Research Report

The Impact of Duty Hours Restrictions on Job Burnout in Internal Medicine Residents: A Three-Institution Comparison Study Jonathan A. Ripp, MD, MPH, Lisa Bellini, MD, Robert Fallar, PhD, Hasan Bazari, MD, Joel T. Katz, MD, and Deborah Korenstein, MD

Abstract Purpose Internal medicine (IM) residents commonly develop job burnout, which may lead to poor academic performance, depression, and medical errors. The extent to which duty hours restrictions (DHRs) can mitigate job burnout remains uncertain. The July 2011 DHRs created an opportunity to measure the impact of decreased work hours on developing burnout in IM residents. Method A survey was administered twice to first-year IM residents at three academic medical centers between June 2011 and July 2012. To estimate the impact of the 2011 DHRs, data from this

Job burnout, defined as a psychological

syndrome characterized by emotional exhaustion, depersonalization, and feelings of decreased personal accomplishment,1 is common among internal medicine (IM) residents2 and may lead to poor academic performance,3,4 depression,5 suicidality,6 self-perceived medical errors,7 needlestick injuries, and motor vehicle accidents.8 Potential risk factors for the development of burnout in IM residents include personality type,2 limited performance feedback,2 educational loan debt,3 and duty hours.9,10 Background

Not surprisingly, excessive duty hours contribute to fatigue in IM residents, and decreased work hours may improve Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Ripp, 1 Gustave L. Levy Place, Box 1216, New York, NY, 10025; telephone: (212) 241-4141; fax: (212) 4265108; e-mail: [email protected]. Acad Med. 2015;90:494–499. First published online January 20, 2015 doi: 10.1097/ACM.0000000000000641

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cohort, including demographics, sleepiness, hospital-based patient service characteristics, and burnout measures, were compared with data from 2008–2009 from first-year IM residents at the same institutions. Results Of eligible residents, 128/188 (68%) from the 2011–2012 cohort and 111/180 (62%) from the 2008–2009 cohort completed both surveys. Yearend burnout prevalence (92/123 [75%] versus 91/108 [84%], P = .08) and incidence (59/87 [68%] versus 55/68 [81%], P = .07) did not differ significantly between cohorts. There was no difference in year-end prevalence of

measures of sleepiness.7,11 In addition, burnout seems to correlate with sleep deprivation in medical students12 and IM residents,13 whereas, conversely, recovery from burnout may improve sleep continuity.14 Given that emotional exhaustion is a component of job burnout, researchers have hypothesized that fatigue resulting from excessive duty hours contributes to burnout.9,10 In 2003, the Accreditation Council for Graduate Medical Education (ACGME) adopted duty hours standards for all specialties. Studies evaluating the impact of these limitations found that emotional exhaustion levels modestly decreased while burnout levels overall were unaffected.9,10 Five years later, the Institute of Medicine (IOM) produced a report, “Resident Duty Hours: Enhancing Sleep, Safety and Supervision,”15 which recommended a protected sleep period of 5 hours during any work shift longer than 16 hours to reduce the risk of fatiguerelated errors committed by residents in the hospital during prolonged duty periods.16 The IOM report acknowledged the paucity of data on optimizing duty hours for physicians in

excessive Epworth sleepiness (72/122 [59%] versus 71/108 [66%], P = .29) between cohorts; however, a greater percentage of residents who developed burnout in the 2011–2012 cohort reported caring for > 8 patients on their service (2011–2012 versus 2008–2009) (29/59 [49%] versus 5/34 [15%], P  70 hours per week (49/59 [83%] versus 18/28 [64%], P = .05). Discussion

Job burnout among first-year IM and combined medicine/pediatrics resident physicians from the three universitybased residency programs we studied did not significantly change after the implementation of the 2011 revised DHRs. The only common significant change since 2008 across all four participating institutions was the 16-hour DHR implemented in 2011 (see Table 1).

The institutions were Icahn School of Medicine at Mount Sinai (New York, New York), Perelman School of Medicine at the University of Pennsylvania (Philadelphia, Pennsylvania), and Massachusetts General Hospital (Boston, Massachusetts). Slight variations in denominators are due to small numbers of selected survey-item nonresponse.

