Wednesday, September 05, 2007

Why "Resident Duty Hour Reform" Did Not Improve Patient Mortality

Soon after a heart-felt post on the Over My Med Body Blog described how it feels to be a sleep-deprived sub-intern, two major studies in JAMA brought media attention to the question of interns' and residents' work hours.(1-2)

These two studies were interpreted by their authors as meaning that reductions in work hours did not clearly do harm.

As MedInformaticsMD noted in a an earlier post, however, a major limitation of the two studies was that they only assessed mortality. While mortality is obviously an extremely important outcome of hospitalization, it is not the only one. Fatigue is likely to cause many errors that lead to bad outcomes short of mortality. Yet the current studies were not designed to determine if the reduction in work hours could have improved patient outcomes other than survival.

Another issue is the nature of the 2003 work hour limitations:
No more than 80 hours per week, with 1 day in 7 free of all duties, averaged over 4 weeks; no more than 24 continuous hours with an additional 6 hours for education and transfer of care; in-house call no more frequently than every third night, and at least 10 hours of rest between duty periods.

Consider the lot of house-staff under these new rules. It is still perfectly legal for house-staff to:

  • Work continuously for 30 hours (24 "work" hours plus 6 hours for "education and transfer of care")
  • Work continuously for 30 hours, get 10 hours off, and then work for another 30 hours (see above, plus provision of "at least 10 hours of rest between duty periods)
  • Work 24 days during a four-week, 28 day period

My still vivid memories of internship and residency were of being pretty fuzzy after working more than 16 hours, and of being a walking zombie after working for more than 24 hours.

And, as noted in the discussion section of the two articles, there is some evidence that limiting shifts to 16 hours might be better justified than allowing 24 or 30 hour shifts.

Yet the reformed rules still allow 24 hours of continuous, intense work, and then another 6 hours of "education" and for hand-off. Then imagine, after such a 30-hour experience, having all of 10 hours to sleep, eat, catch up on life, before it starts all over again....

So another obvious explanation for the failure of these two studies to find much effect of house-staff work hour reforms were that these reforms were woefully insufficient to prevent major sleep-deprivation and fatigue.

Another question is whether the reforms shifted work to those better able to perform it, or merely re-arrange the deck chairs? So who did the work that would have previously been done by house staff working more hours than are now allowed?

My guess is that most teaching hospitals did not rush out to hire more people to take on this responsibility. After all, the house-staff work hour reforms amounted to an "unfunded mandate." Nobody gave the hospitals more money after the reforms went into effect to hire people to do this work. (If I am wrong about this, someone please correct me.)

One possibility is that the same house-staff did the same amount of work, just in fewer hours, i.e., that the reforms resulted in greater intensity of work for house-staff on clinical rotations, and most likely less opportunity to sleep even a few hours when on-call. Another possibility is that the work was given to house-staff who previously were on lighter or elective rotations.

If the reforms did not lessen the overall workload of house-staff, it is doubtful that house-staff as a group are any less fatigued on average after the reforms.

Another possibility is that the work was given to already over-worked and increasingly scarce nurses, and to the faculty in charge of teaching the house-staff, thus reducing the time available to supervise house-staff and teach. These changes could have adverse effects on quality of care that might offset any small improvements made by slightly reducing house-staff fatigue and sleeplessness.

Because of extreme sleep deprivation and fatigue, my internship year was the worst year of my life so far. One reason I went into academic medicine was the hope that I could help reform the system to make it more humane for house-staff, and hence provide them better education, and patients better quality of care.

The gradual introduction of "night-float" systems into many internal and family medicine residencies did substantially reduce sleep deprivation and fatigue, although the work load shifts they caused lessened the possibility that house-staff would have any rotations that were not intense.

However, I am afraid there are still far to many "opportunities" for house-staff to be over-worked and sleep deprived.

In a two-trillion dollar plus US health care system, there ought to be some money to pay for the work that would allow house-staff to get sufficient sleep. But unless the money is forced to follow the mandate, to quote Over My Med Body,


interns on little sleep who’ve admitted patients all night, who are writing orders at 2 or 3 in the morning is, in the best of worlds, sub-optimal, and in the worst of worlds, dangerous.

ADDENDUM (6 September, 2007) - See also comments on the Medical Humanities Blog.

References

1. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shosan O et al. Mortality among hospitalized Medicare beneficiaires in the first 2 years following ACGME resident duty hour reform. JAMA 2007; 298: 975-983. (link here)

2. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shosan O et al. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA 2007; 298: 984.992. (link here)

6 comments:

MedInformaticsMD said...

So another obvious explanation for the failure of these two studies to find much effect of house-staff work hour reforms were that these reforms were woefully insufficient to prevent major sleep-deprivation and fatigue.

My concern is that studies showing little benefit from work hour reduction will increase the pressure from reactionary educators and those addicted to cheap labor to reverse the "changes" (as ineffective as they may be in preventing fatigue).

