For Whom the Bell Commission Tolls: Unintended Effects of Limiting Residents' Hours
2009; Elsevier BV; Volume: 54; Issue: 4 Linguagem: Inglês
10.1016/j.annemergmed.2009.08.008
ISSN1097-6760
Autores Tópico(s)Healthcare Policy and Management
ResumoThe intentions behind the regulation of residents' hours under New York State Department of Health Code section 405.4, the model for the national standards set by the Accreditation Council for Graduate Medical Education (ACGME) in 2003, are intuitive and admirable: no one wants exhausted, inexperienced, under-supervised residents seeing patients. Research on human sleep cycles suggests that a cowboy ethos is both unrealistic and dangerous; the image of constant clinical heroics performed under conditions too grueling for mere mortals to tolerate, these policies imply, belongs to mythology rather than reality. The high-profile Libby Zion drug interaction case that led to the state's 1987 Bertrand M. Bell Commission report, and thus to state and national limits on duty hours, put an unforgettable public face on this problem.1Lerner B.H. A case that shook medicine: how one man's rage over his daughter's death sped reform of doctor training. Washington Post, November 28, 2006; p. HE01.http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.htmlGoogle Scholar The Zion case, however, involved errors in 2 causal categories: those due to long duty hours and those due to poor oversight by attending physicians. The Bell Commission addressed both, but the more widely publicized reforms that followed its report correct only one of them. Some emergency physicians believe these regulations, which restricted duty to an 80-hour-per-week average, 24 consecutive hours, and a 12-hour limit in emergency departments (EDs), correct the wrong problem–the easier one to measure, but not the deeper reason for the Zion incident or other tragedies. Regulating the numbers of hours, says Jeffrey A. Manko, MD, assistant professor of emergency medicine at New York University and director of the emergency medicine residency at Bellevue Hospital Center, is “low-lying fruit”; upgrading the quality of supervision, the more substantive problem, is harder. Moreover, rigid limits on hours may actually harm patient care in the long run by limiting the scope of residents' education. “When you talk to residents and interact with them,” says Richard C. Dart, MD, PhD, professor of surgery and emergency medicine at the University of Colorado Health Sciences Center and director of the Rocky Mountain Poison and Drug Center in Denver, “they are not getting the experience that they used to get. They don't know the things that they should know; they haven't had the number of patients that they should have, and therefore they haven't seen all the different permutations of a disease … and unless you've seen a disease many, many different ways, you don't understand how to diagnose and treat that disease.” While acknowledging the need to minimize resident fatigue, says Dr. Dart, with tight duty-hour limits “the pendulum has swung too far, and you're actually doing more harm than good.” Residents' need for adequate sleep is beyond dispute, but it is not the only value at stake in the debates over hours. With the quality of patient care at the top of the hierarchy of priorities, and a related consideration, the breadth of postgraduate education, a close second, residents' quality of life comes in a distinct third. That emergency medical practice is scheduled on a shift-work basis does not imply that either emergency physicians or residents would want to operate under clock-punching conditions. Handoff points between physicians, too, can be the site of gaps in communication, and thus a schedule that requires more such transfers increases, instead of reducing, the chance of errors. The relevant committee of the Institute of Medicine (IOM) has recently examined the 2003 ACGME standards and issued a report calling for something stricter: 5-hour sleep periods protected from work and call during shifts lasting beyond 16 hours, as well as the 80-hour average workweek, limits on night-float duty to 4 consecutive nights followed by 48 hours off, and tighter adherence to the 2003 rules.2Ulmer C. Wolman D.M. Johns M.M.E. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety Report by Institute of Medicine Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety. National Academies Press, Washington, DC2009Google Scholar, 3Iglehart J.K. Revisiting duty-hour limits – IOM recommendations for patient safety and resident education.N Engl J Med. 2008; 359: 2633-2635Crossref PubMed Scopus (90) Google Scholar The potential consequences for continuity of coverage, clinical experience, and the costs of resident education, say the report's critics, add up to an instance of regulatory backfire, creating disturbing discrepancies between systematized prudence and research-based, patient-centered policies. The tradition of working extraordinary hours, Dr. Manko says, hearkens back to the days when the term, “house staff” referred to residents quartered on the hospital premises. This system, adapted by William Osler from the German postgraduate model and first instituted at Johns Hopkins, lasted until nearly the mid-20th century; after World War II, residents were no longer literally resident, but the demanding hours remained standard. Perceptions of these conditions as either professionally appropriate or as unprofessional enough to border on hazing4Cousins N. Internship: preparation or hazing?.JAMA. 1981; 245: 377Crossref PubMed Scopus (50) Google Scholar have made duty-hour restrictions a contentious topic, pro and con. The schism in opinions can appear roughly generational, but framing it as “old-school versus newcomers” is overly simplistic, whichever way one might assign evaluative terms to either side. Some view the conflict as pitting enlightened and overdue measures to protect both workers and patients against irrational, exploitive practices commonly justified with nostalgic rhetoric. Others see it as a tradition of professional rigor and commitment versus a rule-bound coddling tendency that risks producing a generation of underprepared physicians. The motto that the chief drawback of every-other-night call is that “you miss half the good cases”5Lewis Jr, F.R. Should we limit resident work hours?.Ann Surg. 2003; 237: 458-459Crossref PubMed Scopus (18) Google Scholar is far from obsolete; many of today's residents embrace that level of avid commitment and chafe at rules that pull them away from patient encounters merely because a certain amount of time has elapsed. Part of the confusion around this issue, Dr. Manko observes, is the dual status of residents. They are present in the hospital both to learn and to serve. In their capacity as students, they need to maximize their exposure to a range of clinical situations; they owe it to their future patients to see as many current patients as possible. In their capacity as a hospital's medical labor force, they can provide patient care relatively inexpensively from the institutional point of view, but only if they are neither overtaxed to the point of compromising patient safety nor overregulated in ways that thwart their ability to give a patient close and prolonged attention. “As a program director and an advocate of residents,” says Dr. Manko, “I also see them as part student, so I have to protect them and make sure they're not just there to do work, but … to get educated as well.” He notes that catching up on sleep is not the only thing residents do with non-duty time: they need time to attend conferences as well as get direct bedside teaching. His residents and the patients they serve, he says, derive distinct benefits from post-Bell Commission policies. “I think we all know that if you're well rested and thinking clearly, you'll probably deliver better patient care. I don't know that that's a big stretch.” Nevertheless, Dr. Manko believes the new IOM report has departed from reality. “The way I'd revise the IOM recommendations would be to throw them out,” he says. “The idea that somehow you're going to have residents in the middle of their shifts take naps, the fact that you're going to say that a resident who works 3 continuous shifts needs 48 hours off–there are a lot of things that [would] wreak havoc with the whole system. You could never do it. Logistically, it would just be a nightmare.” A common situation, he has observed, is for a resident to be working with a patient whose condition requires close attention and time: a critical illness with family present and death imminent, for example, or a complex problem requiring several procedures. “Yet if it goes over that 12-hour mark for a shift in emergency medicine,” he says, “someone taps you on the back: ‘OK, tag team, you're out, I'm in; you have to go home.' That takes away from that fundamental doctor-patient relationship that we all believe is so important to good patient care.” Time micromanagement also puts the resident in the untenable position of having to abandon a patient for a specified period, stay later for the patient's benefit and fudge a time sheet, or report the time accurately and put the residency program under a cloud with the ACGME. Preventing exploitation is essential, Dr. Manko believes, but time-limiting measures need to be leavened with clinical common sense: “On a day-to-day basis, programs get penalized if residents violate the duty hours, even if they do so willingly … . Did the resident do anything so bad? Did the program do anything so bad, that they didn't throw the resident out when he was actually performing something very compassionate and honest?” Since not all long hours represent abuse, critics of the IOM report say, the distinction between voluntary and mandatory duty is worth observing. “Limiting duty hours is a blunt instrument that is effective when circumstances are that people are being ridiculously overworked,” says Andrew E. Sama, MD, chief of emergency medicine at Huntington Hospital, Huntington, NY, and vice president of emergency services at North Shore-Long Island Jewish Health System, Manhasset, N.Y. That instrument is seldom relevant to emergency medicine, he adds, where “we're a little bit different from other specialties, primarily because we have direct supervision of residents, in most cases direct contemporaneous supervision … . Most specialties seek that as well, but we actually do it regularly.” Emergency practice is an area where stamina and sustained attention are qualities a resident specifically needs to cultivate. “You have to have some ability to respond to challenges intermittently,” Dr. Sama says, “whether it's a complex case requiring significant cognitive and technical skill in an off hour, or whether there's some multipatient encounter that means you need to raise your level of performance for a 60- to 90-minute period … . Certainly, in emergency medicine, that's a behavior characteristic and a developed skill that has to be mastered.” He is quick to add that pushing this skill to unreasonable extremes is counterproductive: “To suggest that you have to