A Chance to Cut is a Chance to Cure

Wednesday, November 10, 2004

The Future of Surgery V...
I've been posting a great deal on the effect of residency program changes on the practice of surgery as a whole. One reason is that it is something that interests me. Another is the fact that there has been a great deal of primary material in the surgical literature. The Bulletin of the American College of Surgeons strikes again this month with How will limitations imposed on residents' work hours affect medicine?
The article begins with the well-known history of the Bell Commission and the implementation of the guidelines by the ACGME:

Over time, the ACGME hopes to gather information from the New York State experience to support the thesis that working excessively long hours negatively affects the cognitive performance and function of house staff officers. Since New York State restrictions were instituted in 1989, studies have shown that patient care has neither diminished nor improved. Gradually, through prospective and retrospective studies, training programs in New York are gaining insights into the changes in residents' attitudes about the residency program modifications.

Two things: even with the recent studies in the New England Journal of Medicine the "evidence based" case for the workweek limits has yet to be made. Secondly, the studies from New York themselves seem to be a wash. Moving along:

Considerable debate among hospital administrators, medical directors, department chairs, and teaching program directors has arisen over the implementation of these requirements. Those individuals who concur with the new directives and regulations believe that house staff fatigue correlates directly with physician error, depression, anger, and lack of compassion for patients. These advocates for reform see benefits in adjusting oncall schedules, recruiting and educating physician extenders, and scheduling "night float" residents responsible for overseeing patient care on the evening and night shifts.

Other members of the community oppose the new regulations, arguing that more patient transfers between physician caregivers will lead to increased medical errors. The critics of these regulations emphasize that a key goal of house staff training is to engender a sense of accountability and responsibility. They also express concern over the loss of professionalism among resident physicians who regard themselves as "hourly workers." Will these restrictions inhibit or, even worse, sever the unique bond between patient and physician that has been the foundation of our profession and the public's perception of us?

Night float programs have been used in primary care residency programs for years, and many surgical programs are beginning to utilize them. The difficulty of a surgical night float is that while a medical admission (DKA, for example) that comes in at one o'clock in the morning is evaluated and treated pretty much the same way as one that comes in at one in the afternoon. Elective surgery is almost always a 7AM to 5PM schedule. The "night float" resident misses out. With the increasing non-operative management of trauma patients the night float experience consists of emergency surgery (appendectomies) and trauma resuscitation.
The controversy over the "sign out" is not likely to abate soon. In the surgical patient not only is there a risk for information loss, but in patients that are being followed by serial physical exam, a subtle finding may be lost on a "new" examiner that the initial physician may have picked up on. The authors opine:

Is a "night float" system the answer? Studies have demonstrated that a "night float" system (in which designated residents cover night call for a specific time period) may be more detrimental to good patient care than the present system in which the same team provides continual care. This implies that a team of physicians, although fatigued, knows a patient and the nuances of his or her care and is, therefore, better suited to upholding continuity of care than a well-rested team that is unfamiliar with the patient. The residents who are part of the "night float" system are frequently pulled from their time on research electives, which is all about education unrelated to the issues of hospital coverage.

The patients of today, and the care they require, are vastly different than those of the past:

The stress and intensity of caring for patients in teaching hospitals is far greater now than in the past, creating disturbing shifts in the attitudes of residents. House staff work-hour reforms reflect a response to changes in medical care in America, including decreased length of hospital stay, advancements in medical technology, and increased severity of illness.

This is one thing that the "old fogeys" of surgery need to remember. In the old days patients would come in days before planned surgery for medical work-ups, colon preparation, ect. The length of stay for operations such as herniorraphies and appendectomies ranged from days to weeks. Since these patients nowadays do well as outpatients, most of that care was just to "feed and water" them. The acuity of hospital inpatients has risen expoentially over the past 10-15 years or so. So while the residents of yesteryear were on call every other night and in the hospital 150 hours a week, the "level of intensity" was lower.
So how are the residents taking this?

A survey of residents enrolled in general surgery programs throughout New York State confirmed that most respondents attempt to comply with Code 405 regulations. Although the majority of residents find that these regulations improve their quality of life by decreasing their stress level, a significant number are convinced that the rules negatively affect their surgical training and the quality, intensity, and continuity of patient care. A predicted reduction in educational operative opportunities was considered detrimental. Concern about the transition to a shift-worker mentality was a prevalent theme. Interestingly, negative perceptions of the impact of duty-hour restrictions are more prevalent among senior residents and residents at academic institutions than among junior residents at community hospitals. As reported from an inhouse survey at New York Presbyterian Hospital, residents and faculty believe schedule changes have a deleterious effect on patient care.

The paper's abstract may be found here with my take on it here. Now these are mainly academic arguments, the real nugget of this article, and one that ties it to the article discussed last month:

Surgeons in private practice will face many practical concerns regarding the eventual effect of ACGME guidelines on the surgical workforce. The availability of surgeons to care for patients presenting to emergency departments or needing elective consultations is a significant issue in private practice. The majority of surgeons currently practicing in both academic and nonacademic practices are extremely concerned that the new guidelines may adversely affect the expectations that young surgeons have regarding call coverage and continuity of care. Surgeons in communities throughout America feel that they have a moral and ethical responsibility to care for urgent and emergent problems, and this concept has been a very significant component of surgeons' training. The disparity between the 80-hour workweek during residency and the expectation that hospital staff surgeons may be pressured to provide every third night on call once they enter into practice may produce some significant discontent in young surgeons entering the private workforce. These new ACGME guidelines may produce expectations of structured time off that are incompatible with the demands of private practice. Surgeons in private practice, while acknowledging the shortcomings of the traditional Halsted hierarchy training system, remain wary of the long-term effects of the ACGME guidelines.

This has been my main objection to the workhour limits, the "artificial reality" that it imposes on trainees, that in all likelihood does not exist in the "real world".

Labels: Future of Surgery