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Wednesday, December 3rd 2008

Protecting Patients From The Ivory Tower

When a medical student graduates as a physician they go on to residency. Such a time in a physicians life has been glorified by shows like Scrubs and Grey’s Anatomy.

My Goal Is To Be Like J.D. During Residency

Residency is a grueling apprenticeship. In the American and Canadian model it probably represents one of the most time consuming apprenticeships on earth. Residents play a huge role in patient care and several years ago the question over resident errors when they were tired led to rules which restricted how much residents could work. Technically residents are not supposed to work more than 80 (or in some cases 88) hours a week; averaged over four weeks.

Questions of compliance, especially in the surgical specialties, remain.

Nevermind, because now a panel from the Institute of Medicine have recommended further restrictions on how much residents can work.

While the new recommendations do not reduce overall working hours for residents, the report says no resident should work longer than a 16-hour shift, which should be followed by a mandatory five-hour nap period.

The committee also called for better supervision of the doctors-in-training; prohibitions against moonlighting, or working extra jobs; mandatory days off each month; and assigning chores like drawing blood to other hospital workers so residents have more time for patient care.

Okay, to be fair, it is a better report than some of the working drafts that were leaked. Initially it looked like the panel was going to propose that the 80 work week be reduced to a 56 hour work week. That would’ve truly been insane.

Yet still, the Institute of Medicine panel has very poor perspective on what they’re delving into.

There is a very sound argument that surgical residencies are the most time consuming and that neurosurgical residencies are the most grueling of the grueling. I want to be a neurosurgeon. I’m not going to get pumped up and claim that I’m hyped about the long work hours. But they’re necessary.

The prospect of mandating restrictions on resident work hours in a neurosurgery residency is dangerous. I actively oppose both the current work hour restrictions and the new proposal from the IOM.

As I said, the IOM panel has a very poor perspective. It is difficult to degrade the efforts of a panel composed of such esteemed individuals but consider the following: nearly half of the panel is non-physicians and the panel included just one surgeon (an otolaryngologist).

A panel in which eight of seventeen members are not physicians and in which only one of the members is also a member of a surgical specialty; the specialties to be most effected by the recommendations (if implemented). I cannot believe, even with all the credentials of the panel members and the ‘exhaustive’ input the panel solicited, that anyone is taking this study seriously. It is laughable for a group to be making such recommendations without the first hand experience to bolster their voices.

The AHRQ, who commissioned the report to be done, had this to say,

“The Institute of Medicine study provides the clear evidence to prove what we have long-believed is true—fatigue increases the chance for human error,” said AHRQ Director Carolyn M. Clancy, M.D. “Most importantly, this report provides solid recommendations that can improve patient safety, as well as increase the quality of the resident training experience.”

As can be imagined, not all physician groups are cheering, the American Association of Neurological Surgeons came out with a strong statement against the panel’s recommendation. There are three main arguments against resident work hour restrictions.

First, while resident fatigue promotes errors so do “hand offs.” Hand offs occur when you turn care of a patient from one resident to another. As you can imagine, restricting resident work hours increases the number of hand offs. By some estimations the panel did not adequately weigh such risks to patients.

“The IOM committee, in making these recommendations, has failed to adequately consider the key patient safety issues – the considerable risks associated with too many patient handoffs and lack of continuity of care in complex neurosurgical disease or injury cases,” remarked AANS President James R. Bean, MD.

The IOM report was published just months after a major study published by the Joint Commission. This study, done at MGH, found that,

A significant percentage of resident physicians report that patient handoffs – transfer of responsibility for a hospitalized patient from one resident to another – contributed to incidents in which harm was done to patients. The study, published in the October 2008 Joint Commission Journal on Quality and Patient Safety, identifies situations in which problematic handoffs are more likely to occur and factors that may interfere with the smooth transfer of crucial information.

“Our findings suggest that patient harm from problematic handoffs is common,” says Barry Kitch, MD, MPH, of the Massachusetts General Hosptal (MGH) Institute for Health Policy and Harvard Medical School (HMS), lead author of the study. “In fact, problematic handoffs may be as significant a source of serious patient harm as are medication-related events.”

Second, the changes will limit the experience resident physicians get. In complicated surgical fields such can be an actual detriment to future patient care. Neurosurgery residency, for instance, is already up to eight years in length. There is nowhere to go to extend the length of time you spend in residency. And so neurosurgery residents are literally getting less training than before the work hour restrictions, as the AANS/CNS/SNS press report points out,

Additional restrictions in resident work hours will also create a new generation of surgeons with reduced surgical experience and expertise due to less exposure to complex surgical cases and direct patient care. “Unless the residency training period is extended considerably, residents in neurosurgery will receive 25 to 50 percent less training than residents received prior to 2003,” stated M. Sean Grady, MD, Charles Harrison Frazier Professor and Chairman, Department of Neurosurgery, University of Pennsylvania and current ABNS chairman. “One could reasonably ask whether any patient would choose to be treated by a neurosurgeon who receives half the training of today’s practitioners.”

Third, residents are cheap labor. That’s just honesty. Plenty of teaching hospitals in part actually need residents to make the system work. These are, often, full fledged physicians working at a fraction of their real earning potential to further their training. They’re cheap. Restricting their hours can significantly raise the costs of health care. Back to the New York Times piece,

“We know there is a cost to this,” said Brian W. Lindberg, a panel member and executive director of the Consumer Coalition for Quality Health Care in Washington. “If we’re enabling residents to have sufficient sleep, someone has to cover care during those periods. We also believe if you look at the totality of the recommendations, there is the potential for efficiencies in the system and savings from reduction in errors and harms. In the long run, it won’t cost as much as one might estimate.”

Plenty of other stakeholders, besides those groups representing neurosurgery, think the IOM has jumped the gun. The American Association of Medical Colleges tip toed around the issue but had this little rebuke for the report,

If the current duty hour limits are modified, it will be important to consider the impact of potential changes on other members of health care teams and the effect on patient care.

Putting the 2003 ACGME standards into practice has been a complex undertaking. The planning and implementation of any further changes will require significant time and resources.

The Institute of Medicine report holds no force of rule. Instead it is a recommendation for the actual self governors of medicine, namely the ACGME, to change the rules. Let’s hope that the ACGME is smart enough to simply ignore it.