RAND-UCLA Study Sheds Light on Proposed Resident Duty Hour Limits

From http://www.aafp.org/online/en/home/publications/news/news-now/resident-student-focus/20090527rand-hours-study.html

Report's Authors, AAFP Share Same Doubts About Further Restrictions

By Barbara Bein
5/27/2009

A report from the nonprofit research organization RAND Corp. and the University of California, Los Angeles, or UCLA, says that new recommendations to further limit the work hours of medical residents would cost the nation's teaching facilities about $1.6 billion a year to hire additional personnel to fill in for residents coming off work shifts. That's a high price to pay for the uncertain effects that adopting the recommendations would have on reducing fatigue-related medical errors in many clinical settings, say Academy leaders and other medical education experts.

"This report confirms our concerns. Not only are (further restrictions) costly, but there also is no evidence that they will actually improve patient safety," AAFP President Ted Epperly, M.D., of Boise, Idaho, told AAFP News Now.

The RAND-UCLA study, "Cost Implications of Reduced Work Hours and Workloads for Resident Physicians," was published in the May 21 issue of the New England Journal of Medicine.

The new report comes five months after the Institute of Medicine, or IOM, recommendedthat continuous on-site duty periods for residents not exceed 16 hours unless a five-hour uninterrupted sleep period is provided between 10 p.m. and 8 a.m. Other recommendations proposed reducing residents' workloads and increasing the number of days they would have off each month.

The IOM's own estimate of the cost of shifting resident work to other clinicians was about $1.7 billion a year, more than the $1.6 billion a year estimated by the RAND-UCLA report, which expanded on the IOM's cost analysis by using published data to estimate labor costs associated with transferring excess work from residents to substitute clinicians.

Academy leaders have disagreed with many of the IOM recommendations, and the RAND researchers point to key reasons for those concerns.

"Adopting new restrictions on the work hours of physicians in training would impose a substantial new cost on the nation's 8,500 physician training programs," said lead author Teryl Nuckols, M.D., an internist at the David Geffen School of Medicine at UCLA and a RAND researcher, in a May 20 press release. "There is no obvious way to pay for these changes, so that's one major issue that must be addressed."

The RAND-UCLA report says teaching hospitals would have to make up for residents' shorter work hours by hiring other health care professionals, such as physician assistants, to do the work or by expanding the number of residency positions offered at teaching facilities.

Hiring additional clinicians would cost each major teaching hospital $3.2 million a year, according to RAND researchers. The other option to make up for residents' shorter work hours -- expanding the total number of residency positions offered -- would ease physician shortages in some specialties but would lead to oversupply in others, the report says.

Epperly echoed that latter perspective, saying that such a move could have the unintended effect of increasing the overall physician workforce in the same proportions as what he termed "our already out-of-balance workforce."

"More of the same workforce is not a solution, but only contributes to the problem," Epperly said. "We need to rebalance this workforce with a greater number of primary care physicians."

But perhaps the most significant question addressed by the RAND-UCLA study is whether reducing resident work hours would cut down on serious medical errors. The report's authors say that although one study of shorter shifts suggested that a 25 percent decrease in serious errors might be plausible in hospital intensive care units, overall, few errors cause patient injuries, and the effects of making such work hour changes could differ in other clinical settings.

Moreover, the additional patient hand-offs could actually increase the number of preventable adverse events, says the report, which concludes that "implementing the … IOM recommendations would be costly and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high."

Epperly -- who is program director and CEO of the Family Medicine Residency of Idaho in Boise -- agreed. "We may be substituting shorter work periods on the residents' part with increased fragmentation of both patient care and (residents') educational experience," he said of the report's findings. "More frequent hand-offs of patient care have been associated with increased medical errors. Therefore, we may actually be making patient care more unsafe, instead of safer."

Epperly is scheduled to speak about the proposed duty hour restrictions during the Accreditation Council for Graduate Medical Education's National Congress on Duty Hours and the Learning Environment, June 11-12 in Chicago. Also speaking will be Marjorie Bowman, M.D., M.P.A., of Philadelphia, professor and chair of the University of Pennsylvania Health System Department of Family Medicine and Community Health.

