Recently, the New York Times published an editorial reviewing medical errors in the setting of duty hour restrictions. (“The Phantom Menace of Sleep-Deprived Doctors” by Darshak Sanghavi, August 5, 2011). Dr. Sanghavi’s review of this subject noted that duty hour restrictions have not significantly decreased medical errors. He argued that increased sign-off frequencies left gaping holes in medical information for the “on-call” physician to make informed decisions. He cited the index case of Libby Zion, an 18-year-old who succumbed from serotonin syndrome that was undiagnosed and was blamed on the sleep-deprived intern. Dr. Sanghavi noted that lack of supervision and medical knowledge contributed significantly to Zion’s death and sleep deprivation was not the only culprit. He concluded that with improvements in “hand-offs” and electronic medical records, such mistakes are reduced. With these changes, more restricted duty hours (the new 16 hours a day for interns without overnight call) and a hospitalist system, the trainees will have fewer patients and more time to learn their field. While I agree on many levels with Dr. Sanghavi regarding the causes of medical errors, I find that his solution is directed towards training residents in medical specialties that ultimately deliver care in the outpatient setting. He asserts: “Defenders of the old-school way argue that the demands of medical practice justify the brutal hours. But after their residencies, most doctors practice in outpatient settings and work regular daytime hours as members of large groups. They treat chronic problems that need weeks or months of periodic outpatient follow-up, not high-intensity hospital-based care lasting only a few days.” The reality is that many fields of medicine primarily deliver inpatient care, a subset of which has critically ill patients. This is where arguments for further duty hour restrictions fall apart. To date, there has been much controversy from senior level physicians regarding duty hour restrictions. Many feel that medical training has “gone soft” and has produced less confident and more untrained physicians. I am a recent graduate of a Neurological Surgery residency program and, as such, I fall into the not-so-old guard of duty hour restrictions (which began to be enforced one year prior to my training).  I, therefore, have a somewhat mixed view on duty hour restrictions for sleep deprivation and prevention of medical errors.  I never truly experienced the days of 120-hour work weeks and living in the hospital for days on end, although I was exposed to that during medical school.  I did certainly appreciate the scheduled days off and early post-call hours that were enforced by law (allowing me to feel better rested at times and also enjoy a personal life). However, I must state that I do disagree overall with the recently implemented duty hour restrictions, particularly for fields such as trauma surgery, neurosurgery, cardiothoracic surgery, pediatric surgery, pulmonary critical care, or other specialty with emergent procedures, long-duration operations and critically ill patients. First, there has been a fundamental shift amongst residents and even medical students regarding patient care within these restrictions.  I personally experienced this difficulty as a junior resident rounding on a service of over 50 patients.  Since the duty hours restrictions limit the time spent with patients, medical decisions rely more frequently on "hand-offs" or "sign-out" lists with each iteration relaying even less information (and less accuracy).  In a model where a resident rounds 2 of every 3 days, patient information gaps occur that have had quite serious consequences.  In a day-shift, night-shift model, these gaps are even more striking. Ultimately, the trade-off for physician fatigue has resulted in less accurate medical information. Second, the overall attitude of the resident has changed shape. This environment has bred residents who expect to learn their discipline only at work. Gone are the days of “eat-when-you-can, sleep-when-you-can…” Such deceleration of resident efficiency has encouraged a level of complacency in these fields. Throughout various fields of medicine and surgery, the number of publications that a resident produces has diminished, requiring more incentives to reinvigorate that drive. Time spent away from the hospital is used increasingly less for academic and educational purposes. Perhaps this is due to the association of leaving the hospital with stopping work altogether. Or, this may be the result of attracting a different breed of practitioners. Third, this "shift-work" paradigm that works well for emergency medicine and radiology, breeds an atmosphere lacking in patient ownership.  More often than not, residents (particularly junior residents) just shrug their shoulders and blame a "poor sign-out" when they do not know or are surprised of pertinent patient data.  This complacency trickles down to the medical students who, as a result, aren't taught stringent medical ethics from the get-go.  While the ultimate clinical responsibility lies with the attending physician, the sense of personal responsibility must be inherent with the training physician and not a new concept upon graduation. Fourth, as work hours are reduced, the opportunity to learn critical patient care is diminished.  Particularly, the onus lies with the resident, and not the system, to develop an understanding of positive and negative outcomes of clinical decisions, and thus to hone his or her clinical acumen. In the day-shift/night-shift model (which the 16-hour-per-day model requires for interns), residents are disconnected between their actions and their consequences.  An intern who orders a basal rate on a PCA during the day, which ultimately causes an aspiration pneumonia and hypoxia requiring intubation at night, may not directly tie the two together.  