While the "mortality rate" metric is scientifically incomplete, these studies will probably not aid those who wish to reform work hour rules for trainees further.

Not included in the calculus of the author's articles is the effect of the work hours and work environment on the health and well-being of the trainees themselves.

Like Roy, my internship in the early 1980's was the worst year of my life, bar none. The psychological abuse, delivered under conditions of serious sleep deprivation, was, in retrospect, simply shocking.

I left the malignant environment of that inner-city internal medicine program and completed my residency at a suburban facility, Abington Memorial. At the latter hospital the residents worked hard, but the hospital was relatively well-funded via endowments (it was built in memorial to wealthy Philadelphia "society" victims of the Titanic disaster) and we were spared much scut work at night.

More importantly, the attendings were deliberately selected by this hospital for personality and treated the residents well, unlike the oftentimes arrogant, self-important a**holes in the "big name" hospitals.

Finally, Abington Memorial in the past two decades has become the largest in the Philadelphia region, surpassing the "downtown" hospitals in size, due to its reputation and attraction of yet more contributions from the very wealthy.

The very wealthy apparently also prefer their care to be provided in a setting that treats trainees decently.

Anonymous said...

This topic has appeared in a number of blogs of late. While some excellent programs exist, I am still surprised when I read comments from doctors about “In the day.” Given all the advances in training, it is hard to imagine the medical community sticking to an educational system so out of date.

We as patients see the results of this system with the over scheduled, sleep deprived, family physician going through the motions of caring for their patient panel. They firmly believe that the schedule and working conditions they encountered in training are the same ones they should impose on their patients, now that they are in private practice.

Doctors often lament the lack of physicians going into front line care, while ignoring the often-stated reason, is a desire to spend time with patients. I do not feel it is a great leap to see this as a desire to get away from the meat grinder environment they are exposed to in their training.

Steve Lucas

Val said...

If a news team discovered that a widget company was requiring its staff to work for days on end without going home, and to forgo sleep for two nights at a time for a salary just barely above minimum wage, and with potentially lethal consequences if errors were made in the widgets they built: what sort of outcry would we hear? Why, people would be picketing outside the corporate offices, the company would be blacklisted, there would be a unionized walk out, and perhaps even Michael Moore would show up.

And yet, these are exactly the conditions under which most resident physicians are trained. Why is this tolerated? Because cash-strapped hospitals save money by hiring fewer staff, and because the medical establishment has turned a blind eye to this injustice. “Let them suffer because we suffered” is the attitude shared by many. Then they try to justify their position with average patient mortality rates – and how they don’t always appear to be influenced by work hour limitations. The old “patients don’t appear to be dying frequently because of this” argument. Another favorite argument is that residents cannot learn all they need to in only 80 hours/week. What’s magical about learning in residency? Doesn’t the learning process continue on into post training years? Doctors get better and better at procedures the more they do – but is it worth it to put patients lives at risk while exhausted physicians perform their 100th same procedure? And finally there’s the “continuity of care” argument. That if a physician goes to sleep, their patients will be at risk because others might not care for them as well. But if a physician hasn’t slept, is she better equipped to care for that patient?

This is plain crazy. In our “evil corporation” analogy – do you think that the press would say, “well, we see that these people are being treated inhumanely, but let’s wait to find out if maybe the widgets are affected by their work hours.” And then when it turns out that some widgets are indeed faulty, but that many of them are not – would they say, “Aha – so the majority of widgets are still coming out of the factory in tact, so we can leave the work hours as they are.”

How much more important are patient lives than widgets? As American citizens, aren’t resident physicians entitled to reasonable work hours and conditions? With no one to fight for their rights, they have had to unionize out of desperation and despair. May medicine be more humane to all – yes, even the doctors.

MedInformaticsMD said...

Doctors get better and better at procedures the more they do – but is it worth it to put patients lives at risk while exhausted physicians perform their 100th same procedure?

No.


... there’s the “continuity of care” argument. That if a physician goes to sleep, their patients will be at risk because others might not care for them as well. But if a physician hasn’t slept, is she better equipped to care for that patient?

No.

This is plain crazy.

Indeed.

I often find amazing the level of rationalization people may use in an attempt to justify these practices.

However, when one's cerebral hemispheres become too enlarged, they tend to crowd out the common sense lobe.

Kim Sanders-Fisher said...

I am not one of those who believes that it just takes intelligence to become a Doctor, it takes phenomenal stamina as well. There are members of the old school of Doctors who, adamant that nothing has changed, still l insist that they coped so well during their own training with almost zero sleep and mounting patient care responsibilities. When examining the facts however, their claims of having dealt with an equally demanding schedule are not quite true. There is one added dynamic that I am sure most practitioners are already aware of: the increased acuity of today's typical Hospital patients. If a patient is not half dead they are discharged, leaving you to care for only the very sickest individuals under the same demanding Residency routine as your predecessors worked so well with. But it doesn’t end with just the increased responsibility of sicker patients, there is another important dynamic affecting the workload of Medical Students and Residents that you may be far less aware of: Deliberate Negligent Understaffing. This does not fall under the jurisdiction of your medical programs or even include your personnel and it is not controlled by ACGME, but it does impact your workload and your current debilitating lack of time to rest up.

