Work Hour Restrictions--Resident Opinions

How convenient!  In the latest issue of the New England Journal of Medicine, there is a follow up study on the new resident work hour restrictions, last updated in June of 2011.   The researchers decided to send a survey out to current resident physicians, asking how they liked the new 80 hour work week and how their medical training and lifestyles have been altered due to these restrictions.  I thought there were quite a few interesting results of the survey, and I'll talk a little about what I've noticed in the hospital as a result of all these changes.

In 2003, the 80-hour work week restrictions were put into place, stating that residents could not work more than 80 hours per week, averaged over a month.  Shifts were limited to 24 hours + 4 hours for educational purposes (i.e. lectures), and call was limited to every third night.  In 2011, shifts were cut for interns to 16 hours + 4 hours, but higher level residents were still held to the 24 + 4 limitation.  (Here is a table comparing the 2003 and 2011 regulations) As would be expected, there was a slight outcry in the medical community that duty would be shifted from interns to higher level residents, since they worked longer shifts.  People complained that continuity of care would be lost for interns and that they wouldn't be as prepared for subsequent years in residency.  People on the other side of the argument said that more medical mistakes were being made because residents were so tired and overworked.

Let's see how the residents felt about all of this.

First off, 123 of the 682 ACGME-accredited residency programs participated in the survey, and the researchers received a 23.3% response rate from residents at these programs (6202 individuals).  All specialties and subspecialties seemed to be well-represented, with internal medicine the largest group, composing 28% of the total responses.  The responses to the questions were based on a simple, 3 point scale:  worse, unchanged, or better.  If you take a look at table 2 in the article, you can see what the doctors thought of the new changes.  In summary, it seems that residents thought that the safety of patient care, the amount of rest they get, the availability of supervision, and the total number of hours worked this year as compared to last year remained unchanged after the new 2011 regulations.  The only thing that was remarkably better, according to the survey, were the quality of life for interns.  About 30% of those polled felt that they get more rest after the restrictions, and about 30% feel that their work schedules are better.  The things that were remarkably worse after the new restrictions were quality of life for senior residents, work schedules (43% felt they got worse), and preparation for a more senior resident role.  The quality of resident education overall was either unchanged or worse after the 2011 restrictions.  As feared, the number or frequency of handoffs in patient care was thought to have increased, as was the frequency of senior residents taking on work of more junior residents.  I would have liked to see a better breakdown of the responses, especially by specialty and by year of residency.  I'm sure they have this data, it just wasn't presented in the article.

In conclusion, 48.4% of residents disapprove of the 2011 regulations, 28.8% are neutral, and 22.9% approve of them.

Wow!  I bet the ACGME isn't too happy about the results of this study.  Unfortunately, I haven't been working in hospitals enough to really confirm for myself whether these 2011 changes, coupled with the 2003 restrictions, have or haven't been beneficial.  I do see a lot of work getting dumped on senior residents because the interns have to go home, so as not to go over their hours.  I have also noticed a TON of handoffs occurring, and I have noticed that many things often get lost in the mix.  Imagine the "telephone game," where one person whispers something into someone's ear, then they whisper something to the next person, and so on until the original message returns very distorted from how it started.  In a milder sense, this is what is happening with increasing handoffs in medicine.  The more whispers, the more can get distorted or misunderstood.  I actually have seen some pretty important information missed during a handoff that made for a poorer outcome for a patient.  If residents were at the hospital for longer periods of time, the argument would be made that they retain the continuity of care, know the patient's story, and are less likely to miss a small detail as compared to a resident who just acquired the patient 2 hours ago during a handoff.  The resident who has known the patient for 2 hours is obviously less invested in the patient, as opposed to someone who was paying close attention to that patient for a continuous 20 hours.

I have also seen work hours being violated in certain departments, especially surgery.  One of the main problems with how this system is set up revolves around the reporting of work hour violations.  Residents who want to file a work hour violation complaint are NOT protected by whistleblower laws.  This isn't anonymous reporting.  Also, why would any resident want to report work hour violations, when the penalty to their program is loss of accreditation if these violations pile up?  If the program dissolves because of the violations, residents are left out of a job, and it becomes infinitely harder to get licensed.  Anyone with common sense sees that you're just shooting yourself in the foot by reporting work hour violations.  That's why resident work hours are believed to be vastly understated, especially in specialties such as surgery and OB where very long days are the norm.  We clearly need a better reporting system.