In addition, the evening resident may not have known about the basal rate and would struggle to reverse the narcotic effect until quite a bit after the code-blue was initiated.  Neither resident truly has ownership of the patient and the responsibility is bumped upwards, effectively shielding the younger residents. Fifth, particularly in specialties with emergent and long surgeries or critically ill patients, many learning opportunities are missed when the resident is sent home to comply with the various arbitrary duty hour rules (10 hours off per shift, must leave the hospital at 30 hours).  For example, if a patient with subarachnoid hemorrhage arrives overnight, the on-call resident does the work-up, stabilizes the patient, treats the ICP (places a ventricular drain), and gets all the diagnostic tests completed.  However, the next morning, when the patient is taken to the OR for treatment of the aneurysm, the resident is sleeping soundly, missing critical learning opportunities.  Perhaps remaining awake would increase risk, (although very little if the resident was just observing as is traditionally done), but so is the risk of this surgeon - now years out of training - who feels less comfortable treating this patient given his or her lack of training.  A ruptured aneurysm does not abide by the duty hour restrictions, and neither should the physicians ultimately treating them. Physicians now and always are always expected to be infallible.  The litigious climate in certain states emphasizes this fact.  Patients (and lawyers) don't care what time it is when they present to our doorstep -- they still expect and deserve the best possible care and treatment.  Therefore, it is pertinent to train physicians to think on their feet and not let fatigue slow them down.  This is why frequently the post-call resident is "pimped" on rounds, to reinforce the concept of functioning at one’s best at all times.  It is how an attending surgeon can do a 20-hour surgery on a complex case and still be able to function if an emergency occurs that evening.  One aspect of training is to work with fatigue and not ignore it, as the real world will certainly expect one to function at all times. While the old system of residing in the hospital was deleterious on many levels, so is this restrictive system of duty hour logs and severe repercussions of their violations.  Most physicians who occasionally don't comply with the duty hour restrictions do so out of the interest of their patients or their education.  I personally felt cheated when I was forced to go home when an interesting or rare case was being treated on my post-call day.  I was initially surprised and ultimately dumbfounded that I was reprimanded when I wanted to stay over to learn from that case or to ensure that the patient that I had spent all night resuscitating was treated appropriately.  The governmental mandates have struck fear into everybody, including program directors, administrators and residents, that their programs and hospitals would be put in jeopardy because the residents are worked too hard.  Residents are now rewarded when they comply with these bureaucratic rules, as opposed to seek out the best interests of their patients. With the current systems in place, there is no penalty for leaving early and, therefore, there shouldn't be a penalty for volitionally staying late. Many institutions have established solutions for duty hour restrictions.  These include increased ancillary staff (NPs, PAs, etc), increased number of residents, better electronic records, and better "hand-off" or "sign-out" systems.  While there have been some notable improvements as a result, it has come at a cost.  NPs and PAs seem to take the place of the residents' expected thorough knowledge of their patients. Surgical training programs are uniquely affected by increasing the number of residents. With more residents training at each program, this dilutes the number of surgeries per resident.  Hence, they are less trained upon graduation compared to their previous counterparts, and are typically required to pursue fellowships - lengthening their training - to improve their education. Arguably, the comfort level of the surgeon and the technical skills may be reduced due to the fewer surgeries performed.  While electronic medical records do provide increased information at the users’ fingertips, it is still up to them to verify the information.  The "cut-and-paste" nature of inpatient electronic notes permits much misinformation.  There is room to improve here, but ultimately the responsibility lies with the physician being trained. With the most recent duty hour changes, interns will ultimately learn less by working 16 hours a day and not taking contiguous overnight call. However, the relaxation of the upper level residents' hours may allow for improved training.  The resident should be given the choice to improve their clinical exposure (in a safe manner) and not be punished for that desire.  Increased education and attention to sleep hygiene should allow for this safe transition. If the current national momentum does not swing the other way, the duty hour restrictions will continue to breed less trained physicians with a diminishing work ethic.  The medical error rate will continue to increase (despite advances in electronic medical records and such technology), trainees will know less and less about their patients, and these physicians will train the incoming classes, adding to the vicious cycle that has already begun. The nation should learn from this policy iteration and apply more thought-out and fitting laws. The specific residency review committees (RRCs) that are more familiar with their respective specialties should be given more authority to adjust the duty hours as necessary. Our ultimate goal, of course, is to give the best possible care to our patients - now, and in the future.  Increased duty hour restrictions is just not the right answer. Garni Barkhoudarian, M.D. Pituitary and Neuroendoscopy Fellow Brigham and Women's Hospital Boston, MA, USA

