Sunday, November 22, 2015

Why doesn't medical care get better when doctors rest more?

A few days later, the resident caring for the patient neared the teaching hospital’s witching hour: whether or not his work was done, he had to leave at 6 P.M. That’s because, a decade ago, largely in response to widespread concerns that tired residents were making too many errors, the Accreditation Council for Graduate Medical Education enacted nationwide rules that limited the number of consecutive hours residents can work. Five years later, a review of the data suggested that, on average, the rules had failed to make our nation’s teaching hospitals any safer. Proponents of the reforms argued that the rules had neither gone far enough nor been properly enforced. Accordingly, in 2011, first-year residents were limited even more—to sixteen-hour shifts, rather than the thirty hours previously allowed. Training programs scrambled to comply...

The data evaluating the impact of the 2003 reforms suggest that, when it comes to patient safety, little has changed in teaching hospitals. But when it comes to preparing young doctors to manage disease, the training environment has been completely transformed.

For a young doctor, the right course of action isn’t always clear. Acquiring the necessary knowledge and experience requires feedback, which strengthens one’s ability to anticipate how the many variables and small decisions might affect the patient. What’s more, learning how to manage illness demands infinite tweaking; each patient is unique.

But now, residents spend less time directly caring for patients than they once did, and the feedback inherent in the hours once spent with more seasoned physicians has also diminished...
The stories of our patients, which we used to own, now come in fits and spurts, passed along via an unending game of telephone. “Anyone know why the heart failure patient’s diuretic was held?” the team leader might ask. “Anyone?” With the resident who made the decision often gone, a mad shuffling of pages invariably ensues, as trainees flip through their lists until someone finds the patient and utters the six saddest words of the shift-limit era: “I don’t know. I’m just covering.” ...
Everyone knows how it feels to be tired, and there is nothing easier to count than hours worked or slept. I have lost count of the number of conversations I’ve had with non-doctor friends that have begun, “You do realize sleep deprivation is akin to being drunk?” This sentiment is echoed in a recently published survey of U.S. citizens that found that eighty per cent of people would prefer a different doctor if they knew theirs had been working more than twenty-four hours. This conviction—that a rested doctor who doesn’t know you would be better than a tired doctor who does—fueled the 2003 and 2011 reforms...
And although it will be a while before we can really understand the effect of the 2011 reforms, two recently published studies suggest that, right now, both quality of care and quality of education are suffering.
One study, led by Sanjay Desai at Johns Hopkins, randomly assigned first-year residents to either a 2003- or 2011-compliant schedule. While those in the 2011 group slept more, they experienced a marked increase in handoffs, and were less satisfied with their education. Equally worrisome, both trainees and nurses perceived a decrease in the quality of care—to such an extent that one of the 2011-compliant schedules was terminated early because of concerns that patient safety was compromised. And another study, comparing first-year residents before and after the 2011 changes, found a statistically significant increase in self-reported medical error...
But the other night I had a phone conversation with my mother, who’s also a cardiologist...
When she had a cardiac arrest, at home with her boyfriend, she was transferred to my mother’s care. Though the blood flow to her heart had been restored, by the end of the weekend her brain function had not. It was not clear what sort of neurologic recovery, if any, she would have...
“Mom,” I said. “It’s 8 P.M. Why on earth are you going to the hospital?”
“I’m going to see my patient,” she said.
“But you have been working nonstop for five days,” I protested. Of course, no one limits the hours of those already in practice, unlike residents. My mom had already worked eighty hours, in all likelihood. And it was only Wednesday.
“Her boyfriend’s driving in,” my mom explained. “He really wants to talk to me.”
And then, without thinking, the words popped right out of my mouth: “But isn’t there someone covering you?”
“I’m her doctor,” my mom said. “I’ve been with her since the beginning. Don’t you think this is important?”
Courtesy of a colleague

1 comment:

  1. Two trials extending shifts of first-year residents from 16 hours to as many as 28 or more at nearly 190 teaching hospitals to see what would happen to patients and trainees alike have come under fire as "unethical."

    The two trials in question evaluate whether ACGME restrictions need to be revised.

    Leveling that charge is the consumer watchdog group Public Citizen and the American Medical Student Association (AMSA), which includes residents. The two groups say that the trials not only have exposed sleep-deprived residents and their patients to harm but also have failed to obtain informed consent from them.

    "These are among the most unethical studies I've seen in the past couple of decades," said Michael Carome, MD, director of Public Citizen's Health Research Group, in an interview with Medscape Medical News.

    On November 19, Public Citizen and the AMSA asked the Accreditation Council for Graduate Medical Education (ACGME) in a joint letter to rescind waivers on current limits to first-year resident hours that the group issued to make the trials possible. They also have demanded that the Department of Health and Human Services investigate.

    The objections come in the wake of studies reporting that shortened resident hours introduced by the ACGME in 2003 and 2011 have not improved patient outcomes. And ACGME CEO Thomas Nasca, MD, notes that for the sake of fine-tuning training policies, only the Institute of Medicine (IOM), in 2009, recommended large-scale, specialty-specific studies on how resident hours affect patient safety — the sort of studies now being criticized by Public Citizen and AMSA.

    "We received the letter this morning [November 19], and we were a little bit surprised," Dr Nasca told Medscape Medical News.

    In 2003, the ACGME limited the work weeks of all residents to 80 hours, averaged over 4 weeks, and on-site duty, including in-house call, to shifts of no more than 30 hours. These 30 hours consisted of a maximum 24 straight hours of duty and up to 6 additional hours, designed to give residents time for patient handoffs, outpatient clinics, and didactic activities, among other things.

    In 2011, the ACGME restricted first-year residents to shifts of 16 hours, and other residents to 24 hours. For the latter group, "strategic strongly suggested," especially after 16 hours of continuous duty and between 10 pm and 8 am. Residents beyond their first year also can be asked to stay after their shift if need be, but not beyond 4 hours...

    Public Citizen and the AMSA question why the ACGME would permit these longer shifts after curtailing them in 2011 in light of their documented detrimental effects. For residents, they include a higher rate of needle sticks, depression, and motor vehicle accidents on the way home from work. As for patients, the two groups quote the ACGME in 2011 as saying, "PGY-1 residents make more errors when working longer consecutive hours."

    In response, the ACGME's Dr Nasca calls resident scheduling rules a work in progress, especially because only very small, single-institution studies have examined the effect of long hours on residents and patients. "So these groups of investigators put together multi-institution, randomized clinical trials to look at these issues," Dr Nasca said.