This problem has been getting steadily worse since the 90s and has reached epidemic proportions as money hungry Healthcare Corporations have now managed to precipitate a nationwide "Nursing Exodus." This so called “crisis” has driven Nurses away from their regular Hospital jobs and into Nursing Agencies; we pay huge commission fees just to bring back our former staff! How do Nursing and ancillary staff numbers affect you? When fewer people are available to tackle routine tasks, you end up picking up the slack often doing basic jobs that require little or no medical training. When your mentors faced the rigors of Medical training there were more staff and the staff on duty had more experience overall and were less fatigued by unreasonable work demands; bottom line they had great backup! However, if these drudgery jobs are not done they seriously disrupt your work flow so you do not hesitate to get them out of the way. Your ER patient is waiting to go to X-Ray, no one is available for transport, so you take them yourself, sound familiar? It is dozens of mindless unskilled tasks like this that are eating into your rest-time when you should be recuperating to stay alert. These jobs are usually done by minimum wage assistive personnel, but if you shoulder the burden the Hospital can continue to hire fewer people and that fattens their bottom line.

I have witnessed three separate consultancy firms at two different teaching Hospitals analyze the ER and the OR in order to find ways to "trim the fat." On all three occasions the answer was exactly the same: "you are top heavy, trim down on your Management positions." Managers control this ridiculous situation and they aren't about to authorize their own redundancy. By ignoring the advice of Consultancy groups and eliminating jobs at the very bottom they actually make the least possible difference to payroll, but this is all at the greatest detriment to patient care. Encouraging experienced higher paid staff to leave only to replace them with barely trained new Nurse grads and entry level assistive personnel also saves money for the Manager’s year end bonus. By obligingly just getting on with the job you have unwittingly assisted them in implementing this dangerous strategy by filling in for missing Nursing and ancillary staff while compromising your sleep.

There are fewer Nurses available to monitor far sicker patients and less people to implement thorough cleaning just as Hospital bugs are becoming more virulent and resistant to antibiotics. There is no redundancy of personnel, a glut of unfamiliar Nursing Agency staff, minimal breaks, frequent mandated overtime and excessive call among the people who are there to support your work. They are exhausted too, so they make oversights and mistakes that you might well be held partially or totally responsible for not preventing. ACGME needs to target the teaching Hospitals by demanding safe Nurse to patient ratios, higher levels of well trained experienced permanent staff and acceptable levels of ancillary personnel. You need reliable coworkers who vigilantly care for your patients and help to share the burden of a generally sicker cohort of patients. If it were impossible for teaching Hospitals to gain accreditation with substandard levels of staffing, those in training would not be exploited as an enticing slave labor pool!

The general assumption is that you are able to catch some sleep during that extended stretch of duty, but that is no longer a reality due to Deliberate Negligent Understaffing of US Medical facilities. While the public still believes this myth, the Hospitals are fully aware of how to take advantage of every second their eager Doctors in training are available to work. The public needs to wake up to this unnecessary danger and demand safe Hospital care through tighter staffing regulations. Please support the C.U.T! Campaign to CONTROL UNDERSTAFFING TODAY; to read more visit my Blog Site, TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE:
http://medteam.wordpress.com

All Medical staff are being exploited to the point where Medical errors are inevitable. As a Surgical Technologist in Maryland, I was left stranded, scrubbed into Surgery for 12 continuous hours of duty without a break until I nearly passed out: this is an acceptable work demand under US law! Troy Madsen blew the whistle to ACGME on my prestigious former Hospital; I was fired three years earlier in retaliation for reporting serious patient safety issues caused by understaffing incidents like this, but they continue to win awards for quality care. I hope you will review my protest over this dangerous situation in another Blog post on my site:
http://medteam.wordpress.com/keeping-surgery-safe/

The risks we are all taking in the Medical profession would not be tolerated in any other industry and it is about time we stopped expecting Medical staff to be super human. The media also have a responsibility to report the shocking truth regarding the danger posed by exhausted Medical staff. I was told by one investigative journalist that it wasn’t really newsworthy, not unless “people” and yes he did say “people” plural died as a result! I wrote a Blog Post on Media responsibility too:
http://medteam.wordpress.com/media-responsibility/
I urge you to leave comments on my Blog site.

MedInformaticsMD said...

There are members of the old school of Doctors who, adamant that nothing has changed, still l insist that they coped so well during their own training with almost zero sleep and mounting patient care responsibilities.

Even if true, they never considered that perhaps they were the exceptions.

In other words, their attitude is completely unscientific and based on their own biased, anecdotal evidence.

I am never impressed by such arguments in the same way that I am never impressed by the arguments made by practitioners of therapeutic touch.