Resident Duty Hours: Time for a Wake Up Call?

22 02 2010

Anyone affiliated with a teaching hospital knows that the controversy regarding resident work hours is heating up again.  It’s been over 5 years since the ACGME limited resident hours to 80 hours per week with a maximum of 30 consecutive hours.  While this may not sound like ‘reform’, as someone who trained prior to these rules, it is definitely a change. 

More recently, the Institute of Medicine issued a report titled, “Resident Duty Hours: Enhancing Sleep, Supervision & Safety” which recommended cutting hours of resident physicians even more to 16 hours per shift OR a 5 hour ‘mandated’ nap in the current 30 hour system.  The report cites literature from sleep science demonstrating the perils of resident fatigue.  These recommendations have ignited a renewed furor – with groups on both sides of the fence.  For example, the AMA student section recently passed a resolution against the ‘nap’ stating that it would hurt continuity of care.  Other medical societies have highlighted the current issues complying with the 2003 ACGME duty hours and the enormous cost of implementing the IOM recommendations.  The cost of 1.6 billion would be cost-neutral to society if we expected an 11% reduction in preventable adverse events.  As a result of this report, the ACGME has convened a task force to issue new duty hour recommendations in 2011.

As physicians debate these positions, public support for further limits is growing.  Recently, 40 patient advocacy groups, including Public Citizen, have signed a petition urging the ACGME to adopt the IOM recommendations and others to sign the petition at a website cleverly named wakeupdoctor.org.  The website states “Missing: A Patient Perspective on the Need to Reduce Resident Work Hours” and explains the problem “You’ve seen them on Scrubs, ER and Grey’s Anatomy — deeply fatigued interns and residents. But truth is stranger than fiction.” The website does cite evidence that sleep deprived residents make mistakes and the recent IOM report.  Interestingly, the safety risks regarding handoffs are not mentioned. 

With shorter hours, there will be an increase in handoffs, with associated risks for patients.  The IOM report acknowledged handoffs were risky, but highlighted that duty hour reforms should not be hampered due to concerns regarding handoffs.  The IOM did recommend that all trainees receive education on how to perform handoffs.  Unfortunately, it is unclear how to train residents to do handoffs and what improvements actually result in better outcomes. 

Of course, no one wants a tired doctor.  But, the more relevant question is whether you prefer a tired doctor that knows you or a well rested doctor that doesn’t know you? Acknowledging the tradeoff makes it harder to answer.  My answer – it depends.  For a simple procedure, I would choose the well-rested resident (the one that’s most experienced in fact).  But, for a more complex decision where familiarity with the patient matters, I prefer the resident who may be tired, but knows me better.  Of course residents can’t work 24/7 (like they did when they were truly lived in the hospital hence ‘resident’) so handoffs will occur and limits on hours are needed.  But, to arrive at the best solution, we must present this debate in a more informed way for the public.     

Since I’ve explored duty hours in my research, here are my thoughts on some of the common questions I am asked about this topic:

1) Will reductions in hours lead to more well rested residents?   Reductions in hours will lead to some improvement in sleep, but sleep is often deprioritized because residents (like most people) have limited free time and sleep is competing with socializing, family obligations, and other general living life things.

 2) Can we mandate residents take naps (for 5h!)?  No, you can’t force anyone to sleep.  But, you can mandate break time.  Breaks are used in other long shift industries.  Unfortunately, residents are unwilling to use a break or nap if they still have high workloads or are concerned about handoffs.

 3) How can we improve patient safety during handoffs?   This is unclear, but it is clear that the process is fairly haphazard currently so that certainly investments can be made (i.e. formal training etc) so residents feel more capable in conducting handoffs.  More work is needed to know how to train residents in handoffs and also whether handoff improvements actually result in improved safety.

 4) Why not just get rid of extended shifts (longer than 24h)?   This question is interesting and it rests on whether there is really an educational value for residents following patients through the course of disease – and does that experience translate into better decision making in the future.  We don’t know currently since outcomes of residents graduated under duty hours vs. those without duty hours have not been compared since we are just starting to graduate trainees entirely trained under duty hours.  There are anecdotal reports that current resident graduates are less prepared to practice independently after duty hours.

 5) If Europe can have shorter hours for their doctors in training, why is it so controversial here?   Actually, the European Working Time Directive mandates a 48 hour work week for ALL workers, not just physicians.  This includes everyone, highlighting a major cultural difference between the US and Europe.  Junior doctors (what they call residents) were not granted an exception.  Moreover, the leaders of major European medical societies have opposed this regulation and have cited detrimental effects on resident experience.  Reports have also emerged that junior doctors are lying about their actual hours. 

 6) Why can’t we just extend training?  Extending residency training is not a popular option with students.  Unlike Europe where medical education is publicly funded, the average graduating medical student has well over $150,000 in debt.  In fact, due to concerns of a doctor shortage, most specialty societies are advocating for shortening the length of training in the United States.

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Making a Match List & Checking it Twice…

14 02 2010

Past, Present, and Future on the Residency Match & Some Last Minute Tips with 48 hours to go
Every 4th year medical student you know is making a list and checking it twice.  This is because rank lists are due to the National Resident Matching Program (NRMP) on Wednesday February 22rd 2012 at 9pm EST.

