Friday, April 16, 2004

Both Medrants and 2md recently have provided analysis of two articles that appeared in the April 12th and April 19th editions of American Medical News. While DB wants to give the new system time to work out, Cameron sees potential trouble.

From the April 19th paper:

Preliminary results of an Assn. of American Medical Colleges survey tell of a year of significant challenges within graduate medical education as it reshaped resident training to comply with the new 80-hour work week.

Sunny Yoder, AAMC director of health care affairs, presented these initial findings at the Accreditation Council for Graduate Medical Education conference in Chicago in March.

According to an Internet survey of resident program administrators, the specialty facing the biggest compliance hurdles was surgery, with 67.7% of 105 surgical programs represented in the survey saying they were greatly challenged by the new work hours. This was followed by neurological surgery, internal medicine, ob-gyn and thoracic surgery.

No surprise here. Not only are surgery residents involved with care of inpatients, clinic patients, and going to conferences and other such "educational activities", as all residents are, but they also have to spend a little time in that part of the hospital known as the operating room. When you have to squeeze all that into 80 hours per week, the operative experience is sure to suffer. Since each resident has to have a certain number and type of cases before they can graduate, residencies may take longer to complete.

Meanwhile Mr. Page rants on the April 12th article and fears the ACGME is out to repeal the thirteenth amendment:

The Accreditation Council for Graduate Medical Education is considering modifying duty-hour standards for residents in response to feedback from program directors

First of all, they're basing this on feedback from Program Directors? Of course the Program Directors hate the new rules. They have to spend money on new residents because they can't stretch out the old ones anymore. What happened to listening to the residents? That's why we changed the rules to begin with, right?

While program directors may not like the new rules they aren't usually evil incarnate either. The program directors job is to ensure that the residents in a program get a good postgraduate education so that they can 1) pass their boards and 2) be good doctors. As far as "spending money on new residents" I don't think that the ACGME has been allowing programs to expand to make up for the lost hours. Reviewing the data from 2004 U.S. graduates filled only 54.8% of internal medicine slots (overall 97.4% filled), 71.3% of peds slots (97% overall), 41.4% of FP slots were filled by U.S. grads (76.8% overall) and surgery had 84.8% U.S. fill and 99.8% overall. So with the situation as is, there isn't likely to be any new slots created. Moving along..

Also under review is the 10-hour rest period following in-hospital call. The ACGME is looking at ways to credit residents for sleep gotten during the on-call period and counting it toward the recommended break.

In other words, if you nap between 2am and 5am, the hospital can let you go at noon that day and demand you come back at 7pm for another night of work. This doesn't sound like a huge change from the bad old days of sleep-deprived patient care.

I think a more reasonable interpretation of the above statement is that if you get three hours of sleep the night before, you can stay until 3pm the following day instead of having to leave at noon. I agree wholeheartedly that residents call burdens could be diminished significantly if they didn't have to do so much scut work.

My main problem with work hour limits is this: A residency is designed to take a freshly-minted MD and over 3,5, or 7 years turn them into an attending who can work unsupervised and possibly alone in the real world. The 80-hour limit places an artificial reality that is often not the case outside of a residency program. Because I wasn't restricted to 80-hour weeks as a resident, I have gained knowledge of how fatigue affects my judgment and skills. I was able to gain that knowledge while under close supervision, so mistakes were avoided. How will the current residents respond to fatigue and stress after they graduate? Is patient care compromised if the first time they get fatigued is when they are on their own with no one looking over their shoulder? If the old yarn of "surgeons work harder in residency than in private practice while internists work harder in private practice than in residency" is true how will work-hour limits affect this? The program versus real-world argument is further bolstered by Mr. Page's next excerpt:

The ACGME also said it found some programs were so focused on being technically compliant that they were ignoring aspects of patient safety. One program in New York City, for example, was assigning its on-call resident to cover two separate hospitals blocks apart, a situation that was completely unworkable

So this residency program refused to hire enough residents to cover all of its patients' needs....And THAT's the justification for relaxing the rules? Instead of letting them slave-drive their existing doctors, how about we demand that they hire more well-rested doctors? In other words, how about we enforce the rules?

Guess what? In most cases physicians outside of residency programs cover more than one hospital at a time. Mr. Page's solution seems to be to put the ACGME limits into law. Talk about paternalism in medicine....
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