When it comes to medical blogging, no one has been as consistently good, fresh, and snarky as Orac. Respectful Insolence sets the standard for all other medical blogs, and though Orac may not be a media star like some other med bloggers, his writing has had a significant impact on some important medical issues such as vaccination. The fact that he is often the target of vicious attacks by anti-vaccination activists and other quacks and wackos shows just how good a job he is doing.
Though he has been criticized for being a bit loquacious, his thoroughness is one of the traits that makes him so effective. So I was very happy to see his post on the so-called “July Effect”, the idea that hospitals are more dangerous in July when the new interns start. I love July, as difficult as it sometimes is. I always call the new interns “Doctor” and it always makes them do a double-take. Orac’s takes a very detailed look at a new study of the July Effect, and the data still aren’t clear as to whether and how July may be more dangerous to patients.
Another question regarding resident training and safety is resident duty hours. The data are not at all clear as to the effect of these hours on residents and patients, but despite a paucity of data there are reasons to believe that some parts of medical training may not be great for young doctors or their patients. In their continuing effort to address these concerns, the Accreditation Council on Graduate Medical Education (ACGME) today released a new set of standards for medical resident supervision and duty hours.
Before I explain these changes, which residencies will be expected to adopt, let me explain the traditional schedule. It’s no secret that residents work some crazy hours, although over the last ten years there have been some efforts to control this. Residents have been known to have fatigue-related auto accidents, and as stated above there may be patient safety issues related to fatigue. Different specialties have different schedules, with internal medicine (my specialty) being neither the worst nor the best (surgery and OB/GYN tend to be the worst). Classically, internal medicine interns take call “q4”, meaning that every fourth night they stay in the hospital. This means that on Monday, for example, they may come in at 0530 to pre-round, stay all night, finish all their work by Tuesday evening and go home to roll out of bed early again the next morning. It’s usually pretty easy to identify the “post-call” residents: they are wearing scrubs, unshaven (if relevant), rumple-haired, and they look tired.
The ACGME has decided to focus on first year residents (interns) in their new standards, as these are the residents who have the least experience, and the data indicate they may—maybe—be at higher risk for committing preventable errors.
The new standards set a limit of 80 hours of work per week. They also limit interns to no more than 16 hours of work at a stretch, with at least 8 hours between shifts. This is going to have a significant impact on the design of medical residencies. One of the advantages to the more torturous schedule was continuity-of-care. When I admitted a patient on Monday afternoon, I would be with them during the critical first day of their admission, seeing the patient through the whole initial work up. The new standard will essentially mandate a shift-work model, in which an intern will admit the patient, then hand her off to another intern to go get the mandated rest break. The ACGME recognizes the potential problems of “hand-offs” and allows some time “off the clock” for them.
One of the shifts likely to be implemented is “night float”, where a few residents will take admissions and keep an eye on the house. Many programs already have night floats, but the new system will make them nearly unavoidable. When I was a resident, we generally did 14 nights in a row (if I recall correctly) from 11 pm to 7 am. The new standards will limit these shifts to six in a row.
Residency spots are limited in number. Institutions can only afford so many residents per year, and with further work limits, hospitals that depend on these doctors are going to have to rely increasingly on other clinicians to care for patients. Physicians assistants and nurse practitioners are already being used extensively to care for patients in hospitals, and this role will probably increase as a direct result of these changes.
As valuable as my “in the old days” training was, these changes are probably positive in the long run. It’s not good to over-fatigue our young doctors, who may be risking their lives driving home after 30 hours at work, and if it has a positive effect on patient care, great.* But we still must remind our young doctors that when they get out into the real world, there is no ACGME, no limit on work hours.
*DrugMonkey pointed out the implication of this statement. Upon self-examination, a few things underly this. First, I have a responsibility to both my patients and my trainees. The evidence of benefit to patients of these changes is not strong, but I do anticipate benefits to trainees. I am also biased by my own post-call traffic accident.