Darshak Sanghavi recently wrote an excellent piece in the New York Times summarizing the controversy over resident work hours.
The topic has been discussed here frequently, with ramifications ranging from the fact that errors arising from patient handoffs negate any benefit gained from restricting work hours, to surgeons not accumulating enough experience during their work hour-restricted training.
I’ve often said that there are no work hour restrictions in the real world, so residents used to shift work may find themselves in for a bit of a surprise when they graduate.
Dr. Sanghavi notes that since work hours were restricted in 2003, there have been no measurable gains in patient safety:
In normal, day-to-day practice in hospitals across the country, medical errors didn’t fall when work hours were reduced. A massive national study of 14 million veterans and Medicare patients, published in 2009, showed no major improvement in safety after the 2003 reforms. The researchers parsed the data to see whether even a subset of hospitals improved, but the disappointing results appeared in hospitals of all sizes and all levels of academic rigor. “The fact that the policy appeared to have no impact on safety is disappointing,” says David Bates, a professor at the Harvard School of Public Health and a national authority on medical errors.
Important information is lost when the patient is handed off from one doctor to another, and that can lead to a new source of error. Residency programs have worked hard to close that loophole. At Children’s Hospital in Boston, for instance, errors fell by 40% after the patient handoff process was standardized.
But what’s more concerning is that the cause of medical errors is multi-factorial. That is, sleep deprivation is only one facet of failed care:
On a national scale, it seems safe to conclude that the efforts to cut doctors’ work hours failed because the change was made in isolation. A rested doctor plugs a hole in only one slice of cheese. Holes in other layers — the frequency of patient handoffs, the continued use of antiquated pen-and-paper medical charts — remain.
Improving patient safety requires more than forcing residents to nap, or go home. In addition to improving the patient handoff process, better electronic record systems should be implemented hospital-wide, as well as increased supervision from attending physicians. Furthermore, more support staff is needed to compensate for the decreased number of hours residents must work.
All of this costs money. In fact, implementing the Institute of Medicine’s recommendations on work hour restrictions is estimated to cost $1.6 billion, according to a report in the New England Journal of Medicine.
At a time when hospitals not only are being squeezed by health care reform, but also the debt ceiling negotiations, it’s unlikely that many of these additional patient safety measures will be swiftly implemented.
Until they are, simply restricting the number of hours medical residents are allowed to work is unlikely to yield patient safety gains anytime soon.