The history of the Match is actually very interesting.  Historically, physician training in medieval days was arranged when craft guilds matched apprentices with physician masters for their training.  Modern history of the US Match actually describes the situation where hospitals were pressuring students as early as 2nd year to sign up for internship before students knew where else they were competitive for and before hospitals had adequate information about student clinical performance.  In 1952, when the match was first proposed, medical students actually protested the initial algorithm since it penalized students for ranking a hospital who did not want them.  The students proposed the alternate algorithm, the “Boston Pool Modification,” which favored students rank preferences and was ultimately adopted.  Since that time, the growing number of preliminary positions and the need for a couples match has led to redesign of this algorithm, but always preserved favoring the student.

More recently, the Match has persevered in the face of a recent lawsuit that which accused the Match of violating the nation’s antitrust law. The Supreme Court ultimately dismissed the case due to an amendment that was made to antitrust law that exempted the Match.  While the lawsuit painted the NRMP as the evil player, the Court actually concluded that the NRMP and the hospitals’ participation in the Match “are so interdependent that the Court cannot separate them” in the allegations.   One benefit of the match is students are able to make decisions on a standard schedule, without being pressured to commit to a program prematurely.  Both applicants and programs must sign a Match Participation Agreement (MPA), which states that one party cannot solicit a commitment from the other or suggest that ranking is contingent on such a commitment.  Despite this, there is recent concern that these agreements are being violated.

Today, the Match has become even more competitive as the number of US medical graduates has increased with new medical schools and expanded class sizes (a result of the call by the AAMC) while the number of residency slots across the nation remains constant.  Leaders in medical education project that without any increases in residency spots, the number of US medical school graduates will eventually surpass residency spots in 2016.   While calls for increased residency spots continue, for the moment, strategy to optimize successful matching has become increasingly important for US students.  (Update:  2012 is the first year of the “SOAP” or Supplemental Offer and Acceptance Program that will take the place of the prior Scramble.  It is also the first day in recent memory Match Day is on a Friday!)

Here are my top tips for students in the final days of creating their match list:

1. Think twice before leaving off a program that you interviewed at.  Before leaving off a program, consider whether you would rather enter the scramble (aka SOAP) or go to the program.  The length of the rank list is the strongest predictor of matching.  This means you should not “suicide” match – or just list 1 place due to false assumption that you are definitely ‘promised a spot’ there.

2. Consider where you want to live and other non-program factors when constructing your list. When faced with programs that look very similar, think of locations that you would be happy.  Many people settle in the city that they do their residency training in. It may be especially difficult to distinguish between programs the further you go down your list – so definitely consider location at that point.

3. Don’t worry about where the program ranks you.  Remember – the match algorithm works in your favor – so its to your benefit to rank programs in the order you want to go to them and not try to ‘guess’ where they will rank you or reorder your list.

4. Avoid 11th hour changes. These will likely be motivated by faulty reasoning.  Instead, talk over your decisions with your friends and family well before so you can relax

5. Don’t forget to press “certify”! The last thing you want to do is be undone by failure to press this button before February 22nd at 8pm Chicago time.   

 

A video of some of good rank list tips here by Dr. Reddy:

 I should also add that because everyone’s case is different, its important to consult with a faculty member who is knowledgeable about the field and advising you on the process.   Good luck!  I’ll be rooting for you on Match Day.

-Vineet Arora

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Longing for the Doctors Lounge

8 02 2010

I just finished rotating at a community hospital where one of the most interesting things I’ve enjoyed is stopping by the Doctors Lounge. I can always count on a getting coffee there and hearing some good conversation – doctors asking for input on interesting cases, laughing, sharing stories, both personal and professional, and catching up on each other’s busy lives. In fact, I ran into an old friend of mine who I had not seen in some time and we caught up on each other’s lives in the Lounge.

I started to wonder why I found the presence of a Doctor’s Lounge so interesting. I realize it was because the hospital that I routinely work in does not have one. Yet, that was not always the case. I have fond memories of gathering with my medical colleagues sharing conversation over a warm meal. In medical school, the cafeteria had a “special” Doctor’s area with free soup and crackers – a VERY big deal for a medical student! I think I spent my entire year subsisting on that free soup.

In residency, one of my favorite places to eat was the Doctor’s Dining Room. A sea of white coats would gather in a room with wood walls decorated with large framed portraits of luminaries past to give it that ‘academic appeal’. Of course, medicine sat at one table and surgeons at another – but a lot of important business took place in that room that advanced patient care. After all, it was a place where you may run into the Infectious Disease consult resident and beg them for approval for the superdrug that would treat your patient’s superbug. Better yet, the “curbside” where you could feel like you weren’t adding to cardiology fellow’s workday but still get some guidance on whether you were reading and treating the rhythm strip correctly. (Of course, it did not hurt that at night, they also had free cakes for the residents on call.) Then one day, towards the end of my internship, I found out that they were getting rid of the Doctor’s Dining Room. Why? The answer was they needed the space for patient families- and of course no one would ever argue with that. It is now the Same Day Surgery Family Waiting Room. I understand the need for families to gather and wait patiently for news of their loved one. I’m all for patient-centered, but I do think doctors need space to gather and talk too.

In trying to look for any other stories about Doctor’s Lounges online, I am struck by two themes – “the Death of the Doctor’s Lounge” – due to time, workload, reimbursement, budget cutbacks, and the usual long laundry list of other woes in medicine today. But, I also saw references to the emergence of a “new” kind of Doctor’s Lounge — a modern day technological version through online physician communities that provide a social network for physicians to ask clinical questions and share cases (see Ozmosis or Sermo). While I am a big fan of social media (and experimenting with this blog), call me old fashioned… but I miss the days where doctors had a safe place to gather, converse, and meet in person.

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