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety

Check http://books.nap.edu/openbook.php?record_id=12508

Regulation of junior doctors’ work hours: an analysis of British and American doctors’ experiences and attitudes

From http://www.sciencedirect.com

Reshma Jagsi ^, a and Rebecca Surender ^, , b

^a Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Cox 3, 100 Blossom Street, Boston, MA 02114, USA

^b Department of Social Policy, University of Oxford, Barnett House, 32 Wellington Square, Oxford 0x1 2ER, UK

Available online 25 September 2003. 

Abstract

Regulations of junior doctors’ work hours were first enacted in the United States (US) and United Kingdom (UK) over a decade ago, with the goals of improving patient care and doctors’ well-being while maintaining a high quality of medical training. This study examines experiences and attitudes regarding the implementation of these regulations among physicians and surgeons at two teaching hospitals, one in South-East England, and the other in New England, US. This paper presents the findings of a survey questionnaire and a series of in-depth interviews administered to a sample of junior doctors and the consultants responsible for their supervision. The study finds that the different policy mechanisms employed in the two countries have had different degrees of success in reducing the work hours of junior doctors. The results also indicate, however, that even in settings in which hours have been reduced significantly, the regulations have only had limited effects on the quality of medical care, junior doctors’ well-being, and the quality of medical education. A number of barriers to the success of the regulations in achieving their objectives are identified, and the relative merits of political action and professional self-regulation are discussed. This research suggests that recently enacted policies requiring further reductions in junior doctors’ hours in both the US and UK may face similar barriers when implemented. Understanding the lessons that emerge from implementation of the original regulations is essential if future reforms are to succeed and a high-quality system of health care is to be sustained.

Author Keywords: Author Keywords: Junior doctor; Work hours; Legislation; Professional regulation; Medical education; UK; USA

Article Outline

• Introduction

• Methods

• Results

• Work hours and patterns

• Quality of medical care

• Medical education

• Physician well-being

• Gender

• Barriers to implementation

• Attitudes towards further hours reductions

• Discussion

• References

Corresponding author. Tel.: +44-1865-270325; fax: +44-1865-270324

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Social Science & Medicine Volume 58, Issue 11, June 2004, Pages 2181-2191

Medical Education and the ACGME Duty Hour Requirements: Assessing the Effect of a Day Float System on Educational Activities

From http://www.informaworld.com/smpp/content~content=a789375426&db=all

Author: Steve Roey ^a

Affiliation:

a Department of Medicine, Santa Clara Valley Medical Centre, San Jose, California, USA.

DOI: 10.1207/s15328015tlm1801_7

Publication Frequency: 4 issues per year

Published in:  Teaching and Learning in Medicine, Volume 18, Issue 1 January 2006 , pages 28 - 34

Subjects: Teachers & Teacher Education; Teaching & Learning;

Formats available: PDF (English)

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Abstract Background: In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted new resident work hour mandates, which are being shown to improve resident well-being and patient safety. However, there are limited data on the impact these new mandates may have on educational activities. Purposes: To assess the impact on educational activities of a day float system created to meet ACGME work hour mandates. Methods: The inpatient ward coverage was changed by adding a day float team responsible for new patient admissions in the morning, with the on-call teams starting later and being responsible for new patient admissions thereafter. I surveyed the residents to assess the impact of this new system on educational activities-resident autonomy, attending teaching, conference attendance, resident teaching, self-directed learning, and ability to complete patient care responsibilities. Results: There was no adverse effect of the day float system on educational activities. House staff reported increased autonomy, enhanced teaching from attending physicians, and improved ability to complete patient care responsibilities. Additionally, house staff demonstrated improved compliance with the ACGME mandates. Conclusions: The implementation of a novel day float system for the inpatient medicine ward service improved compliance with ACGME work duty requirements and did not adversely impact educational activities of the residency training program.

Resident duty hours: Does more sleep mean safer care?

