White Coat Underground

ACGME moves to limit resident work hours

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.

Comments

  1. #1 Theodore MS3
    June 23, 2010

    I have mixed feeling about these proposed changes. You are right to point out some of the errors that doctors make while working obscene hours. However, the trend lately at-least has been more towards controlling hours and sanctifying or condemning how resident work instead of actually cutting away at the hourly limit. As an up and coming resident though I am not particularly thrilled about these specific changes. I would rather work 80 hours a week at my own discretion, allotted to times that I feel are best for my patients, my own and my families overall well-being. The mandated shifts also are well documented to add a feeling of industry to the practice of medicine, a sense that we are manufacturing outcomes instead of caring for people. The tone of your article claiming that this is a possible mixed blessing as well as a decision not based upon strong evidence is very appropriate.

  2. #2 DrugMonkey
    June 23, 2010

    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.

    Nice afterthought. Glad that you have your priorities lined up properly on this one holmes….

  3. #3 PalMD
    June 23, 2010

    Hmmm….

  4. #4 D. C. Sessions
    June 23, 2010

    I’m still waiting for the “science based” part to kick in. The military have a somewhat longer history of pretending that character, determination, training, and general studliness can overcome physiology (march all day, drink and wench all night, repeat for several days, then trounce the enemy through sheer bad temper.) Read Chuck Yeager’s autobiography for examples in the Air Force.

    Then they started actually studying the effects of fatigue, anoxia, sleep deprivation, etc. on actual performance in even the most routine physical activities and guess what? The discrepancy between how the subjects thought they did and how they actually did grew very rapidly. In fact, the first thing that went was the ability to realize just how impaired they were. Now even the Marines are careful to make sure that the troops get enough rest because it works.

    So when I hear a physician tell me that residency taught him how to perform critical tasks while dead on his feet, the first thing I think of is the alcoholics I know who swear that experience has taught them to be better drivers while drunk than other people are when sober. There isn’t all that much difference between “impaired by fatigue” and “under the influence” — so if you’re OK with someone taking your life in her hands while fatigued, you should be fine with her doing the same after a bottle of wine.

    I want an objective fatigue test similar to a Breathalyzer. Never mind regulating hours, but if the focus is getting blurry ship ‘em to the cots.

  5. #5 WcT
    June 23, 2010

    Speaking as a (very newly) minted intern, I’m a fan of the changes.

    Night float and having numerous signouts come with it’s own risks to patients, but some preliminary studies are already showing that if you structure signout even those risks can be minimized.

    At my own program we’ve already had 2 hours of lecture that work out to “no ego, if you feel so tired you can’t go on, or if your residents are demanding you work illegal hours, use the anonymous hotline, and go sleep”

    Also – I too double take any time anyone calls me doctor.

  6. #6 PalMD
    June 23, 2010

    The closest the rec’s come to that is the requirement for “Alertness Management”

    The Program must:
    educate all faculty and residents to recognize the signs of fatigue and sleep deprivation;
    educate all faculty and residents in fatigue mitigation processes;
    adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, e.g. naps, back-up call schedules.
    Each program must have a process to ensure continued patient care in the event that a resident may be unable to perform his/her patient care duties.
    Sponsoring Institution must provide adequate sleep facilities and/or safe transportation options for residents who may be too fatigued to safely return home.

  7. #7 WcT
    June 23, 2010

    @D.C.

    I don’t know of any objective tests, but it’s not that hard to know when YOU are fatigued, it just requires being honest. Interns (unfortunately, myself included) have too much pride (or maybe fear) to admit to such things.

  8. #8 D. C. Sessions
    June 23, 2010

    PalMD@6:

    I trust we’ve all seen the videos of cadets in the altitude chamber and their attempts to recognize impairment?

  9. #9 Wct
    June 23, 2010

    The closest the rec’s come to that is the requirement for “Alertness Management”

    Yep thats all familiar, we have a “jeopardy call” for backup, and taxi tokens available, and they opened up a new wing of call rooms.

  10. #10 PalMD
    June 23, 2010

    @WcT

    That is very encouraging. I think one of the other solutions is to train supervising staff, other house staff, and NURSES to assess for fatigue, and to make sure the administration backs up judgement calls.

  11. #11 storkdok
    June 23, 2010

    1 in 4 would have been nice call. We only got that “leisure” call on a couple of rotations. Most of the time it was 1 in 3 or 1 in 2. As senior residents you took equal call with the younger residents and you had to come in for any horrendiomas. There was one stretch I spent 4 days/nights in the county hospital with a patient in ICU who’d had an amniotic fluid embolus. I only had a first and second year resident with me on that rotation, they hadn’t even done the Surgical ICU rotation, couldn’t insert and manage lines or ICU, and at the county hospital, there was no cross covering from the medical residents, we did our own. On top of managing the entire OB unit with high risk patients and an average of 18 deliveries a day. We also covered the GYN and GYN ONC patients at night, too.

