Hos­pi­tals, physi­cians de­bate im­pact on pa­tient care

Modern Healthcare - - Front Page -

Dr. Lau­ren Hughes said she doesn’t re­gale first-year res­i­dents with war sto­ries about how, back in the day dur­ing her first year in train­ing, she used to lit­er­ally work all day on 24-hour shifts—which is some­thing they’ll never have to do.

If she wanted to, though, she could—even though, to Hughes, “back in the day” was less than a month ago.

Oc­cu­py­ing some­what the same space as tail-end baby boomers who were in the last round of kids to have black-and-white baby pic­tures, Hughes and her fel­low sec­ond-year res­i­dents are the fi­nal class of doc­tors who, in their first year of train­ing, slogged their way through marathon shifts run­ning on fumes and fu­eled by caf­feine and adren­a­line. As of July 1, the law of the land—as writ­ten by the Ac­cred­i­ta­tion Com­mit­tee for Grad­u­ate Med­i­cal Ed­u­ca­tion—dic­tates that first-year res­i­dents are lim­ited to 16-hour shifts un­der a new rule aimed at im­prov­ing pa­tient safety as well as pro­vid­ing a bet­ter learn­ing en­vi­ron­ment for new doc­tors in train­ing.

Three weeks into the new era, physi­cians run­ning res­i­dent pro­grams at teach­ing hos­pi­tals say the re­stric­tions have forced a va­ri­ety of im­me­di­ate changes, such as hir­ing hos­pi­tal­ists to fill gaps and pack­ing more tasks into shorter shifts. They and their res­i­dents have mixed feel­ings about the clin­i­cal and fi­nan­cial ef­fects of those ad­just­ments, some of which are spurring talk that cer­tain train­ing pro­grams may need to be ex­tended by as many as seven years in sur­gi­cal spe­cial­ties. In ad­di­tion to lim­it­ing the length of shifts, the rules call for in­creased su­per­vi­sion of res­i­dents, more time off be­tween shifts and stricter lim­its on “moon­light­ing,” the prac­tice of work­ing be­yond one’s nor­mal sched­ule— ei­ther in house or at an­other in­sti­tu­tion—to pick up some ex­tra money and ex­pe­ri­ence. The ACGME, how­ever, did keep in place the ex­ist­ing 80-hour weekly work limit (av­er­aged over four weeks) with an ex­cep­tion made for neu­ro­sur­geon res­i­dents, who can ex­tend their week to 88 hours.

Hughes is the for­mer pres­i­dent of the Amer­i­can Med­i­cal Stu­dent As­so­ci­a­tion, an or­ga­ni­za­tion that pe­ti­tioned the U.S. Oc­cu­pa­tional Safety and Health Ad­min­is­tra­tion to usurp and take over ACGME’s res­i­dent reg­u­la­tory au­thor­ity.

A fam­ily-medicine res­i­dent in the Univer­sity of Wash­ing­ton’s Har­borview track, Hughes now holds an am­biva­lent view of the work-hour de­bate. In fact, Hughes said she came to ap­pre­ci­ate work­ing 30 straight hours that in­cluded 24 hours of clin­i­cal duty fol­lowed by six hours of ad­min­is­tra­tive tasks. Hughes said that at Seat­tle Chil­dren’s Hos­pi­tal, the ad­min­is­tra­tion de­cided that hav­ing dif­fer­ent-year res­i­dents work­ing dif­fer­ent-length shifts was a lo­gis­ti­cal mess, so they as­signed ev­ery­one to 12-hour shifts. She said she has learned to ad­just.

“I grew quite fond of the long shifts—there


Univer­sity of Illi­nois Med­i­cal Cen­ter neu­rol­ogy res­i­dents speak with a pa­tient. Be­cause new shift re­stric­tions limit first-year res­i­dents to 16 work­days, some say hand-off er­rors may be more of an is­sue than fa­tigue-re­lated er­rors.

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