4 Comments

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    James Ausman

    Posted September 3, 2011, 1:17 am

    This is a very thoughtful analysis of the effects of resident hour restrictions on the education of neurosurgical residents. The restrictions as stated are based on weak evidence of sleep deprivation as the cause of a patient’s death. Will the loss of direct patient experience during residency be worth the less experienced physician who takes care of patients in practice? I doubt it. These regulations are made by those who do not care for patients, certainly not surgical or high intensity patients. They are the result of the central control of Medicine and the loss of control of the Practice of Medicine by physicians. The effects of this erroneous policy will take decades to appear as the quality of medicine practiced by physicians becomes worse. Yes, there are ways to improve the education of residents but not by reducing their direct patient educational time. That is mindless.

    I have personal experience with his description. My father at age 93 who was in very good health was hospitalized at an academic medical center after a fall and a fractured hip. Although he was allergic to narcotics and this was noted by him and on his chart, he was given narcotics with disasterous consequences. The orthopedic surgeons who fixed his hip signed off the case 24 hours after surgery and he was cared for by medical residents. I witnessed first hand the lack of information transfer as the residents changed shifts. They had no commitment or thorough knowledge of the patient and made mistakes that I had to correct. My father was in intensive care for weeks. He was a physician for 65 years.

    Restriction of duty hours is even worse in European countries with duty hours of less than 40 hours allowed. Will these changes lead to better medical care and personal responsibility for a patient that occurs when one enters practice? Where are the duty hour restrictions on the practicing physician or the CEO of a major corporation or even a politician? We cannot even educate our grade and high school children to be high achievers, and 20% do not even finish their education at that level. Only 3% of graduates from Indian engineering schools are well enough trained to get a job. So, what we are seeing is the regulation of highly educated professionals to become mediocre. The politicians should better spend their time understanding why we will not have enough skilled educated people to assume the demanding jobs in the future and better leave education to the educators. This talent shortage affects every country in the world. Is that the result we will see in Medicine with the central control of education?

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    Clark Watts MD

    Posted September 20, 2011, 2:37 am

    Following medical school in 1962 I performed a rotating internship at Parkland Hospital in Dallas, Texas. This service required a month on the ER where our schedule was 36 hours on and 12 hours off. There were no call rooms because there was no down time to use the rooms. The action as we called it was nonstop. I finished my shift one Sunday morning and started home immediately. I had to drive about 5 miles to home. About two miles from the hospital I noted police lights behind me, and pulled over. I was ready with my driver’s license when the policeman arrived to my car. Noting my white clothing (shirt, pants. coat)and the name Parklad stiched on my coat he asked immediately if I worked at Parkland. I told him of my duty and he immediately opened my car door and told me to move over, he was going to derive me home. While he took the short trip back to the squad car to inform his partner I reflectrd on what he had said. I could not figure out the reason for his decision. Once he was in my car and we were on our way he describd the very erratic driving pattern they had observed, a pattern of which I was unaware. The police with duties near or in Parkland were aware of our work schedules, they knew immediately my problem. The next day when I was back at work I related the incident to a senior surgeon (at that time the ER was under surgery). Everybody had a good laugh. I wonder if we had not laughed but taken the matter more seriously if we woould still be the decision makers today regarding requirements for post-graduate education.

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    Drahoslav Sokol

    Posted September 21, 2011, 1:18 pm

    Very nice analysis however it seems that as restriction of hours didn’t show to decrease medical errors it didn’t increase it either , didn’t it? Statistically. Or so far not yet. In Europe although there is 40 hours restriction in reality resident work at least 60-70 hours a week. My question is: if in Europe there is such a stringent hours restriction compare to USA, do you think there is enormous gap in patient outcomes as well? It seems that answers is indeed in adjusting the hours restriction rather according the specialty than just generalize it to all residents.

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    Garni Barkhoudarian

    Posted September 21, 2011, 7:42 pm

    (In response to above comments)

    These are great points regarding physician fatigue, and they should not be taken lightly. I think most physicians recognize the dangers of a fatigued individual, which can be worse than alcohol intoxication. With the previous 80 (or 88) hour structure, this was certainly addressed. Also addressed were provisions of call-rooms, overnight nutrition, and education time. These days, one can find the infrastructure in most hospitals dedicated to these issues.

    What concerns me is the lack of flexibility of these guidelines and the harsh penalties administered to their violation (fines, suspension of training program). Residency programs should allow for increased hours if the residents are able to monitor their fatigue. Many rotations are unlike a trauma rotation of “on the move nonstop” for 36 hours and residents are able to sleep 3-6 hours a night. This sleep makes all the difference for fatigue management. Of course, the slippery slope of omerta and abuse can occur and this should also be monitored.

    Regarding the lack of increase of medical errors with duty hour restrictions, the argument is more for physician experience. To have fewer duty hours for residents as is in European and other countries, usually this results in increased residents per patient population. Hence, the exposure to different patients and pathology is limited, requiring an increase in the length of training. We are already seeing that with increased fellowships in sub-subspecialties. I completely agree to adjust duty hours according to specialty as procedural residencies need more exposure than non-procedural training.

    What I am most concerned about is “the next step.” To further restrict hours (as the most recent changes did effect to interns) will likely not prevent fatigue related errors and will increase “hand-off” related errors. In addition, commitment of patient care by the residents will further ebb, especially as more residents buy into “shift-work” mentalities. Hopefully, these generalized changes will become more directed and RRCs will take gain more control in the management of their residents’ training.

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