Monday, August 22nd 2011

Does Limiting Physician Hours Help Patients?

New physicians, known as interns, entering residency, which is the training physicians go through after medical school, can no longer take overnight call in the hospital without supervision from a more advanced resident or from a faculty physician. In addition they cannot work more than 16 hours straight. This as of July 1st.

For me this means a situation in which I’m taking essentially the same amount of overnight call as I did last year but, if the interns were part of the overnight call pool I’d be taking substantially less. Let this stand as my disclosure for this post.

The rules for interns are part of new regulations on resident physician work hours from the Accreditation Council for Graduate Medical Education.

For the past decade, the move to limit resident working hours has been a constant debate and struggle. I’ve written about it in the past here and here. Part of the situation is that it has become accepted that longer duty hours, less sleep for resident physicians, who are intimately involved with patient care at teaching facilities, leads to iatrogenic harm and worse patient care.

In moves to improve patient care and, in no small measure, to stem any public outcry and to make sure that resident duty hour regulation remains part of medicine’s self govern mandate the rules on resident work hours have become subsequently more restrictive through three iterations.

The problem is however that no matter how intuitive it may seem that limiting the amount of time resident physicians can work should mean they’re more rested should mean fewer mistakes when treating patients, it turns out that the evidence for such was highly circumstantial when resident work hours were first implemented and has not been borne out since the implementation.

It’s true that there are witnessed attentional mistakes in medicine that lead to patient harm. And it’s true that there is evidence from studies outside of medicine, and our own everyday anecdotal experience, that fatigue worsens attentional mistakes.

A very small 2004 study in the New England Journal of Medicine, 24 interns partook, randomized but did not blind the schedules of these physicians-in-training to a traditional schedule with 30 hour call shifts, where the residents routinely but not always worked over 80 hours a week, and to a float system where the residents worked 16 hour shifts and did not work over 80 hours a week. The interns working more and working longer shifts, made more errors.

But since implementation of resident physician work hour restrictions almost no change in patient’s harmed by errors or in patient outcomes has been seen. This from multiple large retrospective studies looking at data from millions of patient visits to teaching hospitals.

In a very good recent piece in The New York Times Magazine, Dr. Darshak Sanghavi, tried to explain why. The article was aptly titled “The Phantom Menace of Sleep Deprived Doctors,”

About 98,000 people die every year from medical errors. Some of those mistakes are made by doctors whose judgment has been scrambled by lack of sleep. But fixating on work hours has meant overlooking other issues, like lack of supervision or the failure to use more reliable computerized records. Worse still, the reforms may have created new, unexpected sources of mistakes. Shorter shifts mean doctors have less continuity with their patients. If one doctor leaves, another must take over. Work-hour reductions lead to more handoffs of patients, and the number of these handoffs is one of the strongest risk factors for error. As a result, many hospitalized patients are at the mercy of a real-life game of telephone, where a message is passed from doctor to doctor — and frequently garbled in the process.

Shorter shifts mean more patient handoffs, where oncoming new residents have to learn what is going on with complex patients in a short amount of time. As well, other issues are at play, including a lack of standardization of resident supervision by faculty physician.

The point of Dr. Sanghavi, and one that I agree with, is that efforts focused largely on resident work hours have failed to yield the desired results. And it likely isn’t because we haven’t gone far enough in banishing the sleep deprived doctor. I would say it’s probably because the myth of the sleep deprived doctor was contributing very little to poor outcomes. We should be looking at other factors when it comes to resident’s role in patient safety.

To be fair the new instructions from on high have a focus on more than just work hours. For instance, above I complain about the fact that interns cannot work without supervision in the hospital. But further restrictions on how much they and other residents can work likely is only an impediment to patient care. Certainly it hasn’t achieved what the ACGME or the IOM or anyone else hoped in terms of its end result in reducing iatrogenic patient harm.

There are other factors in play here, namely political ones and public perception, but if we were rational about this the next ACGME panel to revise the resident work hour rules would look retrospectively as well and consider not only the possibility of further constricting how much residents can work but also potentially lightening the restrictions which, clearly to date, have failed.

I can dream I suppose.