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.
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
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.
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
I'm curious how the 24-hour shift works. When (if at all) do you sleep?
ReplyDeleteOn a busy service like surgery usually residents don't sleep. They're either answering pages or in actual surgeries. For other specialties, it can really vary depending on the amount of patients on your service and what kind of service it is. Someone in critical care would probably not sleep too much, whereas someone on a not-so-busy internal medicine service would probably get at least 4 hours of sleep. It really just depends where you are and what the patient load is at the time.
ReplyDeleteIt's hard for me to imagine how someone could be up for 24 hours doing demanding, high-stress, or otherwise important things and not have it affect their performance.
ReplyDeleteI appreciate the argument for continuity of care and the possibility of mistakes creeping in during hand-offs. But those are problems that seem like they could be mitigated by instituting appropriate systems/institutions/procedures (I'm thinking of Rule #6 in Don Berwick's User’s Manual For The IOM’s ‘Quality Chasm’ Report: "Current: “Do no harm” is an individual responsibility. New: Safety is a system property. Patients should be safe from injury caused by the care system. Ensuring safety requires greater attention to systems that help to prevent and mitigate errors.")
Cognitive impairment from sleep deprivation, on the other hand, seems to have only one surefire solution. And that one really is in the hands of the individual and not the system.