Comments on: Do resident work-hour restrictions increase surgical complications?

By: “Do resident work-hour restrictions increase surgical complications?”

Wed, 16 Sep 2009 11:48:33 +0000

[...] According to a new study, a high-profile government intervention in physician training may not be working out quite as hoped. [Chris Emery at Kevin MD] [...]

By: Politicking « Dr. Ottematic

Politicking « Dr. Ottematic — Mon, 14 Sep 2009 04:06:59 +0000

[...] There are few big fights here. While the majority of evidence is clear – residents work better when they have sleep and take care of themselves – sometimes the system doesn’t adapt to these changes; a constant argument by those resistant to easing the burden on Resident Physicians is that the shorter the shifts, the more frequent the handover, and the more details get lost, which leads to poor patient outcomes. See Kevin MD’s post about it. [...]

By: alex

alex — Wed, 09 Sep 2009 18:24:38 +0000

This study is almost hilariously bad. It’s an example of database mining to try to send a message; I’m not sure it’s possible to come up with a study design with more potential confounders. Yes, let’s take hospitals at two different time periods, assume the only possible difference besides the handful of factors we can control for is the 80 hour work week (which surgical residents routinely ignore anyway) and then attribute any differences to that. I can literally think of a half dozen other explanations off the top of my head — maybe the trend towards more complicated cases turfed to academics is growing. Maybe they’re correct though — we’re somehow the only country in the world so incompetent that doctors working less than 100 hours a week is a disaster. That’s certainly a palatable hypothesis.

Just a terrible piece of “research”.

By: John Bader

John Bader — Wed, 09 Sep 2009 17:08:15 +0000

I agree with PICUDoc (#5) that the increased number of handoffs has something to do with the increase in surgical complications. In fact, handoffs are coming under increased scrutiny by the Joint Commission and medical specialty associations for their effect on patient safety. A 2006 study by the Joint Commission, the independent body that accredits U.S. hospitals, found that 67% of all hospital sentinel events (patient death or serious injury unrelated to illness) were caused by improper physician communication, i.e. some sort of breakdown in the handoff. The 800 such events the commission identified in 2008 were double the figure for 2002.

More anecdotally, as a maker of an iPhone patient signout/handoff tool for physicians, my company sees a movement among hospitals to replace longstanding, ad-hoc ways of passing patient handoff information with a standardized process that captures and keeps the pertinent Dx and treatment plan information. There is a busy and growing business for us and our competitors in supplying healthcare technology designed to do this.

The patient handoff has even attracted the attention of the mainstream press. The NY Times Well Blog posted on the topic Thursday and drew dozens of comments, many from physicians (http://well.blogs.nytimes.com/2009/09/03/in-medicine-the-perils-of-the-handoff/).

I’d love to see thoughts from other physicians on this topic. Has the increased number of handoffs resulting from fewer hours being worked by residents had a noticeable effect on patient safety?

(Full disclosure: my company, Lime Medical, makes a mobile patient signout/handoff product)

By: Jimmy Z

Jimmy Z — Wed, 09 Sep 2009 01:32:00 +0000

The real motive behind this is MONEY masquerading under the guise of “patient care.” Because it hospital and programs lose money when their slaves have to be given food and sleep, they sponsor studies showing how patients suffer. Any logical, compassionate person recognizes that even 80 hour work week is too much. It is a lame testament to those programs that couldn’t get their sh** together and perform a normal change of watch, like most competent industries are capable of.

By: throckmortons

throckmortons — Wed, 09 Sep 2009 00:30:53 +0000

I am not sure if this is affecting the trend, but I have seen more and more of the care that was performed by residents being taken over by ARNPs.

By: PICUDoc

PICUDoc — Tue, 08 Sep 2009 23:55:25 +0000

I do thing the handoff issue is a big part of it. Since residents can’t stay for the post call day there’s a lot of signing out/handing off/cross covering. When a resident is in “cross-cover” mode they are just there to babysit, no major changes in the direction of care are made so if a resident is cross covering a patient and a development occurs where a patient may discharged that may get put off until the next day. Also with cross covering the residents don’t know the patients as well since they haven’t taken care of any one patient for a continuous length of time.

Overall my suspicious is that with going to the 80 hour work week we’ve gotten rid of errors due to fatigue and replaced them with errors due to lack of continuity.

One option to fix this is a night float/day float system. With having the same resident on call every night for a week you get to know the patients well and feel more comfortable making changes at night.

The problem with this is that it takes more residents to cover a unit with night float than it does using traditional means. Also, there is the issue of didactic education. During the week of night float the resident will miss out on all the day time educational activities.

By: John M. Grohol, PsyD

John M. Grohol, PsyD — Tue, 08 Sep 2009 23:52:20 +0000

Seriously, does anyone do any actual reviewing in peer-reviewed journals any more?

Of course you would expect a temporary rise in problems associated from moving from one type of system (overworking residents as though they were slaves or indentured servants) to another type of system (humane and civilized working hours). What kind of dumb researcher would expect the outcomes to remain the same??

The key is that the increase in problems is temporal and temporary. Once implemented and everyone gets used to the system, then you will start seeing improvements in care.

Change comes with problems during the change. But is that a reason not to change? If that’s the case, every therapist would be out of a job tomorrow.

Do this study 5 years after implementing humane working conditions for doctors, and then let’s see the data.

By: Doctor D

Doctor D — Tue, 08 Sep 2009 19:18:43 +0000

An association doesn’t prove causation. Complications that year could have increased for any number of reasons that has nothing to do with limiting resident’s brutal hours.

I know the unspoken rule where I was at that time was that surgery residents were expected to keep working long hours and lie on their time sheets. What if the long hours added to pressure from your superiors to be dishonest is the cause of the worse outcomes?

By: Chris

Chris — Tue, 08 Sep 2009 16:27:00 +0000

So increase the attendings’ work hours, right? How come that’s never a solution?

I don’t care if there’s an increase in errors. It was completely inhumane to do Q2 in-house call with no 30 hour restriction. PERIOD. There would be no hand-offs ever if the physician just moved into the patient’s house. So why don’t we do that?