Rebuttal: Is the elimination of 24-hour resident call a good idea?

Dr B-Lajoie argues¹ that resident fatigue has adverse consequences. However, the deleterious effects of resident fatigue are not up for debate. Prolonged periods without sleep are deleterious for anyone. Because this is an easy narrative for people of all disciplines to get behind, sweeping legislation has been instituted without considering its effects on training competent expert physicians and surgeons. The question is not “Is performance affected adversely after 24 or more hours of continuous work?” The more relevant questions are, “Does eliminating 24-hour call solve these problems? Is there a quick fix?” The answer to these questions is no. The reasons are 2-fold. First, there are no quick-fix solutions to complex systemwide problems. Second, resident training must reflect the realities of clinical practice.

With respect to the former, current literature suggests that restricting resident work hours does not translate into improved patient outcomes.² Further, residents in disciplines such as general surgery that provide nighttime emergent care are reporting decreased satisfaction, interrupted patient care, increased burnout, and suboptimal patient exposure.^3-5 Yet the focus of the debate continues to be work hours instead of how fatigue can be minimized or mitigated in the context of one's job requirements. Tackling the real issue of fatigue requires broad systemic changes in hospitals, not punitive legislation for one cog in a huge machine.⁵

Dr B-Lajoie also suggests there is no evidence that 24-hour call is required for a resident to become a competent supervisor. This might be true for residents in fields where prolonged overnight duty will never be required. Practitioners in fields that provide emergency care might have no choice but to operate for extended periods of time, particularly in the context of an overburdened and understaffed health care system. This fact is recognized by the Accreditation Council for Graduate Medical Education, with trainees in specialties such as cardiothoracic surgery being permitted to work more than 80 hours per week so as to reflect their responsibilities as attending surgeons. Along these lines, evidence suggests that the deleterious effects of fatigue do not manifest uniformly among new trainees versus attending surgeons, with the latter demonstrating fewer impairments in performance after prolonged call periods compared with trainees.⁶

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