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?”

 

 http://www.newyorker.com/tech/elements/why-doesnt-medical-care-get-better-when-doctors-rest-more

Courtesy of a colleague