From http://www.ama-assn.org/amednews/2009/10/05/prsa1005.htm

Six years after resident work limits took effect, the impact on safety is still hotly contested. A push for more sleep is reigniting the debate.

By KEVIN B. O'REILLY, amednews staff. Posted Oct. 5, 2009.

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Accurate patient records are key to avoiding fumbled patient handoffs. Monal Joshi, MD, then an internal medicine intern at Rush, works to sign out her patients before her shift ends. Proposed work-hour changes could increase the number of handoffs -- and handoff-related errors.[Photo by Tyler Mallory /www.tylermallory.com]

"Oh, I forgot all about that," Monal Joshi, MD, responded to a question from a senior resident during morning report. The internal medicine intern, entering the 25th hour of a 30-hour shift at Rush University Medical Center in Chicago, had overlooked a patient's test result.

The slip was quickly caught by a supervisor, and no harm was done. But was the resident's momentary lapse due to fatigue?

Dr. Joshi had at least two hours of sleep the night before -- pretty good for when she's on call.

Some other members of the five-person Rush internal medicine residency team looked worse for wear as their shifts neared the end one day last spring. Third-year medical student Shikha Wadhwani rested her hand on her head, blinking slowly and yawning widely, as the others went through their reports.

But Yoojin Kim, MD, an intern who slept from 3:30 a.m. to 6 a.m., looked bright as a fluorescent light as she sped through her patient reports.

• Duty hours: Present -- and future?
• More sleep, but at what price?
• Work-hour rules not always heeded
• Some specialties more prone to violations
• Links
• See related content

Sleep scientists say staying awake for more than 16 hours decreases the ability to concentrate, impairs memory and hinders the ability to do tasks such as tracking test results on a monitor.

Yet sleep deprivation does not affect everyone the same way. Such is the enigma of the debate on whether resident duty-hour limits have helped patients.

Six years have passed since the Accreditation Council for Graduate Medical Education cut resident workweeks to 80 hours. The council also restricted shifts to 24 hours of call plus six hours of patient transition and educational activities.

Some health leaders said cutting back the weekend-long shifts and 120-hour workweeks that were common before the 2003 rules would yield a safety benefit -- fewer patient deaths and fewer complications. But it is hard to make a definitive, evidence-based argument that the work-hour limits have improved patient outcomes, experts said.

More adjustments could be on the way. The ACGME is examining whether to adopt a 16-hour shift or mandate a five-hour nap in each 30-hour shift. Those are among changes recommended by an Institute of Medicine panel in a report issued in December 2008. The ACGME could propose new rules next February, taking effect as early as July 2011.

The American Medical Association supports the 80-hour workweek. Its Council on Medical Education will deliver a report at the November Interim Meeting with recommendations about the IOM report.

Examining impact on safety

Kathlyn E. Fletcher, MD, has published systematic reviews of work-hour safety studies and is part of a team helping the ACGME sort through more than 5,000 articles on residency education published since the 2003 rules took effect.

"There is not much evidence to suggest mortality has gotten worse. At worst, it has not changed and, at best, maybe it has gotten better," said Dr. Fletcher, interim section chief of general internal medicine at the Clement J. Zablocki Veterans Affairs Medical Center in Wisconsin. "The studies that have looked at things like complications are more difficult to interpret. Some studies find more complications, and some find fewer complications, and some have shown no change. There's probably a finer look that needs to be taken, but at this point, it looks pretty positive."

The 80-hour resident workweek has been in place since 2003.

Two of the biggest studies of clinical outcomes to date, published in the Sept. 5, 2007 Journal of the American Medical Association, highlight the equivocal nature of the evidence.

The time-series studies, done by the same research team, looked at 30-day mortality among nearly 320,000 VA patients and more than 8.5 million Medicare patients from 2000 to 2005. The duty-hour rules were associated with a significant mortality improvement for VA medical patients, but no change for VA surgical patients. In the Medicare population, mortality did not significantly improve or worsen.

Vineet Arora, MD, who is working with Dr. Fletcher on the literature review, said more sleep does not automatically mean safer care.

