Do resident work hours limits create better physicians?

On a few previous occasions (e.g., Student Debt, Resident Hours, and Primary Care Redux, Jan 2, 2009) I have written about the issue of medical residents’ work hours and the implications that it had, good or bad, for patient care. A recent article in the British Medical Journal (BMJ) by Moonesinghe et al, “Impact of reduction in working hours for doctors in training on postgraduate medical education and patient outcomes: systematic review”, provides the most thorough review to date of studies evaluating the impact of work hours reductions for medical residents in the US and the United Kingdom, where they are even more stringent. They looked at studies examining both “training” (how are the residents learning?) and patient quality and safety.

This was not an easy task; true “meta-analysis” (grouping all the studies together as if they were one and re-analyzing the data) was not possible because they were so different in methodology, issues studied, and quality. In fact, the quality of most of the studies was not terribly high, and they often looked at several different outcomes making it hard to understand whether the changes all went one way, or there were some things that were better and some worse and whether the net result could be stronger (or weaker) if we could focus on only one at a time.

The good news for those who have implemented, supported, and argued for the work hours restrictions is that they seem to have improved the private life of residents, and to have not significantly harmed either the quality of training or patient care, at least insofar as these somewhat contradictory studies seem to indicate. Most of the studies were done in the US, and most were of surgical (28 of 41) or “hospital-based” (e.g., anesthesiology, critical care) trainees, rather than primary care.

Here are some of the results:

Training outcomes:

·    2 papers (both of “low methodological quality”, one of medical residents in the UK and one of surgical residents in the US, which “did not report statistical analyses of the results”) reported an improvement in training outcomes.

·   12 studies found a detrimental association; half from the US (all surgical) and half from the UK.

·    27 studies found no change (20 US and 7 UK)

·    There were also mixed results regarding the quality of “training opportunities” (exam scores, caseload)

Patient outcomes:

·    31 of 34 papers were US

·    4 studies showed improved patient outcomes, including the only randomized controlled trial in the group (note: this was in critical care and coronary care units, where shift work may arguably be more effective)

·    2 studies (in trauma and orthopedics) found increased complications

·    28 studies showed no significant difference

Surgeon and NY Times writer Pauline Chen commented on this article in “Is a well-rested doctor a better doctor?”, April 7, 2011. She describes talking with a surgical resident she knows who is very pleased at how much better her life is than she had feared. “’Training has changed a lot…My life is different than yours was — I have a lot of time outside the hospital.’ She described how she loved her work but was able to sleep at home most nights, go out regularly with friends, stay involved with her church and take an improv class.”  Cool. It is good to know that surgical residents are not acting as slaves, and can have some kind of life outside the hospital.

However, her resident friend was less sure about learning and patient care: “’To be honest, I don’t really know if this is better or worse,’ she said, recounting how she felt she was signing over responsibility for her patients more often than she ever imagined she would, missing key events in their hospital course and even getting dismissed during the middle of a patient’s operation in order to stay within the limits on work hours. ‘Sometimes it seems so counterintuitive to just sign out as if we were shift workers, but this is all any of us know right now…We have nothing to compare it to.’”

So, probably, as Dr. Chen observes, the discussion will go on. Those who believe that working longer hours results in tired physicians and therefore bad patient outcomes will continue to push those ideas; those who (largely, it seems, surgeons) believe that artificial limits on work hours compromise resident learning, thus not only having a negative impact on their current care of patients but, more importantly, their care of patients in the future care because they haven’t had sufficient experience in their residencies. One “side” says “Do you want to be operated on by a surgeon who has been up all night?”, while the other says “Do you want to be operated by a surgeon who is not as skilled because they were coddled in their training and didn’t get sufficient experience?”

