Shorter hours for young MDs, but not all cheering
Young doctors are about to be prescribed more sleep.
Beginning Friday, new rules will reduce the number of consecutive hours that first-year resident physicians can work - from 30 to 16.
The mandate is billed as a means of enhancing patient safety and residents' quality of life by reducing physician fatigue and errors. But it will also boost hospital costs and further reduce the long hours that some doctors believe are critical to learning.
Doctors in Philadelphia, an epicenter of teaching hospitals and medical schools, helped usher in this sea change. Residents are medical-school graduates training in various disciplines at teaching hospitals. The eight-county region has 15 such hospitals, training hundreds of residents each year.
"This is a progressive training model," says Tom Nasca, executive director of the Accreditation Council for Graduate Medical Education. "This is about a trade-off" in patient care that seeks to replace one fatigued but familiar doctor working a long shift with multiple well-rested unfamiliar doctors on shorter shifts.
The issue is a key one for patients. If you go to a teaching hospital, chances are you will be treated by a resident.
These changes mark the second wave of duty-hour regulations that the council has set for physicians-in-training in less than a decade. The nonprofit council accredits resident training programs.
The first rules, implemented in 2003 after a congressional inquiry, initiated the first workweek cap for residents across all disciplines - from neurosurgery to family care - at 80 hours and mandated supervision for practicing residents.
Doctors, overextended and sleep-deprived, were taught to accept the terms as a rite of passage. A "fraternity kind of mentality" prevailed, says William Friedman, chairman of the neurosurgery department at the University of Florida, who recalls being "dead tired" as a resident and operating "on autopilot" at times.
"I've been the tired doctor for most of my career," he says, "and I'm confessing to you that I've made some bad decisions in my career that I've regretted, and I wish there was a more tolerant culture."
The new rules phase out a tradition in medicine whereby hospital doctors stay with their patients as long as needed. That ethos, which can mean countless hours without sleep, "presents an unrealistic view of the world for trainees and doesn't psychologically prepare them" for practice, says Nasca, former dean of Jefferson Medical College. It sends residents the wrong message, Nasca says, that it is more dutiful to work tired rather than go home and get some sleep.
No one wants a repeat of what happened to Libby Zion. Zion, 18, died in 1984 at a New York City hospital after getting a wrong combination of drugs from two overworked, unsupervised residents. Her death influenced the 2003 changes.
This year's rules reduce maximum shifts for first-year residents from 24 hours, with an optional six-hour continuity period, to 16 hours flat. Second-year residents are now subject to 24 hours and a four-hour "continuity." In special circumstances they can stay longer. Residents must take at least eight hours off between shifts and four days off each month, according to the council's Common Program Requirements.
Enhancing performance by slashing work hours is contradictory for first-timers learning about continuity of care, some doctors say.
"There's a pervasive belief that the first 24 hours are the most important for determining a patient's trajectory, and there's a widespread concern that interns there for only 16 hours will only catch a piece of the process, and they'll come back tomorrow and not have a sense of it," says Kevin Volpp, associate professor of medicine at University of Pennsylvania and coauthor of reports on duty-hour reform. "The shorter the shift is, the less efficient the shift is."
Volpp and other doctors dislike what they call the changes' one-size-fits-all approach.
The new rules were recommended by the Institute of Medicine, a nonprofit advisory group that issued a 2009 report documenting the importance of sleep and supervision in hospitals. This year's key change, the 16-hour rule, is designed to conform more to our circadian rhythms, the biology in humans that anticipates night and day.
"After you've been awake 16 hours, there's a buildup of sleep pressure that intrudes into wakefulness and causes mistakes," said Penn sleep expert David Dinges, a key contributor to the report.
The only field report showing a positive correlation between shorter shifts and fewer errors comes from a 2002 study at Brigham and Women's Hospital in Boston, Volpp says. Residents limited to the 80-hour workweek made fewer than half the number of "attentional failures" during on-call nights in the intensive-care unit. But that study does not represent the real world, Volpp says.
That ICU employed about one nurse for every two patients, which takes some of the strain off residents. In regular hospitals, the rate is more like six or eight patients to a nurse, Volpp says. So there is too little information to know whether such improvements would transfer to a hospital or surgical floor.
Studies have linked physician fatigue to treatment errors, misdiagnoses, even car accidents. But the science also shows some people can handle sleep deficits, Dinges says.
The Telephone game
Some doctors argue that post-2003, hospitals have more oversight to safeguard against one tired doctor's bad decision reaching the patient, negating the need for new rules.
Besides establishing the 80-hour workweek, the 2003 rules underscore the importance of the "handoff" of patient data between doctors clocking in and out. Conducting handoffs is like playing the game Telephone, doctors say: The more shift changes there are, the more likely some tidbit of a patient's condition - say, a gradually increasing heart rate - gets lost. The advent of electronic medical records should aid those transitions.
A series of studies trying to gauge the impact from the 2003 rules show indicators such as mortality, readmissions, and medical errors remained static at hospitals.
"It seems like there's a reasonable likelihood that care may not get better," Volpp says. "It may get worse."
It will certainly get more expensive. Hospitals now are poised to hire a new crop of what they call "extenders." Although the 80-hour limit remains, the distribution of shifts will tip heavily in daytime hours to coincide with educational activities, leaving gaps at night. That means hiring more nurses and others.
Penn, for example, is hiring about 17 new employees to cover the shortfall. Salaries, benefits, moonlighting, and administrative services will increase costs by $5 million in the next fiscal year, says Lisa Bellini, vice dean for faculty and resident affairs at Penn. The council estimates the nationwide cost at more than $380 million per year.
Co-payments and deductibles will not immediately jump, but they will rise, and become apparent when it's time to balance the federal health budget, Bellini says.
Duty-hour changes have not altered patient outcomes at Friedman's hospital in Florida, he said, but residents are "happier and healthier."
That may be, but are they adequately equipped for the rigors of medicine?
Volpp aims to find out. He and a team are wrapping up a study on how the 2003 rule changes affect residents' scores on competency tests. The report is due out before summer's end, Volpp says.
One resident says he prefers a few 24-hour shifts to a series of 16-hour shifts because it gives him a crack at the "golden weekend," a full two-day break each month, which may disintegrate if first-year residents work shorter chunks every day.
"When you take that away, people are never going to be able do what you need to do to be human," says Matt Fellows, a Drexel University graduate in family medicine who just finished his first year at Thomas Jefferson University Hospital. "I think a huge part of being a good physician is being able to relate to your patients on a personal level. To do that, you need to be a person yourself."
Further, Fellows says, cutting hours might sever the personal bond that develops between a doctor and a patient during a stay. "I think you'll lose that sense of ownership," he says.
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