    One night at county on OB we were so inundated, I did 10 C/S and IDK how many SVDs, with 3 sets of twins included and I wasn’t even on call AND our attending was doing SVDs on his own and trying to instruct the intern on deliveries at the same time and he was running to the OR to check on me. We delivered more than 50 babies in that 24 hr period. We were delivering in the hallways on gurneys, there was no more room. Gotta love county hospital!

    GYN ONC surgical rotation was very difficult, basically lived in the hospital for 2 months straight as 1st, 3rd and 4th yr resident. I don’t recommend it.

    I think these changes will be good for patients and for residents. Out of our medical school class there were 10 couples within the class who married. My dh and I are the only ones left married (20 years on July 1!). It was hard having both of us on call, we saw each other more in the hospital than out of it. You need a personal life, too.

    And safety, there were many times I don’t remember driving home, and I would wake up in my car in the garage with the car in park, still running, garage door open (thank heaven!). I got pulled over by a cop once post call for speeding (WTH? 75mph is normal in SoCal! and I was following 4 other cars) and he gave me the breathalyzer and other tests because he thought I was impaired from ETOH, I kept telling him I hadn’t slept in 36 hours, I was in scrubs with a name tag on, I was tired. I asked him to just give me the damn ticket and let me go home and sleep. He finally did.

    And yet, I learned so much, and I really LOVED residency, even with the horrible hours.

    I wonder about the pass off, though. There are a lot of things that can get missed if not done well (I think my OCD helped me here). More pass offs, more chances to miss things?

    Great post!

  12. #12 gaiainc
    June 24, 2010

    There are patient charts at my residency where you can pinpoint where I fell asleep writing the note. I have memories of getting pages from nurses about a patient, making some decision, then having no clue who the patient was that I did whatever I did with nor what I did. This was my intern surgical rotation where q2 was not unusual and it sucked. The rest of my rotations were less evil. However, I can function when tired and this ability came in handy when I had a baby.

    I will say I did learn some stuff on call that I didn’t learn at any other time. Like storkdok, there were calls where at the end I wondered how anyone survived. However, I did learn a lot or at least I think I did. I could all just be confirmation bias and recall bias. Overall though, not wearing out the residents and interns is a good idea.

    What I’d really like to see next is work hour restrictions for the attendings. In the past, my current department had the attending covering our maternity service on for 50+ straight. Sometimes that was fine, but being up two nights in a row delivering babies as well as babies in the day? Yeah… not so good. We’ve gotten a little more sane, but each of the three attendings covering our services in the hospital will at some point or another be on call for at least 36 hours. That still can be challenging depending on the service. It’s one of the reasons I’m leaving and no longer doing inpatient work. I’m getting old, I like my sleep, and I miss my family.

  13. #13 Lyle
    June 24, 2010

    If we have limits on the time someone can drive an 18 wheeler, fly a passenger plane, or run a locomotive, it seems that medicine should be no less strict than these fields since medicine involves a higher order of thinking. In addition at least the airplane example is run by checklists which stess following the steps as needed not innovative thinking. Actually the comment in #12 raises and interesting question should inpatient medicine be done only by hospitalists, and it and outpatient medicine be distinct fields.

  14. #14 daedalus2u
    June 24, 2010

    I have mixed feelings about this. IANAD, so what I am saying is dissociated from any actual experience with doctoring.

    Like all things, doing doctoring gets better with practice. Until the practice is done, the performance is not as high as it could be. Until you have practiced under extremely adverse conditions, your performance under those adverse conditions will not be optimal. Ideally, you would want to optimize degree of difficulty, adversity of conditions and patient type and load so as to achieve minimum adverse patient outcome. The problem is that you don’t know what is going to happen tomorrow.

    Storkdoc had an excellent example where they had do deliver a gigantic number of babies in a short time. You can’t wait, or be slow, or not act, or people will die. I suspect that practicing under some amount of fatigue did prep them for practicing under a gigantic amount of fatigue.

    If you are impaired by alcohol, you can always choose to not drive. What do you do if you are impaired by fatigue and there is no one to cover, and there are X CS that need to happen or the babies will die? Yes, the “system” that results in a need for more deliveries than the available staff can handle is flawed and needs to be corrected, but that correction cannot be accomplished before these X CS need to be done.

    Society should be willing to accept some level of doctor error during training, so as to train doctors that will produce less error during the rest of their career. The danger is that this trade-off which is acceptable (in my view) will be used to justify greater profits by working doctors ragged (which I find unacceptable). Or that it will be used to abuse underlings which is also unacceptable.