induce excessive fatigue and sleep deprivation to attain that expertise, I don't think that's absolutely necessary.” The indispensable component for residents to develop professional acumen is time, measured not in consecutive hours but in accumulated hours. Malcolm Gladwell's recent popularization of social and cognitive research related to high achievement in the sciences, arts, business, and other vocations, Outliers,6Gladwell M. Outliers: The Story of Success. Little, Brown, Boston2008Google Scholar posits an approximate “10,000-hour rule,” claiming that excellence in any field requires not only innate gifts and social support but extended concentration in the form of some 10,000 hours of disciplined, dedicated practice. In graduate medical education, the necessary experience to create expertise cannot be crammed into less time than the current 3- or 4-year residencies allow. “If we're going to cut duty hours,” Dr. Sama says, “then the length of training needs to be longer for people to become accomplished experts in their area.“ Dr. Sama's faith in the expertise and judgment of his program's current graduates takes the form of a hypothetical personal circumstance. “Would I want these folks taking care of my family? Right now I'm comfortable with the people we graduate doing that. If we cut the time down by 30%, I think I would have reservations.” Should the hour limits in the IOM report become standard practice in emergency medicine residencies, he adds, “my formal recommendation would be to extend the training period.” There is no substitute for a baseline volume of experience, Dr. Dart agrees: “You need to have all the different strange things that can happen during clinical care happen to you in training, so you're ready when you're on your own.” He also notes that 5-year emergency medicine residencies are common in the UK and elsewhere, providing additional maturity and seasoning. “One of the problems here is, to be blunt, house staff rarely know how to make the best decisions for themselves. We're all like that: as you get older you mature … . We've already reached the point where some of our residents are training for [fewer] hours than they will have to work as faculty members. Explain that one to me: if you're training to be an attending and practice on your own, how do you justify that training should actually have shorter hours that what faculty already have to do?” The increasingly frequent transfers that shorter hours require, Dr. Dart emphasizes, not only sever the individual patient-physician bond but place the incoming resident at an informational disadvantage. “What we have now, especially in internal medicine,” he says, “is coming in in the morning, seeing all my patients, taking admissions that night, and the next day at noon I have to leave. I'm not done working up those patients, and I dump it on somebody who knows the patient not at all. At best I delay their care a day; at worst I miss things, or the next guy misses things. He may be awake, but he doesn't know the patient.” To compensate for information gaps that even orderly communication structures7Bitterman R.A. Fumbled handoffs at shift change: a common liability source for emergency physicians. Reprinted with permission from AHC Media LLC and ED Legal Letter in ACEP's Quality Improvement and Patient Safety Newsletter, April 11, 2008.http://www.acep.org/ACEPmembership.aspx?id=37030#story2Google Scholar and electronic records can't remedy, Dr. Dart finds, contemporary house staff are seeing fewer patients and ordering more tests of questionable value. Efficiencies in cost and throughput that hospitals once derived from residents' presence are evaporating, and “the overall expense to the system actually means that some programs will start to get rid of their residencies entirely,” Dr. Dart says. “People think this is like free labor. It's far from free labor, and I'm not just talking about their salary.” Considering the ripple-effect costs when inexperience leads to longer hospital stays and more diagnostic procedures, some institutions are hiring more attendings, hospitalists, and physician extenders (nurse practitioners and physician assistants) rather than residents. An attending who gains familiarity with local systems as well as clinical pearls spares the institution some reteaching on multiple levels, but the short-term advantages of such a choice are unsustainable societally. Fewer residencies today (especially in emergency medicine, surgery, and other high-pressure specialties) diminish the national reserve of expertise tomorrow. Shift schedules that conform to the new IOM recommendations, say Dr. Dart's colleagues at Denver Health in a detailed professional communication to the ACGME,8Denver Health: draft of group letter under preparation for ACGME, June 2009.Google Scholar would have to take one of 2 forms, an extended duty system and a night float system, either of which would significantly increase the costs of education along with generating the kinds of irregular sleep patterns associated with swing shifts. Some variants would increase patient handoffs; all would increase the number of residents assigned to night duty. Some institutions, unable to cover the costs per resident from Graduate Medical Education allocations, would no longer find it cost-effective to have residents in certain disciplines. An economic analysis recently reported in the New England Journal of Medicine estimated labor costs, mortality and costs associated with preventable adverse events, net costs to major teaching hospitals, and other