Solving the issue of tired doctors: My radical idea

Solving the issue of tired doctors: My radical idea

The problem of medical resident work-hours has vexed medical educators for decades.  The traditional model of sleep-deprived residents led to highly publicized medical mistakes, most famously the Libby Zion case in 1984.

Nobody wants tired doctors caring for them.

In response, various restrictions have been placed on how many hours medical residents are allowed to work.  Since 2011, for instance, medical residents were no longer able to work for more than 16 hours at a time.

But like most regulations, the potential of unintended consequences can arise.  I wrote in USA Today back in 2010 that shorter shifts hampered physician education and increased the number of patient handoffs between doctors, introducing new sources of error.

A recent study from JAMA Internal Medicine confirmed these fears:

Although the trainees working under the current work rules spent fewer hours at the hospital, they were not sleeping more on average than residents did prior to the rule change, and their risk of depression remained the same, at 20%, as it was among the doctors working prior to 2011 …

… “In the year before the new duty-hour rules took effect, 19.9% of the interns reported committing an error that harmed a patient, but this percentage went up to 23.3% after the new rules went into effect,” said study author Dr. Srijan Sen, a University of Michigan psychiatrist in a statement. “That’s a 15% to 20% increase in errors — a pretty dramatic uptick, especially when you consider that part of the reason these work-hour rules were put into place was to reduce errors.”

A damning implication from the study was that interns were expected to perform 24 hours worth of work in 16.  This leads to a phenomenon known as “work compression” which can be another source of error.

Cash-strapped hospitals are partly to blame.  There was never a question that shortening work-hours would cost money.  Even back in 2010, the Institute of Medicine estimated that restricting work-hours would cost upwards of $1.7 billion.  Hospitals did not hold up their end of the bargain by hiring additional workers that could off-load some of the non-educational work performed by medical interns.

There is a radical answer to this problem, and I’m not talking about going back to the old ways.

Extend medical residency by a year.

Surgical interns report that restricting work-hours impedes development of their surgical skills, and medical residents say they’re forced to miss teaching rounds because they went over their time allotment in the hospital.  Another year of residency will better prepare these doctors for what awaits them after training.

And another class of residents will provide the much-needed help to solve staffing issues that arise from work restrictions.

Of course, adding another year of residency is expensive.  But no one said improving patient safety would be cheap.

Stop nibbling around the edges with varying iterations of capping work-hours.  They have worsened patient safety and have done nothing to address the fatigue or mental health of medical trainees.

A dramatically different approach is needed to move this needle.

Solving the issue of tired doctors: My radical ideaKevin Pho is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

Image credit: Shutterstock.com

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  • NewMexicoRam

    How about this instead:
    Eliminate malpractice. Don’t allow any malpractice lawsuits.
    If patients want to be protected against poor medical outcomes, then they need to buy their own malpractice insurance, essentially their own disability insurance.
    Then residents can work as many hours as the medical powers that be say, and patients can determine their own level of acceptable risk.

    • http://www.facebook.com/alex.blanks Alex Blanks

      Umm… Are you serious? This is possibly the worst idea I’ve ever encountered. It does nothing to reduce the instances of poor medical outcomes. I really hope this is a bad joke.

      • McT

        I sort of assumed s/he was just trying to get people stirred up…

      • NewMexicoRam

        The current system is a bad joke.

  • http://twitter.com/KatrinaFirlik Katrina Firlik MD

    But an extra year doesn’t address the problem of errors…

  • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

    Your solution only improves the number of patients seen by the doctor. It doesn’t decrease errors.

    The problem is exactly what you alluded to though. Hospitals did NOTHING to help the residents. Hours were limited but the work remained the same. They now do just as much “work” in less time.

    They are getting no more sleep because they are now doing a lot more of their “work” when they aren’t working. Residents use to read and study during down time at the hospital. Now you have no down time so you have to read and study on your own time.

    Lecture hours and teaching has dramatically decreased in the programs I have seen and is substituted by scut work. Residents should be learning on the job. Not doing the job by themselves.

  • SaraJMD

    It is certainly true, in my experience, that work hour restrictions tend to make life harder rather than easier for residents, compressing tasks into
    impossible time frames (which probably creates even more errors than before). Still, extending residency just avoids the truly fundamental problem of medical training: the issue of residents doing only what hospitals need done as opposed to what will be the best training for practicing medicine after residency. For example, most residents spend the vast majority of their time on inpatient care, even though many will do solely outpatient or ambulatory care after training. For residency to be longer than it is, it needs to have some additional benefit to residents, not just provide additional slave labor to hospitals, which is what I fear this would result in.

