Monday, March 04, 2013

Residency work hours revisited

What do residency program directors and residents think about the restricted work hours that were put into effect in 2011?  They don't like them.  Should we care what they think?

The New England Journal of Medicine reports on a survey of residency program directors.  Main conclusions:

Program directors reported that many aspects of training and patient care have been unchanged by the 2011 regulations, including resident supervision (62.0%), patient safety (57.0%), balance of service and education (60.9%), scores on in-service exams (73.6%), and fatigue (54.4%). Perceived quality of life for residents was the sole area identified by a plurality of respondents (49.5%) as having improved. Meanwhile, a negative effect was reported for resident education (64.8%), preparedness for senior roles (73.2%), and “ownership” of patients (78.6%); respondents also noted diminished continuity of care (82.0%) and increased frequency of handoffs (88.0%). Most program directors reported an increase in their own workload (73.8%), as well as increased utilization of physician extenders, such as nurse practitioners and physician assistants (61.4%). Finally, less than half the program directors (42.7%) reported that their residents are “always” compliant with duty-hour regulations.

In a previous survey of residents themselves, notes Kaiser Health News,

The residents themselves also [had] negative views of the changes.  A similar survey of 6,201 residents published in NEJM in June found that while 62 percent felt that quality of life had improved for interns, half reported that quality of life had gotten worse for senior residents, who were picking up the slack. Meanwhile, 41 percent reported that the quality of their education had gotten worse, and 48 percent disapproved of the rule changes.

What are we to make of this?  One observer on the National Patient Safety Foundation listserv said:

I was dismayed by this when I saw it. Then I remembered that this was an opinion survey. It is interesting, though, that residents and interns have so little regard for (and insight into) their own human limitations due to fatigue. They have already been socialized into the wonderful world of medicine, where everyone thinks she or he is superman, able to leap tall shifts in a single bound. Of course, nurses feel that way too. Most would rather work fewer longer shifts rather than more shorter shifts, even when confronted with evidence that the latter is safer.

Before we reach conclusions, it might be good to look at the science.  I recall a talk years ago by Charles Czeisler, the chief of the division of sleep medicine at Brigham and Women's Hospital.  He certainly made the point that an extended periods without sleep are dangerous (for patients, the residents themselves, and traffic accident victims as residents drove home).  But here's the thing:  I may remember this wrong, but I thought part of conclusion was that the pattern of sleep-and-awake mattered a lot--in terms of attentiveness--not so much the total number of hours of sleep that one got during a week.  If so, the prohibitions set forth by the ACGME may be mis-designed.

But, there is one thing for sure, as noted by the observer above:  Residents will never believe that any set of rules is good for them or their patients.  They are tricked by their own cognitive errors and imbued with a deep cultural prejudice into believing that they can "handle" anything that comes before them. In that regard, the medical education system has failed them.


Anonymous said...

I think the issue is even more complicated than you describe. We have reasonable survey data that show that our graduates are not as comfortable/confident about their clinical skills as they once were, particularly in the procedural specialties. And there has been considerable difficulty in demonstrating that quality of care has improved because of duty hours. Sure, this may be one of those items, like parachutes, for which we say we don’t have to prove that it works given the experimental studies on sleep deprivation; the relevance of some of those studies may be questionable, however, if one adds in what I call “strategic napping” (which I use during my night shifts each month).

The reality is that residents are getting less clinical experience; the solution may be to extend residency training, but no one wants to say that because of the costs both to the individual and to the system. I have no doubt that duty hours are here to stay, but we have to address the law of unintended consequences, which plagues many aspects of healthcare reform.

Lars said...

I would agree with the above - I think the pendulum has swung too far with regards to work hours and will need to correct itself to find a better balance between the additional education that being on duty gives and reducing cognitive errors due to sleep deprivation.

I would also point to the data that demonstrates a lack of benefit for the work hours and decreasing clinical exposure. As a person in training, I would say the better answer is more attending supervision rather than stricter work hours. One would hope that would increase both education as well as patient safety.

Beverly Rogers said...

From Facebook:

I agree with you, Paul; it is critical here to let the science drive the conclusions. Specifically, let us be scientific enough to admit it if the experiment (for that is what it is) is deemed not to have worked, and change it for the better, rather than just sticking with it because we originally thought it would work. Else we fall for the same cognitive misconceptions that the residents do.

Norma Sandrock said...

From Facebook:

As "dismayed" as one may be about residents' insight into their own fatigue, there is not a single piece of evidence that the work hour restrictions have improved patient safety. There is plenty of evidence that increased handoffs have a negative impact on patient safety. Residents are not so short-sighted as to want to trade "a better social life during residency" for better training, which is why they don't like the rules.
Well-meaning people made the rules which have not had their intended effect, at great financial cost to the system (those "extenders" don't come cheap) and at great educational cost to the trainees.
I'm not advocating a return to my days of 120-hour weeks in internship, but I can remember spending many of those hours drawing blood, transporting patients, and doing other "scut" that did not benefit education and did not require an MD to perform.
There must be a happy medium between using house staff as unpaid labor and restricting their educational opportunities.

David Joyce MD said...

Is it so strange that residents want a better social life, code for simply a more manageable joyful existence. Of course not. The question is, how does one achieve that? Business works best when all the incentives in an organization are aligned. The residency training has many different incentives to many different interests, and rarely are any of them aligned. Solution, teach medical students basic business skills. Teach them process decision making based on data, root cause analysis, proper leadership and strategy planning and maybe we will see some change. But whatever you do, do not drag them back to my training where I was did a 36 hour shift every third 14 hour day.

Budd said...

There is a big difference between the motivations of interns and residents vs. nurses, although they might share the "superperson" mystique. The nurses do it for a better life and better pay, despite consequences for patient care. Doctors in training do it for training and patient care (as well as for self-inflation, I guess), and actually take on more responsibility and work for the same pay.

@IshaniG said...

From Twitter: True that we tend to resist change... Duty hours are net + but we need more evidence. My take:

Hilary Corrigan CIR-SEIU said...

It’s worth taking a look back at the 2009 Institute of Medicine report that recommended the ACGME make significant changes in the way residents are trained in safety and quality – including a reduction in their work hours. A subsequent white paper Implementing the Institute of Recommendations on Work Hours, Supervision and Safety – also important reading – brought stakeholders together for a 2 day roundtable at Harvard Medical School to discuss how the IOM’s recommendations could be actualized. The ACGME is making good progress on the safety and quality curriculum front, but still falls short of acting on the mountain of evidence that links acute and chronic sleep deprivation with degradation in human performance. Kudos that interns are now limited to 16 hour shifts, but does it really make sense that on day one of the PGY 2 year, residents must go back to working 28 hour on-call shifts as often as every third night?