Monday, November 30, 2015

Medical residents: Overtired or undereducated - pick your poison

Although ideally doctors would get eight hours of sleep each night, that dream is not the reality of healthcare in the United States. Most physicians, especially those in training, are required to work long, grueling hours.

Medical residents: Overtired or undereducated - pick your poison


by Erica Cohen

You are wheeled into trauma bay A at 3 a.m, barely conscious after a severe car accident. A dozen medical professionals buzz around you with Dr. Teele (a fictitious name), a trauma surgeon, as the lead doctor. He is a new attending physician, and because of residency duty hour reforms, this is his first shift lasting longer than 24 hours. If you knew he was treating you on hour 26 of his shift, would you want him as your trauma surgeon? 

Although ideally doctors would get eight hours of sleep each night, that dream is not the reality of healthcare in the United States. Most physicians, especially those in training, are required to work long, grueling hours.

The road to becoming a doctor is difficult and winding. After 4 years of medical school, physicians begin a  one- to seven-year residency program to gain clinical experience. During residency, physicians treat patients in their area of specialization under supervising physician guidance.

Residents have traditionally worked especially long hours. Prior to recent reforms, those in some specialties worked up to 120 hours a week. In addition to being inhumane, these long work hours create risks to patient safety.

New York State initiated duty hour reforms in 1989 in response to the 1984 death of an eighteen-year-old girl, which was attributed in part to the exhaustion of the residents who treated her. The residents had been working for 18 hours straight.

In 1999, the Institute of Medicine (IOM) released a report titled To Err is Human, which indicated that between 44,000 and 98,000 deaths in U.S. hospitals each year are caused by preventable medical errors. In 2001, advocacy groups petitioned the federal Occupational Safety and Health Administration (OSHA) to regulate resident duty hours on a nationwide basis.

In response, the Accreditation Council for Graduate Medical Education (ACGME), a private organization that accredits residency programs in the U.S., developed duty hour restrictions in 2003. 

The restrictions have evolved since then. Under 2011 revisions, residents can work up to 80 hours a week with 1 in 7 days off, averaged over a month. First-year residents cannot work longer than a 16-hour shift and second-year and higher residents cannot work longer than a 24-hour shift. Residents must have 10 hours off before their next daily duty period after working an in-hospital shift.

But the million dollar question is: are the reforms working?

A 2009 New England Journal of Medicine editorial suggested that the 2003 reforms had not improved patient outcomes. The reason is that while patients are at risk when treated by overtired physicians, they are also at risk when their physicians do not have the necessary knowledge and experience.

Some say “night float” systems implemented to allow residents to sleep result in a “shift worker” mentality for physicians who never learn how complicated conditions evolve. If residents do not see a patient’s care from start to finish, they will not gain the crucial knowledge needed to treat the next patient who is wheeled in with a similar problem. 

The hour restrictions have decreased educational opportunities, particularly clinical bedside and surgical experience. Some program directors have said that unless they extend residency programs to account for the lost educational and clinical opportunities, physicians will be unprepared for independent practice.

Additionally, there are no limitations on the number of hours non-resident physicians may work. Therefore, residents may finish residency and be entirely unprepared for longer shifts.

While resident duty hour limitations are necessary to prevent inhumane working conditions and risks to patient safety, there are significant improvements that can be made. Perfecting sign-out (when residents change shifts and discuss their patients’ past and future needs) and ensuring that nurses, physician assistants, and nurse practitioners are scheduled on overlapping shifts so that all providers are not leaving at one time should help alleviate some of the risks. 

Additionally, allowing exceptions for certain specialties with particularly long surgeries and a need to follow critically ill patients from the beginning of treatment until the end may address some of the educational concerns.

Finding the best balance comes down to a matter of life and death. Hospitals and the ACGME should make the search for solutions a priority.

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Robert I. Field, Ph.D., J.D., M.P.H. Professor, Drexel University Kline School of Law & Dornsife School of Public Health
Jeffrey Brenner, MD Founder of the Camden Coalition of Healthcare Providers, Medical Director of the Urban Health Institute at Cooper University Healthcare
Andy Carter President & CEO, The Hospital & Healthsystem Assoc. of Pa.
Robert B. Doherty Senior Vice President of Governmental Affairs & Public Policy American College of Physicians
David Grande, MD, MPA Assistant Professor of Medicine at the University of Pennsylvania
Tine Hansen-Turton Chief Strategy Officer of Public Health Management Corporation
Drew A. Harris, DPM, MPH Director of Health Policy Program at the Jefferson College of Population Health
Antoinette Kraus Director of the Pennsylvania Health Access Network
Laval Miller-Wilson Executive Director of the Pennsylvania Health Law Project
David B. Nash, MD, MBA Founding Dean of the Jefferson College of Population Health
Mark V. Pauly, Ph.D. Professor of Health Care Management, Business Economics and Public Policy at The Wharton School
Howard J. Peterson, MHA Managing Partner of TRG Healthcare, a national healthcare consulting firm
Paula L. Stillman, MD, MBA Healthcare consultant with special expertise in population health and disease management
Elizabeth A. W. Williams Senior Vice President & Chief Communications Officer for Independence Blue Cross
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