  15. #15 madoc
    June 24, 2010

    My opinion is that residency is virtual slavery,
    We will need to act.

  16. #16 G
    June 24, 2010

    I am horrified that these are limits that need to be set. Wow. I know what fatigue can do to judgment. That people are making medical decisions under that level of fatigue is frightening.

    And…geez, that kind of a work schedule sounds like hell.

  17. #17 rob
    June 24, 2010

    i’m sure this would have been a good post, but i stopped reading after the first paragraph. too many words. think i will go check out the first sentence of orac’s recent post.

  18. #18 Comrade PhysioProf
    June 24, 2010

    The data are absolutely ironclad that sleep deprivation and disruption of circadian rhythms are (1) extremely dangerous to the health of shift workers and (2) severely disruptive to their physical skills and cognitive decisionmaking processes.

    There is simply no question that this is the case, and it is mind-boggling that the clinical training establishment closes its eyes to this. If you want to access the primary literature in this area, I recommend starting with the work of Charles Czeisler.

  19. #19 PalMD
    June 24, 2010

    Is he related to Keyser Soze?

    Yeah the data are clear, although the outcomes data in medical settings aren’t, but given the importance and the plausibility, it’s way past time this happened.

  20. #20 Lisa
    June 25, 2010

    “I would rather work 80 hours a week at my own discretion, allotted to times that I feel are best for my patients, my own and my families overall well-being”

    @Theodore MS3: That’s nice. I don’t think hospital residency is what you think it is. You don’t have discretionary time.

    Trying to find a reference to the Libby Zion case that limited NY teaching hospital residents hours, I found this:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357165/?tool=pubmed

    It’s 5 years old now. I couldn’t find any newer studies.

  21. #21 PalMD
    June 25, 2010

    I have a buttload of studies on my desktop now. I’ll be blogging it.

  22. #22 ACarroll
    June 30, 2010

    The medical establishment needs to get over this self-inflicted romantic mythology of the heroic superman who individually leaps tall buildings in a single bound while avoiding all those speeding bullets. This fear-induced image is no different–and certainly has a lot more life- and death consequences–than fraternity hazing or unquestioning belief in “that old time religion” that was “good enough for Daddy.”
    Perpetuating this mythology runs counter to the well-documented and well-understood need for increased levels of teamwork and communication in health services delivery to improve patient safety outcomes. Why can’t shifts be overlapped and hand-offs be accomplished in the context of the team of clinicians who are caring for your patient? Why can’t better use be made of information technology and more complete documentation so that subsequent caregivers don’t have to have been there to know that a patient experienced an adverse reaction to some therapy or procedure? Why can’t there be more use of hospitalists, whose involvement in patient care has been documented to improve continuity of care, especially for complex patients? Why can’t there be more use of simulation in training, so that clinical apprentices are taught how to overcome the effects of fatigue (if that’s even possible) without experimenting on their patients?

    This argument that professional adversity during the learning process “toughens” providers and helps them “know their limits” is delusional. Tell the truth–do you believe the same about professional airline pilots? Would you put yourselves or your family members on an airplane where you knew the pilot was at a similar level of impaired performance? BTW, pilot apprentices are taught through the extensive use of simulations, and their performance is checked over and over, before they become members of a flight team. They are not allowed to experiment on their customers.

  23. #23 Helen Krummenacker
    July 3, 2010

    I, for one, welcome our new non-sleep-deprivation-addled doctors.

    The lack of continuity seems to me easily fixed by having an experienced nurse overlap between the interns.
    I also think you are likely to see medicine become more attractive to scientifically minded people who previously would have avoided it for the infamously grueling schedule.

    I dont know what the statistics are, but I’ve certainly heard people suggest that doctors with addictions usually pick up their habits trying to get through their residency.

  24. #24 Passerby
    July 5, 2010

    Excessive exposure does not result in superior training. This is known from military studies dating back to WWI starting in France. Further examined and noted in Air traffic controllers decades later. From a medico-legal standpoint, non-licensed residents are still at risk of litigation; they are not usually held to standards of a medical-trainee but rather general practioner. While hour restriction may be advantageous for fatigue it does nothing to correct error while wide-awake and due to inexperience or misdiagnosis. Careful oversight but Attending physicians resolves these most important problems, but these seasoned physicians are typically not in-house 24/7. The only true solution to the problem is pan-supervised managment of patients (either in front of, or behind the curtain) by supervising physicians. This would require more teaching physicians, which requires increased physician work-load, which requires increased medical training populations, something which has been carefully advanced, not for fear of anything else than gross physician yearly revenue. Ultimately, there the best solution is to increase numbers, even at the risk of decreasing pay.

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