Revisions needed for residents? Response to IOM report mixed
New IOM recommendations intended to improve patient care and resident education, but some say training could be compromised.
The Institute of Medicines recent recommendation that more steps are needed to ensure safer conditions for patients and trainees in teaching hospitals has proved controversial.
Issued by the IOMs Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, the recommendation comes five years after the Accreditation Council for Graduate Medical Education (ACGME) imposed the first set of national work hour limits for residents in all specialties.
In this new IOM report, the recommendation to further adjust resident work hours is intended to accomplish three objectives: to prevent fatigue when possible by giving regular opportunities for recovery sleep; to lessen fatigue when residents work extended shifts or night shifts; and to give training hospitals some flexibility in scheduling to provide residents the intensive, in-depth patient care experiences while enhancing a culture of patient safety and health care quality, said Michael M.E. Johns, MD, chair of the IOM committee and chancellor of Emory University in Atlanta.
Although the IOM report does not recommend further reductions from the maximum average of 80 hours per week set by the ACGME in 2003, it does recommend some significant changes. They include setting the maximum number of hours that residents can work without time for sleep to 16, increasing the number of days residents must have off, and setting restrictions on moonlighting during residents off-hours.
Have reduced hours worked?
The issue of duty hour restrictions was prompted in part by the death of patient Libby Zion in 1984. Her death was attributed to an adverse drug reaction allegedly missed by a fatigued resident. Although a grand jury investigation did not provide convincing evidence that work hours played a role, there was a perceived need to help prevent medical errors that could be linked to exhausted trainees.
Photo by Dan Burke
Since the ACGME issued its restrictions in 2003, several studies have evaluated the effect of those changes on patient safety and mortality.
One study, published in The Journal of the American Medical Association, found that restricted work hours at VA hospitals were associated with lower mortality rates in patients with acute myocardial infarction, congestive heart failure, gastrointestinal bleeding or stroke, or a diagnosis related group classification of general, orthopedic or vascular surgery.
A second study, also published in JAMA, showed that in the first two years of implementation, the reduced work hours neither worsened nor improved mortality for Medicare patients.
Long shifts increased errors
Results of recent studies have demonstrated that extended shift hours led to an increased risk for more serious medical errors. Interns made more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts, according to a study published in The New England Journal of Medicine.
Interns made 35.9% more serious medical errors during the traditional schedule with extended (≥24-hour) work shifts every other shift (every third night) than during the intervention schedule with no extended work shifts and reduced hours worked per week (P<.001). There were 56.6% more nonintercepted serious errors, according to the study.
The rate for serious errors on the critical care units was 22% higher (P<.001), and interns made 20.8% more serious medication errors (P=.03) when working the traditional schedule. The researchers noted that interns made 5.6 times as many serious diagnostic errors when working the traditional schedule (P<.001).
Extended-duration work shifts were associated with an increased risk for medical errors, adverse events and attentional failures in a study published in the Public Library of Science. Researchers found more attentional failures during lectures, rounds and clinical activities and 300% more fatigue-related preventable adverse events resulting in a fatality among interns who worked five or more extended-duration shifts per month.
Continuity of care, education compromised
Although there is some evidence that restricting resident work hours may be beneficial, some physicians say those restrictions can have a negative impact on continuity of care and resident education.
Obviously, no one can be in the building 24 hours a day, every day, but it helps to have a sense of a patients history, said Dawn Belt Davis, MD, PhD, clinical instructor at the University of Wisconsin-Madison.
If a resident has to go home at 7 a.m. no matter what, they may miss rounds, seminars or an important event that is happening with a patient, she said.
Juan Rivera, MD, a fellow at the Johns Hopkins Ciccarone Center for Prevention of Heart Disease, said that restricting work hours can diminish the experiences essential for training.
According to William Wood, MD, MPH, there is at least a general concern among some people that the sense of ownership and responsibility may be somewhat lessened by transitioning to a more shift-oriented work system. Wood is a second-year hematology and oncology fellow at the University of North Carolina at Chapel Hill, a member of the HemOnc Today Editorial Board, and has a blog on HemOncToday.com.
According to Jeffrey Weissman, MD, third-year resident at the University of California San Diego, there are times when you would much rather stay and take care of your patient because you are responsible and you have developed a relationship with them. Yet, you are forced to leave.
Lee Berkowitz, MD, professor and residency director at the University of North Carolina at Chapel Hill, agreed and said that adherence to work hour restrictions may result in conflicts for residents.
If residents are at the end of a shift and feel very involved and connected with a patient, it is difficult to say, Well, I have to leave now. Residents deal with that conflict often, he said.
Profession requires hard work
The expectation remains that residents and doctors must be able to tolerate heavy workloads and intense pressure. According to Zachary T. Bloomgarden, MD, professor of medicine at Mount Sinai School of Medicine in New York, being able to get a good nights sleep is not always a realistic goal.
Being a doctor is complicated and requires immense effort its the nature of the job, he said. Almost inevitably, carrying out such work properly will lead to periods of limited sleep.
Noelle LoConte, MD, assistant professor at the University of Wisconsin School of Medicine, wrote recently in her blog on HemOncToday.com that she struggles with feeling jealous of new residents because I did not have such nice work hours, but I also struggle with the thought that there are a crucial number of patients one needs to see to be a well-trained internist, and by cutting back hours without otherwise changing the training, we are further reducing the amount of patient contact.