"Whenever you restrict hours, there will be more handoffs," said Dr. Arora, associate program director of the University of Chicago Pritzker School of Medicine's internal medicine residency program. "There are more handoffs in ... teaching hospitals now, and we know they can lead to patient harm. One of the difficult things to isolate in a complex system is what is the contribution of handoff error to patient harm?

"You have the tradeoff between having a fatigued doctor who knows the patient well and a well-rested doctor who may not know the patient. How good is the handoff that the well-rested doctor can take over very well for the fatigued doctor who signed out?"

John R. Potts III, MD, general surgery residency program director at the University of Texas Medical School at Houston, said the safety evidence does not support shorter shifts.

"The data to say that patient care has improved since the 2003 duty hours were instituted is completely lacking," Dr. Potts said. "I don't think anybody would reasonably argue that a better-rested doctor would not typically make better decisions. But the counterargument, though, is that we do have multiple levels of oversight of graduate medical education in this country.

"You can only provide 24-hour care with reduced duty hours by increasing the number of handoffs, and there is a hopefully small but still universally recognized fumble error in handoffs. So it becomes a question of the lesser of two evils."

The sleep-versus-handover tradeoff is one that residents struggle with daily.

"The 30-hour requirement made it very challenging sometimes, because I needed to be out at 1 p.m.," said Jessica Rouse, MD, who completed a family medicine residency at Fletcher Allen Health Care in Vermont this year. She now practices in Middlebury, Vt. "If I had a couple of hours in the middle of the night, I thought, 'Is it worth it to get a one- or two-hour nap in to be much more efficient in the morning rounds, or should I use that time to do paperwork?' Because when those 30 hours were up, I wanted to make sure everything was done so that I could hand off my patients all tucked in."

Many experts said the recommendation for a five-hour nap in a 30-hour shift was unrealistic, because residents might work during that time.

The IOM's recommendations were based principally on sleep science, said Maureen Bisognano, who served on the panel and is executive vice president and chief operating officer of the Institute for Healthcare Improvement in Massachusetts. The measured effect of the 2003 work-hour rules on patient outcomes was less clear, she said.

"It was a difficult thing to get our hands on in the six years since the new rules took effect, because I don't think the science points us in one clear direction or the other," Bisognano said. Testimony and data from the aviation and trucking industries showed that learning would not be impaired, "but patients would be safer because they would not be in the hands of fatigued providers."

Safety hard to measure

Bisognano argued that reducing medical-resident fatigue alone might not be sufficient to improve patient safety in teaching hospitals. "It's a system of safety, and it all needs attention," she said. "Unless we get to that point where we are looking at the whole system, then incremental change in one piece or another won't give us the kind of change we need and that we owe our patients."

Robert Wachter, MD, chief of the medical service at the University of California, San Francisco, Medical Center, said it is no surprise that the purported advantages of better-rested residents have not shown up strongly when studied.

"One of the challenges in the safety field is that it's pretty hard to measure safety," said Dr. Wachter, a leading patient safety researcher. "It's possible [the ACGME work-hour rules] had some good effects in terms of safety, and it's just not a signal we've been able to detect so far."

Dr. Wachter opposes moving to a 16-hour shift, because it would shorten the handoff process, interrupt continuity of care and worsen residents' learning experiences. "Too much additional regulation may harm as much as help."

Even if moving to a 16-hour shift and giving residents more time off would improve patient safety, some residents prefer the current work schedule. "If you're doing 16-hour shifts, maybe you go home to your own bed at like 11 p.m.," said Dr. Kim, now a senior resident at Rush. "You're dead tired, and you have to come back the next day at 7 a.m., and maybe you get five hours' sleep.

"I feel like on my post-call days, I get to go home and I don't have to think about anything for the rest of the day. I get home by 1 or 2, then I sleep for 14 hours straight -- and I love it."

The print version of this content appeared in the Oct 12, 2009 issue of American Medical News.

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 ADDITIONAL INFORMATION: 

Click to see data in PDF.

