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Reducing Resident Work Hours: Unproven Assumptions and Unforeseen Outcomes

Mitchell Charap, MD
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From New York University School of Medicine, New York, New York.

Ann Intern Med. 2004;140(10):814-815. doi:10.7326/0003-4819-140-10-200405180-00019
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“There must be some way out of here,” said the joker to the thief.

“There is too much confusion, I can't get no relief.

Businessmen, they drink my wine, plowmen dig my earth,

None of them along the line know what any of it is worth.”

“No reason to get excited,” the thief he kindly spoke,

“There are many here among us who feel that life is but a joke,

But you and I, we've been through that, and this is not our fate,

So let us not talk falsely now, the hour is getting late.”

–Bob Dylan

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Professionalism in the era of new work hours
Posted on May 19, 2004
Sarang Kim
University of Pennsylvania
Conflict of Interest: None Declared

I disagree with Dr. Charap's argument that the new work hour regulation for residents is "˜harmful to the future of our profession' (1). Dr. Charap believes that the new system suggests continuity is not important and rewards unprofessional behavior. What he fails to recognize is that the ACGME regulates work hours, not professionalism. Setting a standard for professional attitude and behavior is the responsibility of all of us in the profession. While the new work hour regulation undoubtedly presents a significant challenge for program directors nationwide, it also brings new opportunities for medical educators to take an active role in teaching and promoting professionalism, rather than leaving in the hidden curriculum where it has been for many years.

1. Charap M. Reducing resident work hours: unproven assumptions and unforseen outcomes. Ann Intern Med. 2004;140:814-5.

Conflict of Interest:

None declared

Continuity of Care
Posted on May 20, 2004
Alan Lerner
Case Western Reserve Univ
Conflict of Interest: None Declared

While Dr. Charap makes many valid points, it may be time to uncover all of the hidden assumptions inherent in modern healthcare.

Continuity of care is a laudable goal. It should be pointed out that residents may take the initiative to stay late, and visit with patients, albeit in a non-treatment mode. However, the lack of references in the article equating continuity of care with outcome suggests that the hallowed value of continuity may be somewhat overvalued.

The humanistic core of medicine cannot be denied, and nobody is suggesting treatment by automatons. However,continuity of care as a learning tool may be coming to the end of its useful life, at least in this country with its abundant resources.

Alan Lerner, MD Associate Professor of Neurology Case Western Reserve University

Work Hour Reform May Not Be Addressing Resident Fatigue & Sleepiness
Posted on June 8, 2004
Ilene M. Rosen
University of Pennsylvania School of Medicine
Conflict of Interest: None Declared

The position papers on resident duty hour reform by Charap(1), Skeff(2), and Glines(3) make valid, yet conflicting, observations. They illustrate the lack of historical data around the complex issues surrounding fatigue, sleep deprivation and performance among residents. A premise of duty hour reform was to mitigate the fatigue and perceived decrements in job performance that occur from excessive time-on-task. By reducing time at work and by mandating the education of housestaff and faculty about the effects of sleep deprivation, this reform would reduce medical errors and other untoward effects of acute and chronic sleep deprivation. Unfortunately, a survey of over 3000 residents from 21 specialties performed prior to the institution of duty hour reform showed a less robust correlation between duty hours and sleep hours than was previously thought(4). We suspect resident physicians are not using their free time for sleep to repair their sleep debt. While education about specific fatigue management strategies are helpful, it is impossible to mandate sleep quantities for resident physicians outside the hospital. Additionally, many residents report sacrificing sleep on call in order to accomplish their patient care responsibilities within the 24 hour plus 6 hour limit. This is in direct contrast to the belief widely held in the sleep medicine community that the best countermeasure for sleepiness is sleep. Operational short naps of 20 minutes to 2 hours in length while on call can acutely improve alertness and functioning(5). We believe that a formal evaluation of this process is warranted and that countermeasures utilized in other 24-hour industries including mandatory nap periods should be investigated for feasibility and outcomes in resident physicians. Such an approach would allow for systematic improvement in resident alertness and performance that ultimately will lead to increased patient safety.

1. Charap M. Reducing resident work hours: unproven assumptions and unforeseen outcomes. Ann Int Med 2004;140:814-15.

2. Skeff KM, Ezeji-Okoye S, Pompei P, Rockson S. Benefits of resident work hours regulation. Ann Int Med 2004;140:816-17.

3. Glines ME. The effect of work hour regulations on personal development during residency. Ann Int Med 2004140:818-19.

4. Baldwin DC, Daugherty SR. Sleep deprivation and fatigue in residency training: results of a national survey of first- and second- year residents. Sleep 2004; 27(2):217-23.

5. Dinges DF, Brougthon RJ, eds. Sleep and alertness: chronobiological, behavioral, and medical aspects of napping. New York: Raven Press, 1989.

