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To the Editor: We read with interest the articles and accompanying editorials in the March issue of Mayo Clinic Proceedings that highlight concerns with duty hours regulations in the United States.1-4 We recently conducted a systematic review of publications that evaluated the effect of a reduction in working hours for physicians in training on objective measures of postgraduate education and patient safety and outcome.5 Although the expectation may have been that the recommended changes in duty hours in the United States would have improved patient safety and outcome and led to a deterioration in postgraduate training, we concluded that neither of these outcomes has occurred. Disappointingly, the quality of studies reviewed from the United Kingdom that evaluated the effect of reducing duty hours to less than 56 or 48 per week in accordance with European legislation was insufficient for drawing firm conclusions; it is particularly noteworthy that we identified only 3 studies from the United Kingdom that examined patient outcomes before and after duty hour changes.5 This observation may serve as a reminder to the profession that we must develop systems to evaluate the effect of changes in working conditions to be able to reassure our patients that the standard of both current and future care will be maintained despite these limitations.
The reasons we postulated for this lack of clear benefit or harm in patient safety and outcomes are also discussed in your recent publications. Studies that have evaluated the effect of fatigue on professional performance seem to provide evidence that medical error rates and patient outcomes should improve by reducing residents' working hours and shift lengths.6-8 Therefore, it seems clear that resident work scheduling is only one of a number of elements that contribute to patient safety. Compliance with recommended changes in duty hours may be suboptimal3 and was poorly reported in many of the studies we evaluated in our review.5 Other factors, such as distribution of clinical and administrative work between medical and ancillary staff, cross-cover between different medical teams,2 and a variety of other structure- and process-related parameters, are likely to significantly influence patient outcomes in an era of reduced resident duty hours.
With regard to educational outcomes (although in our review we chose to focus only on studies that reported objective outcome measures), the opinions of both experienced clinicians and physicians in training who have concerns about the quality of education and measurement of competence must be considered.1,2 If a pessimistic view is taken, it is possible that the lack of objective evidence to support the profession's fears regarding the quality of training results simply from the lack of suitably validated measures to assess that quality.9 We agree with the comments by Stain4 that ensuring that time spent performing clinical duties should also provide defined training objectives with measurable outcomes and that this aim should be a focus for the profession; we believe this to be particularly important in the European Union where working hours are now restricted to fewer than 48 per week.
These articles1-5 illustrate that the delivery of high-quality patient care and educational excellence are complex processes that require further evaluation and research. Qualitative experience from the European Union and the United Kingdom in particular may assist US residency directors in the development of curricula and competency frameworks aimed at ensuring that high-quality training can be delivered in a time-limited work-week. Conversely, the United Kingdom has much to learn from the United States about the measurement of patient outcomes in a robust and systematic manner, which can then be used to evaluate the effect of legislative changes on quality of health care.