Duty hours: Present -- and future?

Last December, an Institute of Medicine panel started a new debate about resident duty hours. The IOM recommended keeping the 80-hour workweek but said residents should care for fewer patients and get more sleep and time off. Here is a comparison of current ACGME duty-hour limits and the IOM's proposed changes.

Source: Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, Institute of Medicine, Dec. 2, 2008 (www.iom.edu/CMS/3809/48553/60449/60471.aspx)

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More sleep, but at what price?

It could cost more than $1.5 billion to pay for the attending physicians, nurse practitioners and physician assistants needed to cover for residents so they can get more sleep and time off, said a recent analysis. This breaks down to as high as $3.4 million per life saved. Here's how the estimated costs of implementing the IOM recommendations would play out.

IOM recommendation	Cost
Protected naps during extended shifts	$559 million
Reduced workload	$392 million
Better adherence to 80-hour workweek	$376 million
16-hour limit for shifts without naps	$250 million

Note: All costs expressed in 2006 dollars

Source: "Cost Implications of Reduced Work Hours and Workloads for Resident Physicians," The New England Journal of Medicine, May 21 (content.nejm.org/cgi/content/short/360/21/2202/)

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Work-hour rules not always heeded

Experts speculate that one reason duty-hour regulations have not had more of an impact on patient safety is that residents are pressured to break the rules.

	Programs cited
2003-04	5.0%
2004-05	7.3%
2005-06	8.1%
2006-07	8.8%
2007-08	7.0%

Source: "The ACGME's Approach to Limit Resident Duty Hours 2007-08: A Summary of Achievements for the Fifth Year under the Common Requirements," Accreditation Council for Graduate Medical Education, August 2008 (www.acgme.org/acwebsite/dutyhours/dh_achievesum0708.pdf)

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Some specialties more prone to violations

A resident survey in the Sept. 6, 2006, Journal of the American Medical Association found that about 70% of residency programs violated the 30-hour-shift rule and the 80-hour workweek rule. The top five violators in 2007-2008:

Specialty	Programs cited
Colon and rectal surgery	30.0%
Emergency medicine	28.6%
Anesthesiology	22.2%
Neurology	20.8%
Nuclear medicine	20.0%

Source: "The ACGME's Approach to Limit Resident Duty Hours 2007-08: A Summary of Achievements for the Fifth Year under the Common Requirements," Accreditation Council for Graduate Medical Education, August 2008 (www.acgme.org/acWebsite/dutyHours/dh_achievesum0708.pdf)

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WEBLINK

"Information Related to the ACGME's Effort to Address Resident Duty Hours and Other Relevant Resource Materials," Accreditation Council for Graduate Medical Education (www.acgme.org/acWebsite/dutyhours/dh_index.asp)

"Resident Duty Hours: Enhancing Sleep, Supervision, and Safety," Institute of Medicine, Dec. 2, 2008 (www.iom.edu/?id=60449)

"Cost Implications of Reduced Work Hours and Workloads for Resident Physicians,"New England Journal of Medicine, May 21, abstract (content.nejm.org/cgi/content/short/360/21/2202)

"Consequences of Inadequate Sign-out for Patient Care," Archives of Internal Medicine, Sept. 8, 2008, abstract (archinte.ama-assn.org/cgi/content/abstract/168/16/1755)

"Mortality Among Hospitalized Medicare Beneficiaries in the First 2 Years Following ACGME Resident Duty Hour Reform," Journal of the American Medical Association, Sept. 5, 2007, abstract (jama.ama-assn.org/cgi/content/abstract/298/9/975)

"Changes in Hospital Mortality Associated with Residency Work-Hour Regulations,"Annals of Internal Medicine, July 17, 2007, abstract (www.annals.org/cgi/content/abstract/147/2/73)

An Elusive Balance — Residents' Work Hours and the Continuity of Care

From  http://content.nejm.org/cgi/content/full/356/26/2665

Volume 356:2665-2667		June 28, 2007		Number 26

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An Elusive Balance — Residents' Work Hours and the Continuity of Care

Susan Okie, M.D.

