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HMS Hospitals Hone Plans for Deeper Cuts in Resident Hours
Christine Weeks, a second-year surgical resident at Brigham and Women's Hospital, found the time to train for a marathon and run it last month, despite her busy schedule. Such a feat would be difficult to imagine in the days when residents might spend an entire weekend at the hospital before going home for a few hours of sleep. Though Weeks and her fellow residents still work an occasional 24-hour shift, for the most part, they work 12-hour shifts with 12 hours off between shifts. "You go home every day like a normal person," Weeks said.
Two recent papers on resident fatigue and medical errors "showed that the ACGME regulations don't go far enough," said Andy Whittemore of Brigham and Women's Hospital, which supported the research. (Photo courtesy of Brigham & Women's Hospital)
Times are changing for medical residents. Many residency programs have been cutting back hours for years now. And guidelines imposed in 2003 by the Accreditation Council for Graduate Medical Education (ACGME) formalized those changes. Now, residents can average only 80 hours per week over a four-week period, must take a full day off per week and at least 10 hours off between shifts, and cannot work more than a 30-hour shift with the last 6 hours not devoted to clinical care.
When a team led by Charles Czeisler, the Frank Baldino Jr., PhD professor of sleep medicine at BWH, unveiled data showing that interns were more alert and made fewer serious errors when they worked shifts of 16 hours rather than the traditional 30, the question was once more raised of how severely the residents' hours should be cut. While the study, published in the Oct. 28 New England Journal of Medicine, was conducted before the ACGME guidelines took effect, the control schedule it used was similar to the 80-hour workweek that is now mandated for residents. (See Focus, Nov. 12.) But the new information comes at a time when many teaching hospitals are still struggling with the recent ACGME guidelines, and are not prepared to take steps to reduce hours further.
The Complexity of Cuts
BWH, which helped fund the study, has pledged to take the results seriously. Andy Whittemore, HMS professor of surgery and chief medical officer for the hospital, said, "To take the conclusions of the study to heart, we ought to have everybody on shifts of not more than 16 to 17 hours." But he cautioned that the study, which examined interns in two units in the hospital, may not be immediately applicable to every part of the hospital and every year of residency.
| "The question that is much more complicated is whether we will enhance patient safety overall if we further reduce resident hours." |
In order to make up for the lost hours that residents once worked, hospitals have had to bring in more residents or hire additional nurses, physician assistants, or physicians. Some programs have discontinued elective rotations to keep residents in units where they are needed. At Beth Israel Deaconess, an attending physician is now on duty at all hours, providing more supervision in clinical decision-making. Some departments have chosen to adopt a "night float" system in which residents work only 12-hour shifts.
Graduate medical education directors at the Harvard-affiliated hospitals say that the new data show what many people have long known anecdotally: fatigue takes its toll on performance. "Common sense would suggest that the longer you work, the more tired you get and the less efficient you are," said Michael Freed, HMS associate professor of pediatrics and the director of graduate medical education for Children's Hospital Boston. But Freed added that while residency programs have been moving toward more reasonable hours for years, now it is happening in the context of stricter educational standards and increased financial pressures. "There are educational requirements that are getting tightened up by the residency training committees of the ACGME while they are tightening hours. Medicare is also tightening funding for residents," he said. "The hospitals have to sort out all these competing interests."
A Patient Safety Question
Keeping residents more alert by ensuring they have adequate sleep seems like a no-brainer, but in fact it raises deep concerns among many physicians and education directors that the change to shorter shifts may ultimately harm patient care. "Everyone accepts the concept that avoiding sleep deprivation could reduce medical errors," said Debra Weinstein, HMS assistant professor of medicine at Massachusetts General Hospital and vice president and director of graduate medical education for Partners. "The question that is much more complicated is whether we will enhance patient safety overall if we further reduce resident hours."The greatest concern is that shorter shifts will cause errors as patients are handed from one physician to another, interrupting the continuity of care. "One thing we are doing is looking more closely at the handoff procedure to see if we can minimize errors that happen with that," Weinstein said. Many departments have adopted electronic sign-outs with details about each patient, and residents spend more time at the end of their shifts explaining their cases for the next team.
Education directors also fear there may be unintended consequences of changing the structure of residencies. Richard Schwartzstein, HMS associate professor of medicine and director of graduate medical education for BID, said, "We've had times when we literally had to send residents home instead of letting them go to an educational session." And residents training now have a more disjointed view of the treatment of patients. "The first 24 hours is when most things happen with acutely ill patients," Schwartzstein said. "In the days when people did 24-hour shifts, you would see that process from beginning to end."
While medicine may always be a discipline that demands intense hours, residency programs are moving toward providing a better quality of life, with more time for residents to pursue other interests, have families, or even run marathons. The hope is that a more manageable lifestyle will create better doctors. Freed, who is 61, said that the schedule he worked when he was a resident was "incomprehensible."
"I remember enough of it that I'm not sure I survived it intact," he said, "and I wouldn't wish it on my worst enemy."
--Courtney Humphries