adds the following powerful argument: “On June 7, 2011, a Quebec arbitrator ruled that 24-hour in-hospital calls violated both the Canadian Charter of Rights and Freedoms (Article 7) and the Charter of Human Rights and Freedoms of Quebec (Article 1).” How can you argue against such a position?

Dr Cools-Lartigue, however, sticks to his guns. Making reference to the 2003 recommendations of the Accreditation Council for Graduate Medical Education (ACGME), which indicated that it was forbidden for interns to work more than 16 consecutive hours in a hospital, he points out that, “The ACGME guidelines have been in place for nearly a decade, and a wealth of evidence from the United States has failed to demonstrate an improvement in patient safety since their implementation.” ¹ Then, referring to an article published in JAMA in 2009,³ he adds, “[D]uration of the time on duty … did not correlate with the degree of complications.”¹ He also cites a meta-analysis supporting his position⁴: [The authors] reviewed 20 high-quality studies examining the effects of the ACGME work-hour restrictions before and after their implementation between 2000 and 2009. Again, the authors identified no improvement in patient outcomes in well over 700 000 patients.¹

So are the presumptions that 24-hour shifts will have harmful effects fallacious? Who is right and who is wrong? Whoever can figure that out is pretty smart! We seem to be faced with a debate in which the data and the legal and constitutional rules are confusing and contradictory.

An interesting way to look beyond the debate is presented in Woollard's commentary (page 125).⁵ According to him, the real issue is not the number of hours on shift but something else altogether: “These 2 issues are the dilution of relationships as a foundation for caring and the ascendency of ‘management science’ as the overwhelming influence on the design and function of caring institutions such as hospitals.”⁵

The number of hours in a shift is doubtless a side issue. In fact, anyone has the right to question the evidence justifying this number: why 16 hours instead of 24? On what basis did anyone say that this is the optimal duration of a shift? A person could become dangerous or dysfunctional after 16 hours, but not before? Nonsense! And why not 8 hours? I know many people who, after 8 long hours of work, seeing an incalculable number of patients, resolving complex cases, and doing all this at a frantic pace, are exhausted. If the number of hours is important, why do we still ask (and sometimes demand) that other health professionals working in the same institutions work overtime under the pretext of being short-staffed? To limit the number of hours of work for the well-being of patients can hardly be justified for residents but not for others. That's bizarre.

We could also question the relevance of imposing 24-hour shifts on residents but not on their supervisors, who are ultimately responsible. Why do we have a system in which residents go through rotations and are confronted with potentially serious situations, while their supervisors stay home and take part only when telephoned? Just think of sending an apprentice pilot up in an Airbus A380 while the pilot himself stays in the control tower or at home!

Of course, you could say that we have all been through this, that it was a part of our training, and that it never killed any of us. That being said, there are others who argue that the system just doesn't seem right and that we could talk forever about supposed pedagogic value, not to mention cheap labour.

Finally, this debate about residents' shifts raises many issues beyond those concerning duration. Notably, it raises questions about the pedagogic value of shifts, about the development of leadership and autonomy, and about reconciling our professional responsibilities with the search for a better quality of life. Surely, before we adopt the Quebec position across Canada or import the American recommendations, we should discuss the whole situation.

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