Despite DHR implementation, excessive sleepiness levels (our measure of fatigue) were found to be similar in the two cohorts. This finding may be explained by the similar number of hours worked before and after the mandate. Though residents in the 2011–2012 cohort worked fewer consecutive hours than those in the 2008–2009 cohort, they reported a similar number of total hours worked per week and a similar number of days off per month. It is likely that sleepiness may not accurately reflect fatigue, with fatigue and sleepiness being different constructs.20 Excessive daytime sleepiness, as measured in our study by the ESS,19 primarily assesses the likelihood that an individual will fall asleep in a given situation. The change in extended firstyear IM resident duty hours from 30 to 16 has likely changed the work intensity for trainees of all levels through shifting of tasks from interns to residents and work compression for first-year residents who now have less time to perform

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Academic Medicine, Vol. 90, No. 4 / April 2015

No. (%) 2008–2009 cohort (n = 108)

No. (%) 2011–2012 cohort (n = 123)

P value

Female Married

60/108 (56) 33/108 (31)

51/121 (42) 34/120 (28)

.04 .71

Had break 1+ years before medical school

44/107 (41)

31/118 (26)

.02

Residency track: categorical

83/108 (77)

91/118 (77)

.96

  ≤ $50K

34/108 (31)

44/123 (36)

.49

 $51K–$100K

21/108 (19)

25/123 (20)

 $101K–$150K

18/108 (17)

16/123 (13)

 $151K–$200K

21/108 (19)

24/123 (20)

 > $200K

14/108 (13)

14/123 (10)

Graduate from a medical school outside of the United States

0/106 (0)

6/120 (5)

.01

Self-reported history of depression

9/106 (8)

6/120 (5)

.29

Self-reported history of anxiety

2/106 (2)

9/120 (8)

.07

Characteristic

Educational debt

a

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2011 DHRs, the optimal number and organization of duty hours is not clear. Dutch IM residents, for example, who work fewer hours than their U.S. counterparts, continue to experience burnout, though at lower rates than in the United States.27

Table 3 Prevalence and Incidence of Job Burnout for Two Survey Cohorts, From a ThreeInstitution Study of Internal Medicine Residents Before and After the 2011 Duty Hours Restrictionsa No. (%) 2008–2009 cohort (n = 108)

No. (%) 2011–2012 cohort (n = 123)

P value

Overall burnout  Burnout prevalence at the start of training

40/108 (37)

36/123 (29)

.21

 Burnout prevalence at the end of PGY-1

91/108 (84)

92/123 (75)

.08

55/68 (81)

59/87 (68)

.07

 High DP subscores at the start of training

36/108 (33)

33/122 (27)

.30

 High DP subscores at the end of PGY-1

81/107 (76)

80/123 (65)

.08

52/72 (72)

52/89 (58)

.07

 High EE subscores at the start of training

18/107 (17)

16/123 (13)

.42

 High EE subscores at the end of PGY-1

71/108 (66)

69/123 (56)

.13

55/89 (62)

57/107 (53)

.23

Characteristic

 Burnout incidence Depersonalization

 High DP incidenceb Emotional exhaustion

 High EE incidencec

  Abbreviations: PGY-1 indicates postgraduate year 1; DP, depersonalization; EE, emotional exhaustion. a The institutions were Icahn School of Medicine at Mount Sinai (New York, New York), Perelman School of Medicine at the University of Pennsylvania (Philadelphia, Pennsylvania), and Massachusetts General Hospital (Boston, Massachusetts). Slight variations in denominators are due to small numbers of selected survey-item nonresponse. b Percentage of residents who start training without burnout or high DP and develop burnout and high DP by the end of PGY-1. c Percentage of residents who start training without burnout or high EE and develop burnout and high EE by the end of PGY-1.

similar amounts of clinical work. Such work compression leads to a change in work intensity that might contribute to fatigue without affecting ESS scores. Interestingly, first-year residents in our study reported caring for more patients after the implementation of shift length restrictions, supporting the theory that work intensity may be greater. Though there were lower rates of burnout in IM residents after the implementation of the 2011 ACGME DHRs, the difference did not reach significance, and the majority of first-year residents still developed burnout by year’s end. The persistently high rates of resident burnout likely reflect the multifactorial nature of job stress in doctors-intraining, which includes factors such as work intensity, lack of control over schedules, participation in life-and-death decision making, witnessing tragedy, and the cumulative effect of long duty hours.9,21 Participating in the care of patients with unpredictable courses and the impact of the hidden curriculum may lead to emotional experiences that challenge the values of young trainees and add to the stresses of training.22

