Medical residents used to work shifts so long that fatigue blurred their vision, clouded their judgment, and overall put them on the brink of mental and physical exhaustion. Concern among medical educators and pressure from consumer groups that hypothesized a link, thus far unproven, between medical resident fatigue and unsafe patient care prompted the Accreditation Council for Graduate Medical Education (ACGME) in 2003 to enact an 80-hour work week limitation on residents. Studies since then of the impact of decreased resident work hours are underwhelming; patient safety and mortality remain largely unchanged since the regulations went into effect. That didn’t stop the Institute of Medicine, after a 15-month study concluded in December 2008, from proposing additional resident work hour restrictions, with an estimated price tag of $1.7 trillion to an already cash-starved health care system (see sidebar above).
Explore this issue:March 2009
Michael Stewart, MD, MPH, Chairman of the Department of Otorhinolaryngology at New York-Presbyterian Hospital/Weill Cornell Medical Center (and an editorial board member of ENT Today), who works with a four-resident team, disagrees with the IOM’s recent recommendations. The 2003 work hour restrictions led us to a fairer distribution of the workload among residents, with the junior residents getting more time to read, study, and prepare, he said. But they have also caused less continuity of care, more handoffs, and residents being forced to forgo important educational opportunities even when they aren’t tired. The rules are too rigid.
This comes from a physician whose hospital housed the sentinel event precipitating work hour restrictions-Libby Zion’s death in 1984. That unfortunate medical outcome-in which second-year resident Gregg Stone, MD, after consulting with the attending physician, prescribed Demerol for Ms. Zion’s extreme shaking, not knowing that Ms. Zion had taken Nardil and cocaine-led to monitoring of residents’ duty hours. The assumption that fatigue rather than Ms. Zion’s failure to mention her drug cocktail to Dr. Stone precipitated resident work hour restrictions, in effect in New York since 1989.
The Elephant in the Hospital
While the IOM spent 15 months pondering resident duty hours, it apparently failed to notice the huge workload that the 25,000+ hospitalists in US hospitals have taken from residents’ shoulders (see Hospitalists’ Blueprint below). Michael Johns III, MD, Chief of Otolaryngology at Emory Crawford Long Hospital in Atlanta, and Assistant Professor of Otolaryngology at Emory University School of Medicine (and a member of the ENT Today editorial board), works closely with Emory’s hospitalist cadre, the nation’s largest. We get along very well with them. Patients historically admitted to us now go through the hospitalists and that removed a huge burden on house staff, he said.
Dr. Johns explained that hospitalists manage medical issues, calling in subspecialty residents as needed. The 15 otolaryngology residents deployed in three hospitals serve mostly as consultants and co-managers, with an average daily census of six to eight patients per facility. For example, a hospitalist might call in an otolaryngology, ophthalmology, or neurology resident for a patient with periorbital cellulitis. Dr. Johns said hospitalists allow his program to meet its educational goals without exceeding work hour restrictions. There are fewer battles over ER patients, things flow more smoothly, and care quality is high. The hospitalist-subspecialty resident paradigm works, and residents gain considerable control over their professional lives. Dr. Johns sees the 80-hour work week as a blunt instrument to correct fatigue, burnout, and depersonalization.
The view is different from the hospitalist’s side of the street. William Odette Jr., MD, a full-time IPC hospitalist at Tucson Medical Center in Arizona, has seven full-time and eight part-time colleagues, including a nocturnalist. The team handles an average of 120 admissions and consults a day, and distributes call equally. Dr. Odette said, Our hospital doesn’t rise or fall with the residents because the hospitalist is the responsible attending. The hospitalist admits with the resident handling orders, but the hospitalist supervises and provides continuity of care. Subspecialty residents, including otolaryngologists, are called in to co-manage patients.
Although residents are supposed to cover call, Dr. Odette said that at least one-third of the time the nurses call the hospitalist because the residents, who are paged automatically, don’t respond. They’re not putting in an 80-hour week, in my opinion, he concluded.
His fellow IPC hospitalist Douglas Kirkpatrick, DO, a pulmonologist and critical care specialist, finds it annoying that residents often can’t be found and that nurses page the hospitalists instead. The upside is that the hospitalists provide more seamless care, avoiding awkward and time-consuming handoffs. Dr. Kirkpatrick is accessible to his residents, working long hours the day before covering call, arranging for residents to round at the bedside of interesting and complex cases, and supporting them as they practice procedures. Often the residents don’t realize how much we do. We even model for them how to make a smooth transition from inpatient to outpatient, directing them to case management, calling the PCP, and so on, he said.
