Have duty hour restrictions improved the resident experience?
Click. I hit my alarm and roll out of bed. It’s dark, very dark. What day is it? Doesn’t matter.
Throw my clothes on, grab my lunch from the fridge, and make my way to the car. As I drive to work, a pink sky bleeds into gray clouds. Is it rising or setting?
Again, frivolous question. What matters is that work starts in T-30 minutes. If you’re on time, you’re late—a modus operandi I acquired from my military spouse.
Swipe. Park. Lock car. Walk. A gush of sterile wind blows back my hair as I trot through the sliding doors.
Lights, sounds, smells, and clinical information hammer at the doorway to my senses.
Watching my brain at this moment reminds me of staring at the AOL icon as the internet tries to load. Frustrating, to say the least.
The key is focus. Identify the task at hand and execute. Check your work, and execute again. Now the real test: patient interaction. You know your emotions are down there somewhere, like that thought that sits at the tip of your tongue but just won’t come. You mold your face into a resting smile, double-check the name, inhale, and knock.
Resident work hour restrictions were formally put into place in 2003, and further revised in 2011 by the Accreditation Council for Graduate Medical Education (ACGME). Twenty-eight-, 30-, or 36-hour shifts? Experts agreed that peak function—or even adequate function—cannot reasonably be maintained. Hence the birth of the 80-hour week, the 16-hour shift limit for first-year trainees, and the eight-hour minimum between shifts. Yet many clinicians expressed concern about continuity of care. Who will have ultimate ownership over these patients? Patient care hand-offs are ripe for error. Will these changes really prevent medical errors?
The medical community responded with the FIRST trial, a randomized “non-inferiority” comparison of standard ACGME work hours versus flexible work hours that was published in the New England Journal of Medicine in February. Participants included general surgical residencies and their affiliated hospitals. They measured outcomes including: the 30-day rate of postoperative death or serious complications (primary outcome); other post-op complications; and resident perceptions and satisfaction regarding their well-being, education, and patient care. The study found that the residents working flexible hours were more likely than the standard policy group to report improved experiences on several measures, including continuity of patient care, acquiring of operative skills, and professionalism.
According to principal investigator Karl Bilimoria, MD, of Northwestern University’s Feinberg School of Medicine, “Residents in the flexible duty hour group did not work more hours; rather, they worked more effectively by rearranging their hours.” At the very least, the authors concluded that “less-restrictive duty-hour policies for surgical residents were associated with non-inferior patient outcomes and no significant difference in residents’ satisfaction with overall well-being and education quality.”
The sample size was good, the survey was carefully crafted. And yet, these results do not sit well with me.
Individuals who go into medicine are all, to some degree, perfectionists. We thrive on performance, we push limits, and we have high expectations. The very lens through which we understand reality is inherently biased toward these goals. In many ways, we come to understand our own dissatisfaction as a personal failure—we can’t balance our lives, we can’t appropriately handle the stress, we can’t keep up during long shifts. As such, I begrudgingly admit that we may not be the best judges of our own well-being. Thus mental illness and suicide continue to rise among residents and physicians.
So now what? The debate over work hours and hand-offs, while well-intentioned, somewhat misses the point. I am a trainee in a pediatric medical residency, and would argue that each specialty has its own, unique ecosystem within the medical biome. We need to think larger, and more about process. Helen Darling, CEO of the National Business Group on Health, put it succinctly: “Hospitals and medical schools should use business process reengineering to change the wasted tasks on which residents currently spend their time.”
How can we make residents more productive? How can we remove the systemic barriers to rapid and effective communication, order verification, patient information, and documentation? How can burgeoning IoT (Internet of Things) technologies enable these tasks?
Answering these questions will violate duty hours, indeed.