First to consider is the paramount importance placed on patient care. “Following through with a patient from when you might meet them to how you make a diagnosis to subsequently initiating some sort of treatment is important, obviously, for the patient,” said Dr. Vasan. “But it’s just as important for the physician who is learning how to manage these patients.”
Second, patient care is helped along when staff are able to reduce the number of hand-offs and transitions of care. Limiting one member of a team to an hours limit to which others don’t have to adhere to opens the door to a problem in transferring information. “If you were to have frequent handovers, there’s potential for error,” Dr. Vasan added. “That’s why companies now exist that utilize software as a means to minimize errors and to make sure that everyone’s on the same page. This is something new that has been created because of work-hour restrictions.”
Dr. Zetterman said there is one major study that looked at hours limits and their impact on patient outcomes. The review, which was published in The New England Journal of Medicine in February 2016 and involved 117 U.S. general surgery residency programs and 151 hospitals, found that longer shifts and less time off between shifts were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group) or of any secondary postoperative outcomes studied (N Engl J Med. 2016;374:713-727). “That was certainly an added factor,” Dr. Zetterman said.
The third leg of the proverbial stool that is continuity of care is the health of physicians themselves, Dr. Vasan said. To wit, the NEJM surgical study found “no significant difference in residents’ satisfaction with overall well-being and education quality.”
“That’s one of the things the ACGME stresses, that physicians receive education in terms of recognizing fatigue and fatigue mitigation,” Dr. Vasan added. “It is important for physicians to have an opportunity to rest; that goes hand-in-hand with having these doctors work potentially 24 hours now.”
Dr. Rodney said that the 16-hour limit on interns meant that they could work a few of those shifts in a row, which could be more dangerous for them. “Sixteen hours on paper looks better than 24, but working 16 hours day after day instead of 24 hours with a post-call day off does not result in better quality of life,” she said, “and may actually lead to worse quality of life for the resident.”
Maintaining a Balance
Dr. Zetterman emphasized that while first-year otolaryngology residents and their program directors may be focused on raising the hours cap, the newly unveiled revision to the ACGME Common Program Requirements, the formal name of the rules that govern residents, is much broader. The five-year review placed a greater emphasis on patient safety and quality improvement, added a section to address the critical importance of physician well-being to graduate medical education and patient care, and implemented more explicit requirements regarding team-based care and professionalism, coupled with a framework for clinical and educational work hours that allows for flexibility, with a maximum that aims toward the ultimate goals of physician education and patient care (available at acgmecommon.org).