    Any real improvement in this system requires acknowledging that residents are often cheap labor for hospitals, doing onerous coverage that it may be impossible to hire midlevel providers to take over. Yes, there are costs to running a residency program, but there are huge incentives to inflate those costs, so I often wonder what the financial reality truly looks like for teaching hospitals. Residency may need to be longer, but I don’t think that’s the magic bullet to reduce errors or create liveable conditions for residents.

  • http://www.facebook.com/bradford.holland.9 Bradford Holland

    More radical idea: Go back to the old way. I think you missed the mark when you said you weren’t talking about reverting to the tried and true method, and that is the most common-sense (and even radical) answer you could give.

    • PoliticallyIncorrectMD

      Agree, we should!

  • buzzkillerjsmith

    I’ve been an attending physician since 1989 and I’m tired a good chunk of the time. Hell, I’m right now and afternoon clinic starts in 16 minutes. Maybe my pts should just go the emergency dept while I take a nice long nap?

    Let’s face it. Medicine, in many specialties is wearisome and might be hazardous to one’s health. This is the way it has been, is, and shall be.

    • PoliticallyIncorrectMD

      Cannot agree with you more!!!! I wish future doctors would stop complaining…or find some cushy job in computers or real estate. How would one feel about policeman complaining about being shot at? Some things come with the territory. Nobody seid being physician is easy. If someone does not like it, maybe they shoud reconsider their choice.

  • medical student

    As a medical student, I wish we could revert to the pre-2011 rules. The rules that have been imposed on training have been entirely arbitrary. We put so much emphasis on evidence-based medicine, but never actually researched into work conditions at all before arbitrarily deciding on work-hour restrictions. This is stupid.

    So many studies have shown that work-hour restrictions have not improved patient care and, in many instances, have actually increased the number of errors (due to compression, increased hand-offs, etc) — not only that, we also have to worry about producing potentially inferior products (ie. newly minted attendings who don’t have as much experience as the previous generation did). That is extremely scary to me as a trainee — I want to develop into the best physician I can be and the government/regulatory bodies are doing everything they can to make this difficult.

    Here’s a challenge to those who want to further restrict work-hours — show me the data. The ENTIRE argument so far regarding work-hour restrictions is that it would improve patient care. This has never been about better conditions for residents or anything like that. So far, the evidence is clear — this has not improved patient care, our primary goal. I want to go back to the pre-2011 rules. The current rules are more tiring than doing occasional 30 hour shifts — this is actually a more inhumane situation than the pre-2011 rules were. Ugh.

    • buzzkillersmith

      Wise beyond your years, young doc.

    • JayCeeMD

      …says the medical student who hasn’t yet worked the hours or lived the life of an intern. Be careful opining when you have no experience to back it up.

      • medical student

        As an M4, I’ve done the 30hr shifts during my M3 year — same schedule as the interns (but obviously a lower patient census compared to the interns). You know what happens when you assume…

        The 30hr q4-q8 call I had was infinitely better than the stupid 16hr shifts on my sub-I as an M4. These 16hr shifts are far, far, far more draining — at least with the 30hr shift, you had the post-day to recover. You don’t have that with the current rules and the random weeks of night float completely eff up your circadian rhythm. Seems like the studies that are coming out agree with my own, and my peers’, experience regarding the misery of 16hr shifts compared to the pre-2011 rules. Not only that, but (gasp!) there has been no improvement in patient care (which was obvious to anyone associated with clinical medicine, when you consider work compression and hand-offs). So basically, we adopted a set of (idiotic) arbitrary rules with no evidence behind them whatsoever — absolutely zero evidence — and find that it backfired. Whatever happened to “evidence-based medicine”? I guess it only applies to drugs…

    • Guest

      .

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    As an intern, my covering resident would make us get a few hours sleep when on call and cover us and vice versa when we began to look or feel weary. Our workups were reviewed by the medical student, the covering resident , then again on work rounds, at morning report, at attending rounds and then residents rounds with the chief resident and department chairman. Each new case was reviewed at least 5-6 times. The duplication limited errors somewhat. If work hour restrictions are not reducing errors then there is no reason to restrict the hours. What needs to be evaluated are the systems so that safety checkpoints can be developed and instituted . I agree with Kevin that in the face of work hour restrictions adding a year of training makes sense from every angle except the cost to the institution to train a new doctor

  • http://www.facebook.com/survivor.do Survivor DO

    Working at an osteopathic residency I am still able to work 24 hour shifts. My wife, who works as a resident in NYC, is not able to. My schedule is drastically better than hers. She is by far more fatigued than I. I am a much happier resident than her. In no way does working 24 hour shifts make my life or patient care worse.

