Cutting resident doctors’ hours doesn’t harm quality of patient care, study finds

doctired-300x169Will the medical educators finally get that it makes no sense to force residents to toil like field animals? Yet another study, this latest from Harvard experts, finds that keeping residency training hours at more humane levels does not significantly affect quality of patient care, including inpatient mortality.

Let’s be clear: The grueling preparation for MDs is only relatively better than before, capping their training time to 80 hours a week.

Medical educators, hospitals, and doctors themselves have criticized that limit since it was imposed after long study and much argument in the profession by the Accreditation Council for Graduate Medical Education (ACGME), the group that accredits MD training programs.

Advocates for grinding residents to the bone with crushing hours on duty contend that it benefits them and patients, providing the rigorous preparation that doctors must have to treat patients well. They say that it is critical to cram in as many experiences as possible in the limited time that residents are under the supervision of seasoned practitioners.

But residents and full-fledged doctors who are candid about their medical education tell horror stories about the harms caused to MDs in training — and potentially patients — due to sleep deprivation and exhaustion. When the ACGME seemed ready to back track in recent times from its earlier decision capping resident training hours, doctors wrote in to the KevinMD site with hair-raising stories:

“Doctors wrote about working not 24 but 40 hours straight, and on 110 to 120 hour per week residencies, where they, ‘got to witness colleagues collapse unconscious in the hallway during rounds, and I recall once falling asleep in the bed of an elderly comatose woman while trying to start an IV on her in the wee hours of the morning.’ Another MD wrote anonymously: ‘I have made numerous medication errors from being over tired. I also more recently misread an EKG because I was so tired, I literally couldn’t see straight. [My patient] actually had a subarachnoid hemorrhage, and by misreading the EKG, I spent too much time on her heart and didn’t whisk her back to CT when she came in code blue. She died.’ Discussing guidelines and memos that seek to protect doctors in training from abusive schedules, one physician observes: ‘As a resident in a surgical specialty, my program routinely violated work hours, yet our attending physicians kept talking about how lucky we are because we have ‘work hour restrictions.” ‘ Another said: ‘A dear friend from med school died during her neurosurgery residency. Drove over a median into a tractor-trailer after a 30+ hour shift. She left behind her family, including a twin sister and her fiancé. She was 30.’ “

The new Harvard study, as the online health and medical news site Stat reported, “compared the outcomes for patients of two groups of physicians: those trained before 2003, when the typical work week was 100 hours; and those trained later under the new rules, which capped weekly hours at a mere 80, with no individual shift exceeding 30 hours. For the three quality measures examined — mortality within 30 days of being hospitalized, readmissions, and hospital services used (a measure of efficiency) — they found no differences between the groups. Looking at the data for just the sickest patients in the hospital, a ‘group of patients for whom the experience and training of a doctor is really important,’ said  [Dr. Anupam Jena, a professor of health care policy and medicine at Harvard Medical School,] the authors again found no difference in these three outcomes.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the critical role that poor judgment by doctors — including by MDs who are exhausted and handling excessive cases — can play in patient injury. Indeed, as a federal health care quality agency recounts:

“Little attention was paid to the potential patient safety effects of fatigue among residents until March 1984, when 18-year-old Libby Zion died at New York Hospital due to a medication-prescribing error while under the care of residents in the midst of a 36-hour shift. The subsequent investigation into her death led to the formation of the Bell Commission, which passed regulations in 1987 mandating that residents at New York hospitals should work no more than 80 hours per week and no more than 24 consecutive hours. Though work hours and shift duration decreased somewhat for residents over the next decade, it was not until the goals of the patient safety movement aligned with research documenting a connection between fatigue and clinical performance that stronger regulations came into place [in 2003].”

But with multiple, careful studies building a solid case that patients benefit when residents aren’t exhausted and overtaxed, what to make of professional concerns that doctors trained under new rules with fewer hours might be missing out in crucial skills or experiences?

That’s a tougher question to answer by research, and perception may trump reality. It also is true, though, that more thoughtful advocates push back with different questions: Given how much medicine keeps changing, isn’t it more important to re-examine the totality of doctors’ training regimens, casting a cold eye on whether some time-consuming courses and rites of passage need to stay around still? If residencies are so game-changing for patient care, shouldn’t hospitals expand and lengthen the program — supporting doctors in training and paying them for their labor, rather than also taking advantage of their developing capacities by wringing endless hours from them as a credential?

With medical treatments soaring in their complexity and uncertainty, with high quality care demanding ever more close and careful consultation, does it make sense for patients’ sake to put so much weight on weary doctors in training? Doesn’t common sense say that sleepless professionals of any kind are more likely to err — and is the medical establishment taking due note of the nightmares of medical errors?

Medical errors claim the lives of roughly 685 Americans per day — more people than die of respiratory disease, accidents, stroke and Alzheimer’s. That estimate comes from a team of researchers led by a professor of surgery at Johns Hopkins. It means medical errors rank as the third leading cause of death in the U.S., behind only heart disease and cancer.

Newly published Johns Hopkins research also finds that a third of malpractice cases that result in death or permanent disability stem from an inaccurate or delayed diagnosis, making it the No. 1 cause of serious harms among medical errors. Researchers found that, of diagnostic errors causing the most harm, 74.1% of these incidents are attributable to just three categories of conditions: cancer (37.8%), vascular events (22.8%), and infection (13.5%). These severe cases resulted in $1.8 billion in malpractice payouts over 10 years. Can doctors make sound diagnoses if they can barely stay awake?

With burnout and suicide plaguing the profession, it’s past time to stop sending out a wrong message to doctors, from the beginning of their practices, that cruel conduct is encouraged in medicine and compassion is only an ideal, not a reality.

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