Academic Medicine, Vol. 90, No. 4 / April 2015

There may also be other unanticipated negative consequences of duty hours standards that continue to drive burnout in residents. For example, the majority of surgery residents in a cohort surveyed after the 2011 duty hours standards reported decreased coordination of care and no change in levels of fatigue, while a third of them experienced at least weekly symptoms of depersonalization and emotional exhaustion.23 Some argue that job burnout may be an acceptable consequence of training if it promotes quality of care, and that some aspects of the burnout syndrome, such as desensitization to traumatic patient experiences, could be formative to professional development.24 However, it seems more likely that the continued high rate of burnout is potentially harmful to the trainee’s mental state5,6 and to patient care.5,7,25,26 Further study should attempt to elucidate the components and correlates of burnout that place the physician-in-training at greatest risk both for personal complications of burnout and for medical errors. Despite the possible modest decline in burnout observed with the more restrictive

This study has several important limitations. The use of a historical control group raises the possibility that factors other than the revised duty hours standards influenced rates of burnout. Although all three sites reduced duty hours in accordance with the ACGME mandate, each site employed different changes to the structure of their training program (see Table 1). Because there were similar rates of burnout development after the 2011 DHRs were implemented across the sites, it is reasonable to conclude that work limitations themselves do not significantly lower rates of burnout. The inclusion of multiple sites strengthens the ability to draw this conclusion. Nonetheless, the analysis performed identified correlations only, making it difficult to draw conclusions regarding causality. Furthermore, given the poor response for a few of the variables reported in Table 4, there could potentially be a nonresponse bias for some of these specific outcomes. Also, the response rate in the 2008–2009 cohort was lower than in the 2011–2012 cohort. The impact of the lower response rate on our results is not clear. Burnt-out residents may be less motivated to respond, which would lead us to underestimate the rate of burnout, or they may be more inclined to respond with the hopes that their participation will lead to positive change, which would lead us to overestimate burnout rates. In addition, controversy persists regarding the optimal definition for burnout13,18; the definition most commonly used in studies of resident burnout was applied in our cohort to make our findings most comparable with those from many other studies. Additionally, some attributes associated with burnout inventories (e.g., exhaustion, subjugation of personal attachment) may be related to positive aspects of physician development in ways that are not measurable in this study design. Finally, the measures of fatigue20 and job demands21 that were used are largely self-reported and could be enhanced to better assess the potential mediators of the correlation between burnout and duty hours.

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Table 4 Sleep and Self-Reported Service Characteristics Associated With Job Burnout for Two Cohorts, From a Three-Institution Study of Internal Medicine Residents Before and After the 2011 Duty Hours Restrictionsa No. (%) entire cohort Characteristic Excessive Epworth Sleepiness (post) Program has a curriculum that focuses on balancing personal/professional life

No. (%) burnout-freeb

No. (%) new burnoutc

2008–09

2011–12

P value

2008–09 (n = 13/68)

2011–12 (n = 28/87)

P value

2008–09 (n = 55/68)

2011–12 (n = 59/87)

P value

71/108 (66)

72/122 (59)

.29

8/13 (62)

11/28 (39)

.18

37/55 (67)

41/58 (71)

.70

44/66 (70)

77/123 (63)

.58

6/7 (86)

23/28 (82)

.99

26/32 (81)

33/59 (56)

.02

.10

> .99

.25

Self-reported days off per month  < 4

1/65 (3)

10/123 (8)

  ≥4

64/65 (98)

113/123 (92)

  ≤8

59/69 (86)

71/123 (58)

 > 8

10/69 (14)

52/123 (42)

  ≤ 70

16/69 (23)

35/123 (28)

 > 70

53/69 (77)

88/123 (72)

0/7 (0)

0/28 (0)

7/9 (100)

28/28 (100)

6/7 (86)

16/28 (57)

1/7 (14)

12/28 (43)

2/7 (29)

10/28 (36)

5/7 (71)

18/28 (64)

1/33 (3)

7/59 (12)

32/33 (97)

52/59 (88)

29/34 (85)

30/59 (51)

5/34 (15)

29/59 (49)

10/34 (29)

10/59 (17)

24/34 (71)

49/59 (83)

Self-reported patient service sized

The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.

Internal medicine (IM) residents commonly develop job burnout, which may lead to poor academic performance, depression, and medical errors. The extent...
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