Monday, August 26, 2013

Getting sleep versus staying engaged with the patient

Lisa Rosenbaum has posted a thoughtful piece over at The New Yorker entitled "Why Doesn't Medical Care Get Better When Doctors Rest More?"  After introducing a story about a patient, she says,

A few days later, the resident caring for the patient neared the teaching hospital’s witching hour: whether or not his work was done, he had to leave at 6 P.M. That’s because, a decade ago, largely in response to widespread concerns that tired residents were making too many errors, the Accreditation Council for Graduate Medical Education enacted nationwide rules that limited the number of consecutive hours residents can work. Five years later, a review of the data suggested that, on average, the rules had failed to make our nation’s teaching hospitals any safer. Proponents of the reforms argued that the rules had neither gone far enough nor been properly enforced. Accordingly, in 2011, first-year residents were limited even more—to sixteen-hour shifts, rather than the thirty hours previously allowed. Training programs scrambled to comply.

Rosenbaum then leads to some of the intangible aspects of the work hours rules:

The data evaluating the impact of the 2003 reforms suggest that, when it comes to patient safety, little has changed in teaching hospitals. But when it comes to preparing young doctors to manage disease, the training environment has been completely transformed.

While these studies suggest the complex nature of patient safety—that manipulating one variable, like hours worked, inevitably affects another, like the number of handoffs—there is another tradeoff, more philosophical than quantifiable. It has less to do with the variables within the system and how we tinker with them, and more to do with what we overlook as we focus relentlessly on what we can count. 

Near the end of the article, she starts a story:

As a third-generation physician, I did not think the cultural transformation of our educational environment would affect my fundamental sense of what it means to be a doctor. But the other night I had a phone conversation with my mother, who’s also a cardiologist. 

I'll leave it to you to read the rest. 


Anonymous said...

Sounds as though docs need to learn about handoffs from the nurses. If you can't hand over care of a patient without leaving something out, you won't make it as a nurse. Also, I can't help but wonder why the docs don't have charts to review for their patients with enough detail in them to help understand what's going on. It's very romantic to think of a doctor sacrificing their life and health to "be there" for patients. But I would really question the utility of it.

Anonymous said...

Unless this bone-headed policy is reversed soon on the basis of the plain evidence, we will be sentencing a generation or more of patients to care from poorly trained, disconnected physicians. This has to rank right up there as one of the most misguided, though no doubt well-intentioned, steps ever taken by the profession. I suspect that a root cause analysis of how the decision was taken would reveal lots of politics and very little of true science, as opposed to pseudoscience.


David Joyce MD said...

Physicians based the vast majority of clinical decision making on data driven truth. They also base most of their delivery process (business) decision making, of which the number of resident weekly hours is a prime example, on perception. We must always remember, Perception is the true enemy of reality.
Incorporating the same data driven truth into all process formation will not only make us safer but it will lower cost in all of health care.

Anonymous said...

Paul et al,

I have to disagree with the conflation of care transitions challenges with resident work hour reform, and rather to agree with the first comment, where its noted that nurses engage in such communication many times a day. While the work structure of residency is a worthwhile debate (ask any resident if they'd rather work 6 days/wk or a long shift - then ask any airplane pilot how they feel about long flights...oh wait, you can't... they have shorter shifts to keep us all safe), there is evidence of both successful handoffs (emergency medicine) and unsuccessful handoffs (you name it) throughout clinical care every day. Maybe instead of castigating work hour reform, we should focus instead on how to train our young physicians (and those that aren't so young) to do meaningful, comprehensive, and clinically appropriate handoffs - surely the answer can't be elimination of shifts for physicians, which is the logical follow through on your argument.

Local QI/Safety Pro

hipparchia said...

count me among those who see this as two problems to solve: 1. doctors working too-long shifts, and 2. doctors not learning how to do shift changes properly.

we've made a start on the first problem, but if that new yorker article is indicative of the general state of things, then nobody's really started on fixing the second problem.