In December of 2008, the Institute of Medicine published a report titled: Resident Duty Hours: Enhancing Sleep, Supervision and Safety. I have to admit that I have only read the Report Brief and the table of recommendations found on their website, however, it appears clear that the report suggests modification of current ACGME rules for shift length (although not theoretically reducing the overall 80 hours), and tightening of monitoring processes by the ACGME are needed.
The report was published almost a year ago, why bring it up now? One of the Staff here at the Cleveland Clinic brought the open letter from Dr. Thomas Nasca (CEO for ACGME) to my attention yesterday. I was so impressed by Dr. Nasca's thoughtful response to the report that I decided to scrap the topic planned for November and bring your attention to this document. After reading Dr. Nasca's letter, I wondered what our community was thinking about the IOM report and the ACGME response.
It would be hard to imagine that any physician group would argue against patient safety. The primacy of keeping patients' safe is one of the foundational principles of the social contract that physicians have with the public. After reading Dr. Nasca's letter, I can see that there are many contributing factors to a safe clinical environment. Sometimes these 'competing goods' are in conflict. A well rested resident is a good thing. Fewer staff hand-offs during care is also a good thing. If you haven't read Dr Nasca's letter and you teach residents, I suggest you take the time. I hope you also take the time to share your opinions on this vitally important issue.
http://acgme.org/acWebsite/home/NascaLetterCommunity10_27_09.pdf
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80 hours a week means an average of 11+ hours a day. I think most residents would agree that of that time, a very large portion of it is spent on scut work that will not be essential to their eventual career. What needs to be done is a revamping of medical training so that the time used is spent efficiently. Let's face it, residency is essentially cheap labor and hospitals use them to perform tasks that the hospital would otherwise spend money for. Instead, what you have are old-timers complaining about the "lack of dedication" that today's residents have for patients and work. How insulting.
I think that one (possibly the only) benefit of reduced work hours is that the trainees actually have less "scut" than they used to have- that drudge-work has been passed on to mid-level practitioners in many areas. The problem both for patient safety and for learning is that there are too many handoffs- the patient is NOT safer in the hands of multiple physicians, and the trainee learns less when he/she does not follow the evolution of the acute problem in the hospital setting.
I don't actually know what the document refers to with "fatigue management" is now better since the hours sleeping is the same as now? Perhaps someone could explain.
BJM-R
Tom Nasca gave a great summation of the problems posed by this issue. While patient safety may not have improved, there is no evidence that it declined, which I was relieved to see after the first reports came out, because we all see problems with hand-offs and miscommunication with covering house staff. The more i get immersed in the house staff training, the more i begin to agree that we are creating residents that do not appreciate the need to work a little ahrder or longer for their patients and see this less as a vocation and more as a job. on the flipside, i don't want to return to the days of 130 hours workweeks. Thank goodness for rumble strips on freeways waking up tired residents driving home post-call (me included). Maybe the pendulum is swinging back and we will see some compromise in the system, which will require innovation in how we think about duty hours vs duty to our patients.
Great thoughtful comments, It is not a simple issue. I feel better knowing that Dr. Nasca is at the Helm!
I think further cutting of resident work hours leads would be detrimental. Today's residents are already feeling disenfranchised and disconnected from their patient care responsibilites. I see more apathy toward resposibility than I did 5 years ago. Further reduction in their work hours would result in further fragmentation of their care. They still have the same amount of work to do, but they have less time to do it in. I believe work hours should remain the same, but that better working conditions should be available while residents are on duty.
Residents spend their time doing several things; a list that I came up with on the fly is:
1 talking with and examining patients
2 doing procedures
3 putting in orders
4 reviewing results
5 reviewing archivals(paper/electronic)
6 communicating with nurses, unit secs, case managers, family members, etc
7 documenting
8 getting didactic education (noon conference, morning report etc)
Except for 1, 2 and 8, residents do almost everything else in front of a computer. Unfortunately even 1 is becoming more of a copy paste from the ER note or y'days note.
Residents feel a strong pressure to complete their notes as early as possible. Documentation is a chore and not a time to reflect on the patient, a stimulus to look up reference material, to pick up and call a consultant .....
The time spent with the attending is a vanishing concept. Residency is supposed to be an apprenticeship where you learn from practical experience with a "master" or expert.
The concept of separating teaching from work goes against this philosophy. How can you be an apprentice if you do your work alone and only meet with the attending to "learn". What resident need to learn is how to integrate patient care (history, exam) with communication with order entry, result review, documentation and practice based learning and system based practice all happening concurrently - no artificial separation of these into different time periods.
We are never going to have more time in the day than we did. What we need to do is reorganize the work flow so the residents work WITH the attending as s/he does these multiple functions concurrently and they learn how to do that the right way.
Not only will they get training to survive in the real world, they will also get feedback on the ACGME competencies.
Start rounds as a team - see a patient together, review h/p in exam room, review EHR, results and put in orders while there (we have mobile carts!)- Divide up the tasks - student/intern presents the case, senior puts in orders or looks up reference info, and jots down key points in progress note. Rotate these roles during rounds.
Attending can complete hte note later in his/her office!
IDentify key learning points for each case and have the housestaff look them up and discuss the next day when you see the patient again.
Save time on progress notes, save time on "didactic education" and make it a true apprenticeship. We will be done well within the duty hours!
i am concerned that the strict limitation on hours keeps trainees from developing the sense of dedication that has to be part of the practice of medicine. I agree with dr. Nasca that there needs to be alittle more flexibility in the system--I would have considered it very unfortunate to have had to scrub out of an interesting case because I'd reached my time limit and I would never have learned how to manage other committments in a way to allow for emergencies. I like the idea of a mechanism of "fitness for duty"--it would both help to keep patients safe and might provide an objective measure which would help trinees and boarded physicians from recognizing when they'd reached a point of being dangerous. Of course, I don't know how close we are to such a measure. This might require more flexibility in training programs in that those who are less affected by the cognitive and technical decline of fatigue might acquire skills in a shorter period of time than those who are more affected. Starts to look pretty complicated but if graduate competence and patient safety is the goal, then we are going to need something pretty sophisticated.
There is no question that tired residents are a threat to patients and to themselves. However I'm not sure duty hour limitations the way they've been enforced is the answer. Unfortunately with the shift mentality that has developed as a direct consequence of work hour limitations as now enforced, I think residents have lost a lot more than they have gained. Although I spent more hours in hospital as a resident, and was more sleep-deprived, I'm thankful I completed training before the ACGME enforced work hour limitations. Dr. Nasca's writing shows an excellent understanding of the issues involved and I'm glad he is leading the effort to bring appropriate reform here.
BMJ poll - do restrictions in works hours compromise surgery education?
http://resources.bmj.com/bmj/interactive/polls
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