variables associated with implementation of the new recommendations. These researchers, the same group that had previously analyzed economic effects of the 2003 regulations,9Nuckols T. Escarce J. Residency work-hours reform: a cost analysis including preventable adverse events.J Gen Intern Med. 2005; 20: 873-878Crossref PubMed Scopus (35) Google Scholar found that the effectiveness in averting harm to patients is unpredictable, but that a rise in costs–estimated at $1.6 billion in 2006 US dollars, measured across all ACGME-accredited programs–would be a certainty.10Nuckols T.K. Bhattacharya J. Wolman D.M. et al.Cost implications of reduced work hours and workloads for resident physicians.N Engl J Med. 2009; 360: 2202-2215Crossref PubMed Scopus (98) Google Scholar Expansion of residency programs by another postgraduate year, as Dr. Sama suggests, would involve a different but undoubtedly substantial nationwide expense. Should the IOM measures become ACGME policy, Dr. Sama cautions that the costs of expanding the training period should be viewed in the context of the ballpark cost estimates involved in proposed restructurings of the entire US medical complex: “If we're spending a trillion and a half dollars to reform the health care system, less than 1% of that to improve the conduct and outcome of Graduate Medical Education training in the US would only cost a billion out of $1.5 trillion. I think it'd be money well spent.” An evidence-based approach to institutional policies, as well as to clinical practices, suggests that residents' shifts should be grounded in the observable effects on patients and at least informed by the state of the art of chronobiology.11Heins A. Euerle B. Application of chronobiology to resident physician work scheduling.Ann Emerg Med. April 2002; 39: 444-447Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar However, there is not yet a solid research base connecting fatigue-related impairments in alertness and cognition with differences in patient outcomes, as the IOM report acknowledges.12Ulmer et al., op.cit., p. 179 ff.Google Scholar Some studies find little or no connection between duty-hour protocol changes and patient safety,13Rosen A.K. Loveland S.A. Romano P.S. et al.Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients.Medical Care. 2009; 47: 723-731Crossref PubMed Scopus (63) Google Scholar implying either that time limits are safe or that they are inconsequential and unnecessary. Whether the IOM's report changes ACGME policies or not, commentators emphasize, resident programs that hone their clinical performance in less mechanistic ways can get ahead of the next wave of quantitative limits and perhaps, if program directors find the IOM strictures undesirable, strengthen the case against them. Dr. Dart advises against facile extrapolations to clinical contexts from attention measurements, examination scores, and similar artificial and artifact-prone criteria. “I think there is an uncritical assumption that some impaired performance on a test actually relates to patient errors. There have been some attempts to show this in ways that are simply not rigorous enough to make that conclusion. People do rely on that data too much … we need a lot more research on this.” Another problem is that bad judgment is too easy to blame on fatigue. Hours can be a convenient external scapegoat for anyone unwilling to attribute error to an internal cause. “Anything but ‘you screwed up.' Partly, that's medicine's fault,” Dr. Dart notes. “In the old days, you were excoriated for mistakes. ‘You idiot, you could have killed this patient!' It wasn't a touchy-feely experience, shall we say.” To the extent that cultural contexts can be conducive to either individual accountability or more diffuse attributions of causation, programs that foster both responsible conduct and frank assumption of responsibility can provide alternatives to the IOM's more rule-based approach. “Certain specialties attract gung-ho, action-oriented people, and emergency medicine is one of those,” says Dr. Dart. “That's why I went into it.” Dr. Dart's Denver Health group has followed and promulgated the quality improvement and waste reduction protocols of Toyota's “lean business” philosophy,14Womack J.P. Jones D.T. Lean Solutions: How Companies and Customers Can Create Value and Wealth Together. Free Press, NY2005Google Scholar, 15Womack J.P. Jones D.T. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. Free Press, NY2003Google Scholar taking ideas that originated in manufacturing and transferring them to medical practice. This experience has earned his enthusiasm but also made him skeptical about statistic-driven approaches to best practices. He notes that efforts to root out and prevent organizational waste and error are prone to find problems simply because people have begun looking for them, without clearly demonstrating that corrective measures effectively reduce them. Comparing the lean programs to duty-hour reforms, Dart recommends that efforts to cut medical errors pay close attention to the type and degree of risk to patients, not simply the raw number of procedural errors (important and trivial alike) detected and deferred. A blanket regulation of hours shoehorns the whole population into one sleep-cycle model, even though chronobiological research indicates broad variability in people's circadian rhythms. The bulk of the bell curve breaks down into the proverbial larks and owls: early risers and nocturnalists, respectively. There are also rare people who adopt or advocate unusual sleep patterns, eg, the