PDF PDA Full Text Audio Interview Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear

Four years after national limits on duty hours for medical residents took effect — and nearly two decades after similar limits were enacted by New York State — conversations with residency directors, attending physicians, health care researchers, and sleep-medicine experts suggest that neither patient care nor medical education is optimal under the current system and that further reforms are needed. But there is little agreement on what should be done or even on whether the work-hour limits should be tightened or relaxed.
U.S. teaching hospitals are handling more admissions, treating older and sicker patients, and discharging patients more quickly than in past decades — factors that have intensified residents'workload, despite the limitations in hours. "We're looking at whether the current limits need refining," said Ingrid Philibert, senior vice president for field activities at the Accreditation Council for Graduate Medical Education (ACGME), which accredits U.S. residency programs. The ACGME is "being pushed from both sides," she says, "by folks who think we've gone too far and by those who think we've not gone far enough."
One reason is that there are no reliable national data measuring the effects of the work-hour limitations on training or patient care. The rules were intended to improve patient safety by reducing medical errors and to enhance residents' educational experience and protect them from accidents, injuries, and other consequences of sleep deprivation. Sleep-medicine experts contend that U.S. residents still work too many hours — and that the currently permitted 30-hour shifts and 80-hour workweeks are unsafe for both doctors and patients. Residents in Europe work about 56 hours per week, and after August 2008, they will be allowed to work only 48 hours. Studies have documented that clinical performance suffers and errors increase when physicians are fatigued. "Twenty-four hours is too long" to be continuously on duty, said Steven Lockley of the Division of Sleep Medicine at Brigham and Women's Hospital in Boston. "You can only work appropriately for 16 to 18 hours."

