Wednesday, December 3, 2008

Medical Resident Work Hours

An Institute of Medicine (IOM) panel has recently recommended further changes and modifications to the work rules governing medical residents. The recommendations go beyond the current rules, enforced by the Accreditation Council on Graduate Medical Education (ACGME) that limits residents to working 80 hours a week, no longer than 30 hours in a row, requires 10 hours off between shifts, and requires one day (24 hours) a week off (averaged over a month). The new recommendations do not reduce the total number of hours a resident may work in a week, but suggests limiting shifts to 16 hours with a minimum with a 5-hour nap break between shifts.

To the regular person reading these recommendations, they would at first seem quite reasonable, indeed a “gimme”. If the pre-Libby Zion work hours of some residents were horrific, the fact that the current ones are better does not make them good; even the new recommendations, that still allow residents to work to 80-hours a week, may seem excessive. Maybe, but there are other things to think about.

Let us look at who residents are. They are medical school graduates, MDs or DOs, who are now in training in a particular specialty. They spend a minimum of 3 years (for family medicine, internal medicine, pediatrics, and other specialties) to 5 years (for general surgery) or even 7 years (for cardiovascular surgery) in such training. For most residents, most of training is in the hospital; indeed the very term “residents” derives from when they lived in the hospital; the alternative “house staff” still implies that they are based there. For some residencies, however, mainly family medicine, practice in the outpatient continuity setting is the core focus of residency training. While other specialties (general internal medicine, general pediatrics) are also primary care, the residency programs in these specialties still emphasize hospital care, with usually one half-day weekly in outpatient clinics. Family medicine residents do in-hospital rotations, but, particularly in the last two years of residency, they are expected to develop and follow a panel of patients, and typically see their clinic patients 3-5 half-days per week. This means that they have to be available during the day on a regular schedule to see patients who expect them to be there. Unlike hospital medicine, or emergency medicine, this sort of practice doesn’t work very well with shifts. Such residents also have hospital duties but it is rare that they work more than 80 hours a week. Most programs have adopted systems like “night float” – where one doctor works the night shift for a week or two.

One of the more interesting things in the IOM panel report was its emphasis on “hand-offs”, where the doctors “going off” share the patients’ status and condition with those relieving them. From the NY Times:

“The panel paid particular attention to the so-called patient handoff, the point at which a resident briefs the next doctor about a patient’s history and needs as he or she is ending a work shift. The handoff is a risky time for patients, because rushed and fatigued doctors often inadequately brief incoming staff members, said Dr. Sandeep Jauhar, director of the heart failure program at Long Island Jewish Medical Center and a reviewer of the report.
Dr. Jauhar, who recently wrote about his medical training in the book ‘Intern: A Doctor’s Initiation,’ recalls a time during his own residency when a fellow doctor-in-training rushed a patient briefing without giving him basic facts about the patient’s serious condition.
‘When the nurse asked, “What do you want to do, doctor?” I didn’t have a clue,’ Dr. Jauhar said. ‘I didn’t have his case; I didn’t know what tests had been done. Each time you hand off a patient there is a possibility of error.’’’

There are a lot of issues being confused here. I don’t know when Dr. Jauhar did his residency (the “internship” is the first year of residency) but it looks like it was before the current hours rules were implemented. And it looks like he got poor “sign-out” or “hand-off”, for which there is no excuse. The big problem is that in putting the phrase “Each time you hand off a patient there is a possibility of error” in the context of these recommendations to reduce resident work hours, the implication is that somehow reducing work hours would reduce the frequency of hand-offs, which is entirely the opposite of what is true. The more that work hours are reduced, the more frequently the care of patients has to be “handed off” from one doctor to another. If there are risks inherent in these transfers of care, they will only be exacerbated by have more limited shift hours.

Patients want, and expect, the doctors caring for them to be awake, alert, and on top of their game. They should. However, they also want doctors who know them, know their “case” (what a horrific term for a person suffering an illness), know what has been done and what needs to be done. They should want that too. Ideally, the major decisions are made during the day by the patient’s primary doctor, who has not been up all night. But sometimes stuff happens, especially to sick people in the hospital, when it was not planned, and then there needs to be adequate information available to the responsible physician in house, including access to the ‘attending’ physician caring for that patient. (Note that there is no worry about post-residency physicians being awakened in the night.) Careful planning needs to happens. Schedules have to be designed to maximize learning for the resident, limitations on their hours, and also keep the care of the patient at the top of the list. None of these issues are as simple as they first seem.

Tomorrow, we will discuss another threat to continuity: Hospitalists.

Follow-up on not letting “the perfect be the enemy of the good” (November 28). Robert Ferrer, MD, MPH points out: “The other thing one might say about "don't let the perfect be the enemy of the good" is that it is a dishonest formulation. In most human endeavors, perfection is understood as rarely attainable. Consider the 800 SAT, the perfect game in baseball, the flawless scientific study. "Perfect" lies at the extreme right end of the bell curve of performance. Not so for universal health care, where, somehow, the vast majority of nations have managed to attain "the perfect." Only in an N of 1 scenario, where the U.S. is considered in isolation, can universal coverage qualify as exceptional performance.”

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