Conflict of Interest:

None declared

In response
Posted on June 28, 2004
Mitchell Charap
NYU School of Medicine
Conflict of Interest: None Declared

In Response: Dr. Bedarida laments the effects the work hour regulations. He has already noted a loss of care continuity and a real change in the attitude of residents, some who appear preoccupied with getting out of the hospital. He suggests that our new graduates will be ill prepared after three years of training and contends that they, like their European counterparts, will need to work closely with senior physicians for several years to acquire the necessary skills for independent practice. I share his concern and have observed a lack of clinical maturity in a greater percentage of recent graduates

Dr. Kim asserts that medical educators are responsible for teaching and promoting professionalism. I agree, but suggest that the inflexibility of the work hour regulations insidiously erodes a basic core element of our profession that places the health of the patient above concerns about self

Dr. Lacey recognizes that there will be difficulties in implementing these new regulations and suggests that we need to develop a better sign out systems to reduce errors. I agree with both points. However, I am not certain whether resident satisfaction or professional dedication will be enhanced by the regulations. I have observed the opposite to be the case.

In the 1990s the RRC-IM had the following statement in its program requirements:

Physicians must have a keen sense of personal responsibility for maintaining patient care, and must recognize that their obligation to patients is not automatically discharged at any given hour of any particular day of the week. In no case should the resident go off duty until the proper care and welfare of the patients is ensured.1

Is this paragraph controversial? Are there physicians who disagree? It was eliminated when the new work hour regulations were mandated. Its omission serves as a startling confirmation of the shift in priorities. We must work to restore and maintain this basic principle.

1 Accreditation Council for Graduate Medical Education. Program Requirements for Internal Medicine 1992

Conflict of Interest:

None declared

An evidenced-based approach to work hours
Posted on July 1, 2004
Vikas I. Parekh
University of Michigan Medical School
Conflict of Interest: None Declared

The series of articles on the American Council for Graduate Medical Education (ACGME) work hours rules for residents, while timely, do not provide a complete assessment of the impact of the rules and what medical educators must do to optimize patient care and education in this new era. We believe it is naïve to presume that these rules will be significantly loosened, despite the potential downsides that Dr. Charap(1) and Dr. Schroeder(2) highlight. What we need is an evidence-driven approach to the potential impacts of work hours limitations.

Dr. Charap who criticizes the new rules for their impact on patient care, mainly utlilizes personal anecdotes and opinion as opposed to the evidence. There are at least nine studies that we know of that look at work hours interventions and the impact on patient care. Somes studies suggest harm from interventions to reduce work hours (3) while others show possible benefit (4).

Several studies look at resident experience after work hours limits; At least two have demonstrated that the feared loss of clinical exposure that Dr. Charap suggests did not occur (5,6). However, it is very difficult to look at just one institution or study and extrapolate results to other places "“ each has its own culture around patient care, resident duties and the balance between work and rest. It is imperative that we carry out prospective evaluations of the various systems now in place to determine the best approaches. We agree that some available evidence supports personal benefits for trainees that is highlighted by Skeff et al.(7) in their editorial. Residents report improved personal lives (8) and less stress (9) when interventions that reduce work hours are in place. We caution, however, that such benefits were not universal and residents themselves worried about the impact on continuity (10). This last observation should be of particular interest to Dr. Schroeder who worries about the erosion of professionalism in medicine as increasing emphasis is placed on the balance between lifestyle and work. We share many of his concerns, but do not implicate the new work hours rules as the proverbial "straw that broke the camel's back." Many of the potential positives of work hours reforms such as more personal time, more sleep and less stress may actually improve the professional attitudes of our trainees

In conclusion, we suggest that we owe it to ourselves, our patients and our trainees to look beyond the current debate and critically examine how the new work hours rules will impact everyone involved. Medicine has shown itself to be a highly adaptable profession "“ no doubt we will adapt to these new rules. It is critical, however, that we do so based on the best available evidence. Despite the raging debate, it is clear we all agree on the need for more studies in this critically important area.

1. Charap M. Reducing resident work hours: unproven assumptions and unforseen outcomes. Ann Intern Med. 2004;140:814-5.

2. Schroeder SA. How many hours is enough? An old profession meets a new generation.Ann Int Med 2004;140:838-39.

3. Laine, C., Goldman, L., Soukup, J. R., and Hayes, J. G. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA. 93; 269: 374-8.

4. Gottlieb, D. J., Parenti, C. M., Peterson, C. A., and Lofgren, R. P. Effect of a change in house staff work schedule on resource utilization and patient care. Archives of Internal Medicine. 91; 151: 2065-70.

5. Barden CB, Spect MC, McCarter MD, Daly JM, Fahey TJ. Effects of limited work hours on surgical training. J Am Coll Surg. 2002; 195:531-8.

6. Kelly, A., Marks, F., Westhoff, C., and Rosen, M. The effect of the New York State restrictions on resident work hours. Obstetrics & Gynecology. 91; 78: 468-73.

7. Skeff KM, Ezeji-Okoye S, Pompei P, Rockson S. Benefits of resident work hours regulation. Ann Int Med 2004;140:816-17.

8. Carey, J. C. and Fishburne, J. I. A method to limit working hours and reduce sleep deprivation in an obstetrics and gynecology residency program. Obstetrics & Gynecology. 89; 74: 668-72.

9. Rosenberg, M. and McNulty, D. Beyond night float? The impact of call structure on internal medicine residents. Journal of General Internal Medicine. 95; 10: 95-8.

10. Yedidia, M. J., Lipkin, M. Jr, Schwartz, M. D., and Hirschkorn, C. Doctors a workers: work-hour regulations and interns' perceptions of responsibility, quality of care, and training. Journal of General Internal Medicine. 93; 8: 429-35.

Conflict of Interest:

None declared

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