various polyphasic sleep systems advocated by Buckminster Fuller (“Dymaxion sleep”), catnapping painter Salvador Dali,16Dali legendarily began his catnaps in a chair, holding a spoon in his hand above a tin plate on the floor; he dropped the spoon as he fell asleep, then got the sleep he needed before the spoon landed on the plate with a bang.Google Scholar and sleep researcher Claudio Stampi, MD, PhD.17Stampi C. Why We Nap: Evolution, Chronobiology, and Functions of Polyphasic and Ultrashort Sleep. Birkhäuser, Boston1992Google Scholar Few people adjust to the rigors of true polyphasic sleep, but core-sleep-plus-naps variants have their adherents, some of whom claim that Leonardo DaVinci, Thomas Jefferson, Thomas Edison, Frank Lloyd Wright, and other extraordinary achievers observed similar practices to get more high-alertness hours out of the day. Whatever resemblance polyphasic sleep may have to residents' schedules, there is little rigorous research from medical, military, or other sources to recommend it as a useful model. Still, the wide range of sleep patterns supports the contention of Steven Tantama, MD, that “trying to put everybody into a single mold may not be the best answer.” Dr. Tantama, a physician at the Naval Medical Center in San Diego and Emergency Medicine Residents' Association (EMRA) representative on the Residency Review Committee of Emergency Medicine (RRC-EM), echoes senior physicians' emphasis on common sense by promoting the direct and indirect ways that better resident training can improve patient safety. There are more sophisticated tools of quality improvement, Dr. Tantama finds, than mandatory naps and limits on consecutive night shifts. Such limits actually fight the body's own rhythms, he says, citing the concept of “sleep momentum,” in which a long block of napping is conducive to deeper stages and more severe grogginess when one awakens. “Limiting people to working 4 night shifts in a row I don't think was the intention of the IOM recommendations, but that actually will interfere with the ability to adjust our circadian rhythms,” he says. A transition from night to day shifts “is one of the places where we think it's the worst time … . If you just had the whole block of nights, you could fall into a normal circadian rhythm.” (Dr. Manko notes that residents' informal duty-swapping practices to accommodate family obligations, commutes, and performance differences along the lark/owl spectrum can amount to an ad hoc fine-tuning of scheduling details to optimize different skills for patients' benefit, as a baseball team's manager identifies and deploys specialized leadoff and cleanup hitters within the lineup.) Young as he is, Dr. Tantama emphasizes the long-range historical view, both within medical culture–“I don't think it's a general overall perception that we're not working as hard these days as we used to,” he comments–and in the profession's anticipation of societal demand. “We're short a lot of emergency physician trainees,” he notes; “some say we're not going to meet our needs for 30 years … . It's already a challenge to try to fit our current needs, and then putting on more restrictions … will put a further strain on an already strained system.” The RRC-EM joined 7 other organizations, including the American College of Emergency Physicians and EMRA, in preparing a formal rejoinder to the IOM report, supporting the current guidelines but stressing the new proposal's likely adverse effects on fatigue, clinical educational exposure, and availability of resident services, and finally classifying the proposed regulations as an unfunded mandate.18Association of Academic Chairs of Emergency Medicine; American College of Emergency Physicians; American College of Osteopathic Emergency Physicians; Council of Emergency Medicine Residency Directors; Emergency Medicine Residents Association; Residency Review Committee of Emergency Medicine; Society for Academic Emergency Medicine. Emergency medicine training, patient safety and the effect of duty hours regulations. Draft document, June 2009.Google Scholar Dr. Tantama stresses that this collective opposition expresses not a dismissal of the IOM's safety concerns but a contrasting view of how to put them into practice. “Direct supervision versus hours–both warranted some correction,” he says, “and ultimately we are benefiting from it. It's just, how far do we take that correction, and how much is it going to affect us … on the resident side as well as on the patient side?” As organizations grapple with these apparently insoluble problems, it's helpful to remember, or insist, that the profession's mission ultimately puts everyone on the same side. News & Perspective Piece Fails to Acknowledge Evidence for Resident Work Hours LimitsAnnals of Emergency MedicineVol. 55Issue 3PreviewThe News & Perspective section recently published a piece, “For Whom the Bell Commission Tolls: Unintended Effects of Limiting Residents' Hours,” which purports to address potential negative implications of limits on resident work hours and of the Institute of Medicine (IOM) report's recommendations for stronger enforcement and stricter regulations.1 In doing so, the article unfortunately puts aside the abundant evidence on the importance of duty hours regulations and the significant effort and expertise which went into the report, and, instead, relies on extensive commentary of a few emergency physicians and citations of a single, poorly designed study as the basis for the piece. Full-Text PDF
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