Thursday, April 18, 2013

Resident work hours

When I was a fourth-year medical student in 2002, I signed up for an intense "sub-internship" rotation in Family Medicine.  My goals for this rotation were two-fold: first, I wanted to make sure that I was ready for intern year and, second, I needed a good letter of recommendation to match into a good Family Medicine residency program.

On this rotation, I was essentially treated like the other interns.  I had patients assigned to me and was supervised by the senior resident on the team.  I took ownership of my patients, made treatment decisions, and even wrote orders (all approved and co-signed by the senior resident, of course).  I took night call (along with the same senior resident).  In short, I lived the same life that the interns did, just with more supervision and guidance.

The interns on the service took q5 night call, meaning that every fifth night they each stayed in the hospital admitting patients and responding to emergencies.  So, like the other interns, every fifth night, after working the full day (since 7 am), I stayed in the hospital overnight.  The next day, I worked my regular day, typically leaving around 6 pm.

As you can imagine, these 35 hour shifts were not a whole lot of fun.  Some nights I only got a couple of hours of sleep.  But I slogged though, I learned what I needed to learn, and I got that letter.

When I started residency in 2003, the ACGME began to limit resident work hours. Studies had shown that brains that had been awake for 24 hours functioned like brains exposed to a blood alcohol level of 0.10 (legally intoxicated in most states).  Anecdotes abounded of mistakes made by tired residents.  So, during my residency, I was only permitted to work 80 hours a week, no more than 24 hours at a time, and I had to have 10 hours off between shifts.

Mind you, 80 hours a week is still tiring.  But I felt that these limits were reasonable.  I had accepted, long ago, that the goal of residency was to become a competent family doctor.  I knew that residency was my one opportunity to establish a foundation of skills for my whole career, and I was willing to put in the work to get there.

A few years ago, though, the ACGME decided that further limits were needed on resident work hours.  Fueled by a report from the IOM, the ACGME decreed that residents needed to gradually adapt to working long hours during residency.  So, now first year residents may only work 16 hours without a break.  Senior residents, by contrast, have far fewer restrictions.

I was skeptical of this change, but figured I'd wait to see what would happen.  Interns would now have additional time to sleep, study, and recreate.  With this additional rest and study, surely they'd provide better care.  And, surely they'd be happier, right?

Well, Dr. Pauline Chen in the NY Times this week challenges this notion:

Now, two years after the 16-hour mandate was established, studies on the outcomes are being published, and the results reveal one thing....
Contrary to expectations, these studies have shown that interns have not been getting significantly more sleep. Moreover, they are not happier, nor are they studying more. In one national survey, nearly half of all doctors in training disapproved of the regulations altogether. Another study revealed that interns were spending less time in educational activities because the additional time required for such conferences and lectures would push them over the 16-hour limit.  In addition, there has been no significant improvement in the quality of care since the work limits took effect. 

These findings ring true for me.  Limiting shifts to 16 hours means that everybody has to work more shifts to cover the work.  A full 24 hours off is far more restful than just 12 or 18 hours, but with more shifts that happens less often.  Additionally, with these more frequent shift changes, handoff errors may be happening more often.

It's my fervent hope that the ACGME reverses the decision on 16 hour shifts for interns, but in the meantime, I'm trying to help my residency program respond by authoring a new, longitudinal patient safety curriculum.  I'm currently wading knee deep in best practice articles about handoffs, quality improvement, and other tenets of patient safety.  If you have any useful patient safety resources, I'd sure appreciate hearing about them as I put this together.

Because, at the end of the day, the discussion shouldn't be just about the residents - our patients must be our utmost priority.

ACGME = American Council on Graduate Education
IOM = Institute of Medicine

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