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Thursday, April 29, 2010

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


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

By Barbara Bein
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.

Sunday, April 25, 2010

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


Reshma Jagsi E-mail The Corresponding Authora and Rebecca Surender Corresponding Author Contact InformationE-mail The Corresponding Authorb
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. 


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

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

Friday, April 23, 2010

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


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: journal Teaching and Learning in Medicine, Volume 18, Issue January 2006 , pages 28 - 34
Formats available: PDF (English)
Article Requests: Order Reprints : Request Permissions
View Article: View Article (PDF) View Article (PDF)


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.

Wednesday, April 21, 2010

Resident duty hours: Does more sleep mean safer care?


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.
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 /]
"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.
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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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 (

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 recommendationCost
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 (

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
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 (

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:
SpecialtyPrograms cited
Colon and rectal surgery30.0%
Emergency medicine28.6%
Nuclear medicine20.0%
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 (

Tuesday, April 20, 2010

Refixing the existing Civil Surgeons in general line in the cadre of Chief Civil Surgeon - Re-fitment for the year 2009

DATE OF COUNSELLING 23/04/2010 AND 24/04/2010
Ref.No;78000/E6/1/09                            Office of the Director of Medical and Rural Health Services, Chennai-600 006.
                                                            Dated: 20/04/2010
Sub;     TNMS – Chief Civil Surgeon (common /General/Specialists posts) – refixing the existing  Civil Surgeons in general line in the cadre of Chief Civil Surgeon -  Re-fitment  for the year 2009 – List of Civil Surgeons working in the DMS side qualified for promotion counseling published.
Ref:      1. G.O.(Ms)No;354,H&FW Dedpt,dated;23.10.09
            2.This office Lr.Ref.No;78000/E6/1/09,dated;8.3.10.
            3.This office Lr.Ref.No;78000/E6/1/09,dated:09/04/2010.


In continuation of the correspondence cited, a tentative list of Civil Surgeons in the General side who are qualified for promotion and re-fitment to the post of Chief Civil Surgeon (Common/Specialist/General) for the year 2009 are notified in the Annexure.  As per the records available in this Directorate all the Civil Surgeons who have been promoted upto the panel year 2008-2009 (CML 5347/05) have been taken in to the account for this re-fitment exercise.  All the Unit Officers noted in the dispatch entry are requested to adhere to the following instructions:-

1)          kindly circulate the list to all the Govt. Hospitals/PHCs /ESI Dispensaries/and other foreign service institutions coming under their zone  and also to  paste the list in the prominent place /notice board of the Hospitals  concerned.
2)          The service particulars of eligible Medical Officers notified in the list should be furnished at the time of counseling duly counter signed by the respective Districts Officers. The service particulars obtained  from the Medical Officer incharge / below the rank of DDHS/JDHS will not be accepted.   All the required details should be compulsorily furnished in the prescribed format duly indicating the CML NO 2005/ Qualification / Present Station / Previous working stations for the last 5 years  without fail.
3)          The Medical Officers who have been promoted as Civil Surgeons and their names omitted to be included in the list shall attend the counseling alongwith the details of promotion order of Civil Surgeon / Service Particulars. 
5)         The names of those Medical Officers who are facing Disciplinary action / undergoing punishment / VR / Retired / Expired / Removal / Dismissal and Medically invalidated have been omitted in the list.
6)         The names of those Medical Officers who have tendered Temporary Relinquishment period during the panel years 2005-2006, 2006-2007,     2007-2008 and 2008-2009 and not completed 3 years of relinquishment period as on 23/10/2009 are not taken into consideration for this promotion and re-fitment counseling.

7)         As per the orders contained in the G.O.Ms. No.354 /H&FW/ B2/ Dept, dt:23/10/2009 this counseling is conducted only for the Civil Surgeons working in the DM&RHS side (including DPH&PM / ESI Wing) for the post earmarked as Chief Civil Surgeon (Common/General/Specialist). 
8)         The Doctors working in the DME side even though  promoted as Civil Surgeon are not considered for this counseling since DME have become a separate unit as per the G.O. mentioned in para No.7.
9)         The names will be called for as per the list arranged and notified.
10)     This list of qualified Medical Officers can be accessed through E_mail ID’s of all District Officers and can be browsed in &
11)     The Official call letter and the list will be communicated shortly and therefore all the unit officers are requested to treat the list hosted in the website as an official document for all purpose.
Kind co-operation is solicited in the matter.
Director of Medical and Rural Health   Services
All the Joint Director of Medical and Rural Health Services in the state
All the Regional Administrative Medical Officer (ESIS) in the state
All the Superintendent of ESI Hospitals in the state
All the Deputy Director of Health Services in the state
Copy to: The Director of Public Health and Preventive Medicine, Chennai-6. (*)
Copy to: The Director of Medical and Rural Health Services (ESI), Chennai-6. (*)
-          (*) They are requested to inform all the unit officers in writing /
 E-Mail instruction the Medical Officers coming under their control to attend the counseling duly follow the instructions as mentioned above.
Copy to : The Director of Medical Education, Chennai-10.
He is requested to kindly communicate the contents of para 7 & 8 to all the unit officers / Doctors working in the teaching side without fail.

Copy submitted to
The Principal Secretary to Government,
Health and Family Welfare Department,
Chennai-600 009.

The Project Director and Special Secretary to Government,
Health and Family Welfare Department,
Chennai-600 009.

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