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There has been considerably less research, however, on whether preventable errors also increase when responsibility for patients is transferred repeatedly from one resident to another. Such "handoffs" have become much more frequent in teaching hospitals as a result of the scheduling changes made to comply with the work-hour rules (for example, the use of "night float" residents who admit patients during the night and pass them on to another team in the morning). At the University of California at San Francisco, for example, such changes in scheduling resulted in an average of 15 handoffs per patient during a 5-day hospitalization. Each intern was involved in more than 300 handoffs during an average month-long rotation, a 40% increase in the number reported before the duty-hour limits were in place.¹ With 6 million patients receiving care in U.S. teaching hospitals annually, the impact on medical care is potentially large — but difficult to measure.
As an attending physician supervising residents at Houston's Michael E. DeBakey Veterans Affairs Medical Center, Laura Petersen, an associate professor of medicine at Baylor and one of the authors of a study showing that multiple handoffs increase errors,² said, "I'm really the only person who seems to have continuity with the patients. . . . The residents are coming and going. . . . I know things are falling through the cracks." Petersen and her colleagues published a follow-up study demonstrating that using a standard, computerized sign-out form to transmit key information about patients could prevent such errors,³ but less than 5% of U.S. hospitals have adopted such procedures. In 2006, the Joint Commission, the accrediting body for hospitals, implemented a requirement that handoffs be standardized, and Philibert said the ACGME will probably address handoff procedures in a revision of its residency-accreditation requirements.
Nationally, there is no evidence to date that the duty-hour limits have had a measurable effect on preventable medical errors or on patients' rates of death. Most research on the subject has consisted of small, single-site studies, lacking in statistical power. "Nobody at the ACGME expected a huge reduction in errors," noted Philibert. "Residents are not the sole providers" of care, so their errors "may be caught by other parts of the system."On the other hand, sleep-medicine experts say that in general, new schedules have not shortened shifts or reduced fatigue enough to greatly improve residents' clinical performance. A recent study surveyed 2737 residents at monthly intervals during their internship year about medical errors they had made; it found that the odds of reporting at least one fatigue-related clinically significant medical error increased by a factor of 7 during months in which they worked five or more overnight shifts, as compared with months in which they worked no overnight shifts.⁴
Kevin Volpp, an assistant professor of medicine and health care systems at the University of Pennsylvania, is conducting a large national study of patient outcomes that attempts to examine the impact of the rules, using data on millions of patients in the Medicare and Veterans Affairs systems. "We're basically looking at the net effect of reduction in sleep deprivation versus reduction in continuity of care," he said. "One of the big challenges is figuring out how to tease this apart and examine the tradeoffs." Volpp said the evidence is compelling that assigning residents to shorter shifts reduces errors caused by fatigue. However, shortening residents' shifts requires adding staff such as physician assistants, nurse practitioners, and hospitalists, and he noted that despite receiving Medicare subsidies for residency training, teaching hospitals operate on slim financial margins and have recently seen substantial reductions in Medicare funding. Considering the cost of further reducing duty hours, Volpp asked, "Is this the best use of resources that could be targeted to reducing medical errors?"
At a recent meeting hosted by the Commonwealth Fund in New York City, physicians who supervise residents in the city's teaching hospitals said that the workloads of residents are higher than ever, which reduces the time available for education and adds to the clinical responsibilities of attending physicians and medical students. "On our medical service, the average age of patients is over 80," said Andrew Yacht, program director of the internal medicine residency program at Maimonides Medical Center in Brooklyn. "Over 20% of our medicine beds are occupied by ventilator patients." Residents "are stretched way too thin. . . . They're just trying to tread water." Patients suffer when responsibility for their care shifts repeatedly from one resident team to another, said Abigail Zuger, an attending physician at St. Luke's–Roosevelt Hospital Center in New York. "It's a misery for them — they don't know who is in charge of their case. They see an endless parade of strangers," she said.
In trying to mold residents' schedules to the new rules, program administrators "have come up with solutions that are not best for patient care nor best for fatigue," said sleep expert Lockley, whose team is creating software programs to help residency directors predict the effects of various schedules on sleep time and alertness. The fact that attending physicians usually meet with residents to hear about new patients only once a day "is what's really driving the 24-hour shift," Lockley added; twice-daily attending rounds would facilitate shorter shifts. How to devise schedules to reduce fatigue and improve education and continuity of care "is probably the most interesting question right now," agreed Kathlyn Fletcher, an assistant professor of general internal medicine at the Medical College of Wisconsin in Milwaukee, who has studied the effects of schedule changes. Fletcher believes that the work-hour rules are "only going to get more stringent."
To create training programs that deliver safe and excellent patient care, high-quality medical education, and sufficient sleep for residents, residency directors will need to implement far-reaching reforms to reduce workload intensity and to impart professional standards that emphasize working as a team, said Ethan Fried, vice chair for education at St. Luke's–Roosevelt Hospital Center. "You absolutely, positively need to have duty hours . . . [but] it's duty hours in concert with a much more highly developed system for teamwork and for passing work along — which we're really still struggling to develop," he said. "We're looking at ways to reduce caps [the maximum number of patients cared for by one intern] and ways to fund the faculty to supervise the handoff process, but all this is work — real work that needs to be supported and paid for."
Philibert said the ACGME wants to collect feedback and data to help it decide how to "refine" the current duty-hour rules and is encouraging residency programs to submit proposals for pilot projects to study the effects of innovative schedules and other changes. There is no funding available, but in exchange for conducting approved pilot projects, programs could receive incentives such as accreditation waivers (exemption from certainrequirements or extension of accreditation beyond 5 years), she said. Some pilot projects are expected to start this July, and results may be available by the middle of next year.
The biggest challenge, according to several observers, is teaching residents that their conscientiousness is best expressed by ensuring that their patients will be well cared for by colleagues while they are off duty, rather than by working to exhaustion. "That is a big challenge to the profession," said Carolyn Clancy, director of the federal Agency for Healthcare Research and Quality. "I think it has to be addressed head on, and it's a much largerquestion than how many hours are enough — or too much."


Source Information
Dr. Okie is a contributing editor of the Journal. 

An interview with Ethan Fried of St. Luke's–Roosevelt Hospital Center can be heard at www.nejm.org.
References

1. Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006;1:257-66. 
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