“The most important test of success of postgraduate training,” say Moonesinghe and colleagues, “is the professional performance of those who reach the end of it.” They go on to make several suggestions, including, most importantly I believe, that “a consensus should be reached by the medical profession on appropriate measures to assess the quality of postgraduate medical training.” They agree with the assertion (from Temple, et al, “Time for training. A review of the impact of the European Working Time Directive on training 2010”) that “training is patient safety for the next 30 years”. Wise regulation must understand the balance, the risk-benefit of any change, and try to reach the greatest benefit with the least risk.

I would like to comment a bit upon the issues as they relate, in particular, to primary care training. Most of the studies that have been done have been on surgical specialties, which can measure surgical complications, deaths or morbidity, or in anesthesiology or critical care, because these are hospital based and more amenable to shift work. While a very few of the studies were in pediatrics, they also examined hospital work; none were looking at the training of primary care or family doctors. One of the other reasons that the surgical specialties have been so studied is that they have long been those with the longest work hours; thus, they are both the greatest target of reformers and the greatest resistance by current surgeons and teachers who fear that work hours restrictions will jeopardize the skill of their future colleagues.

The irony is that, as in so many areas, when laws or rules are being violated by one group, they are tightened on everyone, and those who were not violators of the old rules find their greater restrictions to comply with while, often, those who were violating it before continue to. In the 1970s when I was in training at Cook County Hospital, we had a resident union (yes!) and were limited to every-4^th-day overnight call. But the surgeons were on more often. If family medicine or internal medicine or pediatrics violated the rule, they were penalized, but the surgery residents were afraid to complain. And so, today, the violations of hours rules in some specialties increases the restrictions for all.

The problem with applying these rigid rules to primary care is that it is not shift-based. While residents spend time on inpatient services, the core of family medicine training is the continuity clinic where those doctors-in-training follow their own patients. It is important to be able to do this, to show up for your office hours to see your patients who are expecting to see you, even if you were up much of the night delivering the baby of one of your patients. If that happened every day, it would be a big problem, but it doesn’t. Yet there is a “zero tolerance” for work hour violations by the Accreditation Council for Graduate Medical Education (ACGME), so the program would be cited. Rigid cut-offs, indiscriminately applied, are a bad idea.

Residents should have work hour restrictions; they shouldn’t be on call every third night and up all night. They should get days off, should get time to spend with friends and family or sleeping. But the restrictions need to regulate hours in a more global fashion: hours in a week, days off in a week, average or typical number of hours off between shifts. They should not be counting minutes (and they currently do!), not create automatic violations for each instance in which, say, a resident returns to clinic after only 9 ½  instead of 10 hours off. They also should be specialty-specific, examining the character of the specialty’s practice, not to allow exploitation but to make them appropriate to how the specialty is practiced.

Some fields, like ER and critical care, work well with shifts. Some, like most hospital work that characterizes internal medicine and pediatrics training, generally work pretty well with “night floats” and days off, as long as there is careful attention paid to information transfer at the shift changes (“hand-offs”). Surgery may require longer shifts with more days off. And family medicine needs to allow residents to occasionally deliver their babies at night without canceling all the patients on their schedule the next day, as long as it is not the everyday norm.

We can do this rationally. We can have training that both provides time for the non-work lives of residents and good training for their careers; that ensures quality care of their patients now and in the future.

Resident Work Hours: Addendum

I know I said wouldn't post daily, but a short addendum to the Dec 3 post on Resident Work Hours, motivated by the Editorial in the NY Times today (http://www.nytimes.com/2008/12/09/opinion/09tue3.html?_r=1&ref=opinion)
The article notes that the Institute of Medicine (IOM) report expresses concern about the current 10-year old regulations may not be being enforced: "By most accounts, the current, weaker rules are widely ignored, so it will be imperative to make sure that any revisions are adhered to..." While this raises the obvious question of "how" this will be done, it also raises the issue of where this assertion, "By most accounts..." comes from. I have seen no citations, and know of no programs where these rules are violated in any regular way (of course, there may be a rare intermittent exception). The Accreditation Council for Graduate Medical Education (ACGME) monitors this very closely, and programs violating it have serious sanctions, so I am quite surprised and wonder whether this is really true.

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.”