SHORTER RESIDENCY HOURS WEAKENS PATIENT CARE

RESIDENT WORK SCHEDULES LIGHTENED

The current residency training programs are creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

In 2003 the Accreditation Council for Graduate Medical Education (ACGME), which accredits U.S. medical training programs, instituted rules for resident work hours, sometimes called "the eighty-hour workweek.  The new rules limit residents' duty hours to no more than eighty hours a week.

Besides ensuring excellent medical treatment for patients, the ACGME work rules are intended to keep residents alert so that they could fully engage in the work and education needed to become fine physicians.

COMPLIANCE TO THE NEW RULES

These rules govern the working conditions of the 100,000 young doctors-in-training in teaching hospitals across the United States and were developed both to protect patients from potentially unsafe medical practices by sleep-deprived physicians and to improve working and learning conditions for residents. The work rules, among other stipulations, limit both the number of consecutive days in a week and the number of consecutive hours in a shift that a physician-in-training can work; in addition, the rules require rest periods of at least ten hours between shifts.

Compliance with the new work rules reduces wandering attention on the part of the residents, might reduce actual or near-miss car accidents involving exhausted residents who've worked extended hours, and appears to reduce serious medical errors in the ICU. 

Young physicians learning to be clinical specialists, have long been the mainstay of medical care in teaching hospitals. Because residents traditionally worked in hospitals in the name of receiving education and because altruism is a hallmark of doctors, physicians-in-training have provided a considerable amount of clinical care while working long hours for relatively short pay.

HOW TO CARE FOR ALL THE PATIENTS 24/7

Nobody wants procedures or important decisions to be made by exhausted, blurry-eyed, muddle-brained doctors, so the intent was to form medical teams that would work in rotating shifts, thus providing the physicians with adequate time off. As a result, several times a day, responsibility for patient care shifts as it is passed from team member to team member.

Residents aren't available to examine their patients, to learn about new symptoms from the parents, to review the results of the most recent lab and radiographic tests, to review the nursing assessments for the past twenty-four hours or to make recommendations for ongoing care for their patients.

Resident physician work schedules now look more like Bingo cards than a comprehensive system for providing coordinated medical care or educating future medical specialists. The erratic schedules are the unintended consequences of the new rules on resident work hours.

Stopgap measures designed to provide physician care to all patients around the clock, seven days a week, are found in every teaching hospital in the United States.  By limiting the number of work hours of each resident, however, the new ACGME rules have effectively decreased the hospital's resident physician workforce by 25 percent—in other words, a full quarter of them have gone missing.

At the same time that the new rules have come into effect, the resources to pay for medical care are vanishing.   Medicaid and Medicare payments for health care services are decreasing, and insurance payments are following this lead.  Furthermore, more and more patients—forty-seven million currently—have no insurance, which means that they don't pay—because they can't pay—the bill.

 

Many physician extenders, as physician assistants, command salaries similar to those of physicians-in-training yet work only forty hours a week. Hiring them as replacements would mean a 100 percent increase in costs.    The ACGME requires training programs to report the actual hours spent in the hospital.   It leaves it up to the training programs to figure out how to get the work done in the time allotted.

 WHO IS GOING TO DO THE WORK?

The resident is up against the limits of the work rules and is told to leave the hospital. There's no wiggle room. If the resident continues on duty beyond the dictates of the rules, his training program might be cited for noncompliance. The penalty for too many citations: probation for the training program or possibly withdrawing the program's ACGME accreditation. A training program on probation or without accreditation has an extremely hard time attracting excellent resident physicians.

Losing 25 percent of the workforce hasn't been accompanied by hiring additional physicians. As a regulatory agency, the ACGME issues mandates to ensure that young physicians receive excellent clinical training.  It usually doesn't approve adding increased numbers of residents to a training program just to plug a hole in a hospital's need for clinicians.  A hospital's inability to increase the number of resident physicians isn't the only barrier to improved staffing.  Most hospitals can't afford increased numbers of residents anyway.

The RULES ARE BACKFIRING

Residents no longer are able to observe the timing of a patient's response to an intervention.   They can't follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to.  Their heads are crammed with the facts they've learned during medical school, but they can't see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making.

Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

Residents often ask for increased autonomy. Yet with their current here-today-and-gone-tomorrow schedules, they can't be given increased autonomy.  They won't be around for the next step or haven't been around for the last step. They don't get the big picture.

HOW TO WORK SMARTER!

In terms of the new ACGME regulations and providing medical care we can't seem to figure out the money part.  Programs might be able to work” smarter" with new technologies and information systems and must figure out how to streamline communication among the many team members.  Resources are needed to create real teams and that takes money.

What's more important than healthy patients and well-educated physicians? We know the answer: Nothing.  What is being done to meet the challenge of having enough doctors for enough hours in all of our hospitals?   Nothing.

sources: New York Times, Wall Street Journal, Dec 8,2008

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