Implementation should vary
Flexibility and adaptation are key to successful implementation of the IOM recommendations, according to David F. Dinges, PhD, professor and chief of the division of sleep and chronobiology at the University of Pennsylvania.
It should not be assumed that one prescriptive formula will solve every problem ... that all specialties are the same and that what is good for surgery will be good for internal medicine and so forth. This is discussed in the report, Dinges said.
It is not that one perspective is consistently right or wrong; it is about looking at the reasonable factors, how they relate to the scientific literature, and what would be an appropriate set of recommendations going forward, he said.
Rigid limits on working hours leave no room for differences among physicians, according to William Law, Jr., MD, a clinical professor of medicine and chief of the section of endocrinology at the University of Tennessee Graduate School of Medicine at Knoxville. Even though some physicians thrive in a high-pressure and intense environment, others may be less than competent without enough sleep. Law agreed that there should be a greater flexibility of the work-hour restrictions for smaller training programs.
Large programs with 12 to 30 plus residents a year have sufficient manpower to accommodate unanticipated increases in workforce demand created by resident illnesses, pregnancies and post-partum absences, he said.
Smaller programs with three to six residents a year may not have the extra manpower to cover all medical resident professional responsibilities, according to Law. Further, these smaller programs currently train a disproportionate number of the primary care physicians that serve the medical needs of millions of Americans living in smaller communities. Yet they must still keep within the 80 hour per week proposed limits.
In addition, they are more likely to lack the financial resources to hire hospitalists to do this work at 400% of the residentss salary, Law said. Since it is well-established that the single most accurate determinate of where a physician ultimately practices is where they completed their residency training, such rigid limits could conceivably force such programs to close their doors, thus depriving the smaller communities of the source of many of their practicing physicians.
Beyond duty hour limits
Although limiting hours is a critical component of the recommendations, not all health care professionals are convinced that it is the only answer. Workload and supervision are also part of the bigger picture.
Let us be clear that fatigue and long working hours are not the only factors that influence whether patients receive high quality care in teaching hospitals and academic health centers. Residents are not the only people who can make errors, Johns said.
Dinges said that there are factors other than duty work hours that should be monitored keeping track of the number of patients a resident has to handle; ensuring that there is adequate supervision by established, experienced physicians; ensuring that handovers of patients from one physician to another are not done too quickly so information is transmitted properly; and ensuring that there is a team approach so everyone accepts accountability for ensuring a patient has continuity of care.
Carl J. Pepine, MD, Eminent Scholar Emeritus and professor of medicine at the University of Florida agreed that supervision is vital. When I trained, there was a pyramid of trainees, so you maybe had 50 interns, 30 first-year residents, 20 second-year residents and 10 third-year residents. There was a pyramid of people at various skill levels supervising.
With all of the changes that have occurred over the past 10 or 15 years in training programs, that pyramid of supervision has been disrupted, said Pepine.
Financial burden of the changes
Financial costs and an insufficient health care work force are the most significant barriers to further revisions on resident work hours. The IOM has said that additional funding perhaps as high as $1.7 billion per year for teaching hospitals will be needed to cover the costs associated with shifting some work from current residents to other health care personnel or additional residents.
From my perspective as a residency director, the cost is a concern; for example, if you had one resident gone an extra day per week, 52 weeks out of the year, you can see how much that pulls a person out of rotation, Berkowitz said.
Law also observed that most training programs purposefully assign formal professional responsibilities to their residents designed to occupy most of the allowed 80 hours per week.
According to Law, the average medical resident has incurred a debt of $150,000 to $200,000 for his or her medical school education. Many residents traditionally rely on the extra income provided by the real-world level of compensation earned through moonlighting to supplement their salary.
The inclusion of all moonlighting hours, not just in-house institutional hours, in the 80-hour total may have the de facto effect of severely restricting their freedom to earn a living while in training, which may in turn further discourage residents from entering traditionally lower compensated fields, such as family practice, general internal medicine, and pediatrics, Law said. This is not a desirable development from a societal standpoint.
In early March, the ACGME will hold a conference with leaders in graduate medical education to review the IOM report and discuss possible revisions to the duty hour standards.
The nation must take a hard look at its residency programs including hours, schedules, supervision, patients caseloads and handovers and ensure that they serve both patient and resident safety today and education needs for tomorrow, according to the IOM.
Altering resident work hours is not sufficient to maximize safety and learning, according to the IOM report. Until these changes take place, residency programs are not providing what the next generation of doctors or their patients deserve. by Christen Haigh
For more information:
- Accreditation Council for Graduate Medical Education: www.acgme.org.
- Ann Intern Med. 2004;140:814-815.
- BMJ. 2003;327:E88-E89.
- Institute of Medicine of the National Academies Resident Duty Hours: Enhancing Sleep, Supervision and Safety Public Briefing: www.nationalacademies.org
- Institute of Medicine of the National Academies Resident Duty Hours: Enhancing Sleep, Supervision and Safety Reports: www.iom.edu
- JAMA. 2007;298:1055-1057.
- JAMA. 2007;298:984-992.
- JAMA. 2007;298:975-983.
- NEJM. 2004;351:1838-1848.
- NEJM. 2008; DOI:10.1056/NEJMp0808736. Accessed Dec. 10, 2008.
- Public Library of Science, 2006; DOI:10.1371/journal.pmed.0030487. Accessed Jan. 12, 2009.