Trainees are an essential part of the continuous healthcare system. The role of the trainee probably lies between the cynical view that trainees are an inexpensive solution for 24/7 care and the nurturing view of trainees as the custodians of future high-quality care.
Public perspectives of the tired doctor contrast with expectations receiving care from a doctor they know, and have been accompanied by the use of duty-hour legislation to influence trainee work environments. Objective data are frequently absent.
Describing phenomena related to the work environment of trainees in hospital systems. Identifying associations.
Articulating assumptions, refining, refuting and evaluating solutions.
Limited relevance of duty-hour regulation. In a prospective observational study of senior ICU trainees we found that duty hour regulations dis not protect against high overnight workload (average 6.3km walked, ketonuria in 21%) and routine acute sleep deprivation (CMAJ 2004). This work was editorialized (Gaba, Howard), was featured on the cover, preceded the wearing of pedometers in the resident awareness day, and was the founding publication of the CONTINUOUS system research program.
Temporal changes before duty-hour regulation. Over the 4-year interval before and then after reducing overnight duty periods from 28 to 24 hours paediatric residents reported increased workload, decreased sleep and perceptions of reduced supervision (Bismilla, Paediatrics 2011).
Residents work overnight in ICU. A cross-sectional survey of overnight staffing in 88 ICUs in Canada. The 60% of ICUs with physicians in-house overnight, were larger and more frequently were paediatric ICUs. Results were contrasted recommendations for in-house physician staffing by the Society of Critical Care Medicine (CCM 2006).
Learning: familiarity vs. fatigue. The effects of post-call fatigue on learning in case-based teaching sessions were counter-balanced by increased familiarity/engagement with cases discussed (Smith PCCM 2008).
Duty-hour pilot RCT. The effects of 12, 16, and 24 hour overnight duty in adult ICU, resulted in similar patient mortality and adverse events. The data suggested a trade-off between resident wellbeing and patient safety: there were signals of increased preventable harm (7 of 8 events) in the 12-hour overnight schedule and staff perceptions of compromised safety in the 16-hour overnight schedule. These were counterbalanced by increased somatic symptoms of residents while at work in the 24-hour overnight schedule (NCT00679809). Resident educational outcomes were not assessed (CMAJ 2015).
National Canadian Review. The Canadian national document – “Fatigue, Risk and Excellence: Towards a Pan-Canadian Consensus on Resident Duty Hours” (LINK). A separately published systematic review found potentially worse outcomes in surgical patients after duty-hour reduction (Ahmed, Ann Surg 2014).
Reflection: safety and duty-hours. First-principles were applied and complemented a synthesis of published literature suggesting unnecessary conflation of resident schedules / duty-hour regulation with patient safety outcomes (Osborne, BMC Medical Education 2014). Our suggestion that these factors might reasonably be de-linked is consistent with findings from two subsequent randomized trials of duty-hour policy for residents in surgical and internal medicine training programs. This article was part of a Royal College funded supplement entitled “Duty Hours without Borders” published in BMC Medical Education (editors Imrie, Frank, Parshuram).
Resident Learning during ICU rotations. Residents cognitive and procedural skills improve over 4-week rotations in critical care (CJA 2021). This work informed the selection of educational skills checks in the InCURS cluster randomized trial.
Unplanned extubation in PICU. This 12-year case-series, showed declining rates of unplanned extubation in this cohort of 11,310 patient-admissions. The 458 unplanned extubation events (0.61 events/100 intubation-days) in 410 (3.39%) patients, had consequences in 245 (53.5%) including cardiac arrest in 9 (2%) (Al-Abdwani, JCC 2018).