There are a few studies out there that disagree whether morbidity and mortality is actually increased or not when residents stay up for long periods of time.  It really seems like these arguments for or against work hour restrictions are based more on anecdotal and theoretical evidence than hard facts.  One thing is clear from this study, however...residents aren't too happy with the 2011 regulations.  It seems to me that, if there really isn't a difference in patient outcomes with longer hours and residents aren't a fan of the current system, maybe some further adjustments have to be made with these regulations.  As it stands, I find myself leaning more towards having longer hours for residents.  I like continuity of care, and I personally hate handing off patients every 12 hours or so.  I feel less responsible for my patients, less connected to them, and ultimately less interested if I know that the next team will be handling the brunt of my patients' problems during their shift.

I'd be interested in seeing if Stanek has run into anything regarding this stuff during policy-making discussions.  I don't know much about the financial aspect of these regulations, or the implications on federal/state/hospital policy.

I'd also be interested to hear whether nurses and other staff have noticed a difference in patient care now that the new regulations are in place, or if things have remained about the same for the past 10 years.  What does everyone think?

Jim

Be Nice to Residents

So it's 5 am and I'm on my 2 week internal medicine night rotation, sitting here in the resident's lounge on the top floor of a huge hospital. We haven't seen a patient in 7 hours because the day team already "capped", meaning we can't accept any more patients tonight unless they are bouncebacks to our team. My two residents went to the call rooms to sleep (I certainly don't blame them!), leaving me to watch old reruns of sportscenter and the history channel. It's actually a nice time to reflect on topics that I haven't thought about in a long time, just because I've been so busy studying. One of the things I've been meaning to discuss on the Speakeasy pertains to residents, the docs that actually take care of you when you're an inpatient at the hospital.

Let me preface this by saying what I'm going to talk about applies mostly to large teaching hospitals, not the smaller community hospitals that do not accept resident physicians. A lot of people don't realize that, when they are admitted to a large hospital, most of their care is not managed by seasoned physicians like House. Usually a team of doctors, who aren't that far out from med school, are the ones really taking care of you. This team includes interns (first-year residents right out of med school) all the way to 5th year senior residents in some specialties. It's a hierarchy of power and decision-making capacity, designed to deliver the best care while providing the most education for these new doctors.

I want to run through what usually happens if you come into the ER at 2pm with a simple complaint like a skin infection (I'm going to pretend you're one of the patients that we saw tonight). You'll probably spend a few hours in the waiting room, depending how busy the day/night is. Unfortunately for you, your ailment isn't nearly as urgent as the 40 pack-year smoker having chest pain, that guy on a motorcycle who was just hit by a semi, or the little old lady with dementia who fell on her hip. You could be waiting for a couple hours just for an ER room. Once you get one, you'll probably spend another hour answering questions from a nurse, having vitals taken, and answering questions from another nurse. Then, if there haven't been a ton of other admissions to the ER more urgent than you, you'll get to be seen by an ER intern. He/she will ask you a bunch of questions, going over all of your past medical history and the history of your current illness. Then you'll wait as the intern eventually meets up with the chief resident or attending (depending on who is at the hospital at the time and how serious your complaint is) to present your case. The attending will eventually get to see you, popping his or her head into your room to eyeball you. They make a decision on whether to consult with the intention to admit or "treat and street", meaning they take care of you in the ER and send you home right from there. If they suspect that you will be admitted, the whole cycle starts again. In your case, they consult internal medicine, and the intern (with a medical student) comes down to the ER to see you. They ask you all of the same questions that the other resident asked, but because they're a different service, they have to ask you everything again so they can put it in their history and physical on the Electronic Medical Record (EMR). Once they are done, the intern presents you to their chief, and the chief comes down to see you (and often asks the same questions again, filling in any gaps the intern missed). The chief resident decides whether to admit you or not, in most instances. Not the attending. The attending is probably asleep, because by the time that decision has to be made, it's 11:30pm. regardless, it takes about a half hour to put in orders into the computer to admit you, and you find yourself in a room around midnight, finally ready to sleep.