    Survivor D.O.
    http://www.survivinggrays.com

  • N N

    The only problem that an extra year of residency solves is by giving one more year of indentured servitude to hospital administrators. If your goal is for students to run away even more than they already are towards non-tertiary care specialties, then by all means go for it. Your premise from the very beginning in the Zion Case that it was due to resident exhaustion is incorrect, as it was found out later it was due to drug interactions between the drugs she was taking before she was in the hospital. It’s probably not a good idea to use The New York Times as a guide for reengineering resident education.

  • http://twitter.com/Cascadia Sherry Reynolds

    Expensive yes but to who? Not to the intern or to the hospital (in most cases)

    Interns are paid as are the teaching hospitals that train them To the tune of 9 billion a year – not many people realize that it is CMS – Medicare and Medicaid that pays the bulk of that cost.. (that is why they are expected to treat medicare and medicaid patients for slightly less when they graudate.. they are paying back a loan/grant of close to 1million)

    Intern/ Residents are paid to work (typically 40 to 60 k a year which is the average income in the US and another 40k goes to the teaching hospital) but I am not sure about the “lost income” part.. Does that imply they are also able to billing for services tat the same time as their attending does? IE if they did the surgery did they bill also?

    • John Henry

      No Sherry, there is no requirement that residency graduates see Medicare or Medicaid covered patients as a condition of having been trained at a hospital that receives CMS funding. And there should not be either. The government gets its pound of flesh at the time, paying someone with a doctorate and who is motivated to work 80 hours a week for $40K. Two weeks vacation. Minimal benefits, no retirement, no 401K, none of the kinds of things someone working for the government–like a teacher, for example–would get for working far fewer hours with far less responsibility. Residents don’t owe anyone ever the obligation to take Medicare later. They have already paid, in spades. And CMS prohibits the residents or the hospitals from billing for any services they render, whether the patients receiving the service are Medicare beneficiaries or not. And where do you get the ridiculous idea that anyone is paying back a loan or grant? That is not true at all. The residents’ educational debts are theirs alone, CMS isn’t paying any of that, during residency or later.

  • Dr. B

    Residency is a pain but necessary. Perhaps the errors aren’t related to sleep deprivation at all, but rather that we are all human, errors are innate, and that our check and balance system isn’t as secure as it should be.

  • IK

    How about making processes more efficient in the hospital so residents dont have to waste time on scut work. No need to extend residency.

    • John Henry

      “Processes” to reduce scut work means labor by someone else, someone whose work cannot be leveraged by academic requirements, and whose expectations of pay and working conditions will likely be consistent with unionized labor, who will expect, not unreasonably, the pay, benefits and working conditions of unionized employees. That is expensive. The government, insurance companies and patients don’t want to pay more.

      • IK

        I disagree. We are already paying for these inefficiencies in our system and we are not getting any value out of it. Garbage in, garbage out. We need to work “smarter.” We need to stop having the physicians do scut work and begin working at the top of their licensure. A process improvement activity could involve the implementation of a simple checklist or protocol. No need to hire additional people or buy a fancy EMR. Just have the current folks work in new ways that promote efficiency and team work.

        • John Henry

          Don’t get me wrong, I have done ample scut and wouldn’t want more. But the reality is that work has to be done somehow by someone, which costs. You my believe efficiency by optimizing physician time will pay for these task re-distributions, but that would only occur if fewer residents or hospitalists were employed doing more high-skill work. That is a management issue.

    • http://www.facebook.com/shirie.leng Shirie Leng

      I definitely agree with you IK. Make all the clinical time USEFUL clinical time.

  • http://www.facebook.com/shirie.leng Shirie Leng

    Yes, we could extend residency by a year. But with the amount of debt people have coming out of medical school that’s just another year delay on actually making any returns on that debt. Besides, some surgery programs are already 6 years or more. You’re 30 before you make a dime. I actually have a different solution. Make the clinical time residents do have more educational. I spent an awful lot of time in residency sitting in lap cholecystectomies and foot cases because the hospital needed to staff the rooms. If I could have been in complex cases or practicing line placement or regional blocks every day, I would have felt more like my time was being spent LEARNING instead of STAFFING.

  • jloos

    This sounds strangely like you advocate putting the debt of hospital coverage onto the backs of already debt -riddled residents and interns instead of the hospitals assuming it.

    “Hospitals did not hold up their end of the bargain by hiring additional workers that could off-load some of the non-educational work performed by medical interns.”

    Surely I have misinterpreted?

    Maybe the whole MD training program should be reevaluated and streamlined to eliminate any redundancy, out-dated information, and unproductive concepts of sufficiently paying one’s dues? Would there still be a need to extend that year?

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