For teaching hospitals, adding hospitalists to cover the workload formerly carried by residents involves increased faculty pay without significantly increasing professional fee revenue. Although expecting financial self-sufficiency of such programs is unrealistic, some programs incrementally increase consultative revenue as specialty patients get placed on general medical services rather than being cared for by a resident and a specialist attending.
The Big Picture
Gerald Healy, MD, Children’s Hospital of Boston’s Otolaryngologist-in-Chief and the first otolaryngologist to be President of the American College of Surgeons, said he is not a fan of the IOM’s duty hour restrictions or any program not anchored in research. We wouldn’t give a new drug to patients without thoroughly testing it. So why is the IOM flying by the seat of its pants in assuming that the 80-hour work week is correct? Their report is based on an untested premise, he said.
The impact on surgical training is onerous: You don’t learn surgery from a textbook, because every patient’s anatomy is different. The more procedures you do, the more you learn. Work hour restrictions threaten surgical training, he added. He fears that we are treading the European path that turned surgical trainees into shift workers and has seriously harmed the doctor-patient relationship.
Dr. Healy advocates a large multicenter study to determine what factors have an impact on residents’ fatigue and burnout, rather than a clumsy reliance on the 80-hour work week.
Dr. Stewart pointed out that for specialties such as otolaryngology-head and neck surgery, excessive work hour restrictions may be overkill. Disagreeing with the IOM report that suggests that ACGME adopt even more restrictions, he said that the rigidity of such limits will gradually have an erosive effect on the culture of medicine. I am very worried that we’ll be losing professionalism in medicine. Where will the role models be for young doctors? My generation of doctors and earlier ones were taught to make personal sacrifices for our patients, but the new message is to be committed to your patients, but go home because an arbitrary limit has been set for you, he said.
IOM’s 12/14/2008 Proposed Additional Changes to Residents’ Duty Hours
- Five-hour protected sleep period
- Increased minimum time off between scheduled shifts
- Four-night maximum on in-hospital night shifts; 48 hours off after three to four nights of consecutive duty
- Increasing from four to five the number of days off per month
- Restricting moonlighting by including internal and external moonlighting hours against the 80-hour cap
Hospitalists’ Blueprint for Non-Resident Services
With ACGME’s 2003 implementation of the 80-hour resident work hour restrictions, academic medical centers were immediately confronted with handling increased inpatient volume as resident availability decreased. Some hospitals responded by creating hospitalist services independent of residents, thereby leaving residents with fewer patients and tasks. While such services usually don’t break even financially, they help hospitals comply with ACGME rules.
Here are the parameters used to structure a non-resident hospitalist program:
- Set clear goals based on rigorous data analysis.
- Decide what patient volume must be removed from average daily census to ensure work hours compliance.
- Gather data on daily variations and trends on inpatient admissions, and peaks/troughs of admissions times.
- Examine patient volume under different scenarios: removing a fixed number of patients per day, creating intern-admission caps, alternating admissions between residents and hospitalists.
- Examine call-reduce or eliminate short-call, change the frequency of long-call, or implement limitations on night admissions to house staff.
- Ponder patient population for the non-resident service: What percentage of low-complexity, non-teaching cases is appropriate?
- Set average daily census for senior residents (8-10), attendings (9-11), and physician extenders (4-6).
Source: The Hospitalist, Jan/Feb 2005.
The Global Debacle
Since the 1980s, physicians in training outside the United States have been protected from the long hours that promote continuity of care and exposure to surgical and other technical skill practice. New Zealand caps residents’ weekly hours at 72, France at 52.5, and Denmark at 37. In 2009, European countries are expected to implement a 48-hour work week. Work hour restrictions have already cost the EU 1.75 billion euros ($2.38 billion), and left Britain’s NHS alone short 15,000 physicians. A 2002 survey by the British Orthopedic Association concluded: To become a competent surgeon in one-fifth of the time once needed either requires genius, intensive practice, or lower standards. We are not geniuses.
Sir Bernard Ribeiro, former president of the Royal College of Surgeons of England, an outspoken critic of shorter work hours as a deterrent to producing proficiency in the OR, testified before the recent IOM’s Resident Duty Hours Panel to help the United States avoid the same mistakes. Sir Bernard noted that British surgical residents perform 25% fewer procedures than did their predecessors before duty restrictions set in. The IOM turned a deaf ear, claiming that every system is different, and it’s hard to generalize, according to committee member Dr. Kenneth Ludmerer, Professor of Medicine and History at Washington University in St. Louis.
©2009 The Triological Society