Not many people actually know how much is decided for you by the resident when you go to the hospital. Let's start with your skin infection. They have to decide whether it looks bad enough to get surgery involved in your case, or whether it can be managed medically. You'll need IV antibiotics, labs, and an x-ray if a bone infection is possible. You also need IV fluids, depending on the labs drawn in the ER. If you were taking medications at home, those have to be reviewed and either continued or discontinued in the hospital. You have to be put on a diet, you have to be given bathroom privileges, and orders for tomorrow morning have to be put in (especially for labs). Contact precautions, because the last time you were in the hospital you had a MRSA infection, have to be initiated. You will need cultures of your skin infection, as well as nasal cultures, to prove that you are a MRSA carrier during this hospitalization. These are just some of the dozens of decisions and orders that have to be made for you, the easy patient with a simple skin infection. Imagine a patient with 12 current medical problems, with crazy abnormal labs, needing a slurry of decisions and orders to be made for each of these problems. Even though only one of those problems may have brought them to the hospital, they all have to be managed appropriately for the duration of their stay. The point of this is that residents do a shitload of decision-making and are really in control of over 95% of your treatment while in the hospital.

Ok, back to your skin infection. In the morning, you'll be bombarded by questions from the new nursing staff, medical students, and a whole new day team of residents. They will all have a meeting with the attending during or before morning rounds, talking about you and how to manage your problem. The attending will probably make only a few adjustments with the orders, everything else being taken care of by the night intern who admitted you or the day intern that you saw very early in the morning. Around 11am, the entire student/resident/attending team will show up in your room, the attending will say a few words to you and wish you luck in your recovery. Depending on their schedule, the attending will probably leave in the early afternoon to take care of other business, or more complicated patients. But to bill for the entire hospital stay, the attending must "lay eyes on you" at least once per day. That's it! He or she really needs to only see you for ten seconds. The attending will sign off on the resident's progress note, and the next time you will see the attending will be around 11am on the next day. Every question that the nurses have about you will go to the intern first, the up the food chain of residents until it gets to the chief, if it needs to go that far. Usually everything is taken care of by the intern. Unless something very serious happens, the attending will only find out about the previous day during the next morning rounds. Things can get much more complicated if multiple consults are made, or if you have procedures done to treat your illness. But for the sake of argument, we'll say that you didn't need any consults and you didn't need to have that skin infection drained.

Because you're such a healthy patient otherwise, your IV antibiotics do a good job taking care of that skin infection, and in a few days you're ready to go home. Before you can go, the attending must again "lay eyes" on you that day...then you're free to go! The residents handle most of the paperwork, including the discharge summary that goes to your primary care doc (and any other pertinent healthcare providers) summarizing your hospital visit. Oh, and they are most likely handling about 7 more patients more complicated than you at the same time they are taking care of you and your skin infection.

So the point of all this, if you made it this far in the post, is to demonstrate how much residents actually do for you while you're in the hospital. A lot of people immediately ask for the attending when they get here, not understanding how the system really works. In fact, consider yourself lucky that you're in a hospital with residents in the first place. A lot of smaller hospitals don't have this resident backbone, and in my opinion this can cause your healthcare to suffer. A lot of double-checks and discussion about your case takes place in these larger hospitals, both between residents and students, residents and residents, and residents and attendings. All this communication can only help when it comes to improving a treatment plan...the more minds, the better. However, you'll be sacrificing in time what you gain in brainpower, a concept that many patients don't understand when they come to very large hospitals. They assume that care will be faster because there are more resources, more staff, and more collective experience in the bigger hospitals. That's definitely not the case, and you may be waiting a very long time if you have a relatively minor complaint (minor in the eyes of the healthcare providers--I understand that even minor things can seem really scary and bad to patients).

One moral of this post is that everyone should get a primary care doc and go to them when they have smaller issues (or call them when you're not sure). I should practice what I preach, since I don't have a primary care doc while in med school, as don't many med students and residents--a topic for another post!

The real moral of this post is to be nice to your residents when you go to the hosptial. I'll try to talk a little more about resident work hours in yet another post, because this is one of the hottest topics when it comes to resident education in the US. Just remember that you are lucky to have them, as they are also lucky to have you as their patients and to learn from you. Consider that extra time you spend in large teaching hospitals to be a good investment in your health, since so many problems and mistakes get caught by people other than the lone attending watching over you from a distance, especially by residents and students (and nurses--another post topic!)

I'm really setting myself up for failure by suggesting all these future post topics...but hopefully I'll have some time on nights to address all these things. Let me know if there's something that strikes your fancy that I might be able to talk about more in depth. I want to get some quality stuff on here in the next two weeks.

Jim