What do residency program directors and residents think about the restricted work hours that were put into effect in 2011? They don't like them. Should we care what they think?
The New England Journal of Medicine reports on a survey of residency program directors. Main conclusions:
Program directors reported that many aspects of training and patient care have been unchanged by the 2011 regulations, including resident supervision (62.0%), patient safety (57.0%), balance of service and education (60.9%), scores on in-service exams (73.6%), and fatigue (54.4%). Perceived quality of life for residents was the sole area identified by a plurality of respondents (49.5%) as having improved. Meanwhile, a negative effect was reported for resident education (64.8%), preparedness for senior roles (73.2%), and “ownership” of patients (78.6%); respondents also noted diminished continuity of care (82.0%) and increased frequency of handoffs (88.0%). Most program directors reported an increase in their own workload (73.8%), as well as increased utilization of physician extenders, such as nurse practitioners and physician assistants (61.4%). Finally, less than half the program directors (42.7%) reported that their residents are “always” compliant with duty-hour regulations.
In a previous survey of residents themselves, notes Kaiser Health News,
The residents themselves also [had] negative views of the changes. A similar survey of 6,201 residents published in NEJM in June found that while 62 percent felt that quality of life had improved for interns, half reported that quality of life had gotten worse for senior residents, who were picking up the slack. Meanwhile, 41 percent reported that the quality of their education had gotten worse, and 48 percent disapproved of the rule changes.
What are we to make of this? One observer on the National Patient Safety Foundation listserv said:
I was dismayed by this when I saw it. Then I remembered that this was an opinion survey. It is interesting, though, that residents and interns have so little regard for (and insight into) their own human limitations due to fatigue. They have already been socialized into the wonderful world of medicine, where everyone thinks she or he is superman, able to leap tall shifts in a single bound. Of course, nurses feel that way too. Most would rather work fewer longer shifts rather than more shorter shifts, even when confronted with evidence that the latter is safer.
Before we reach conclusions, it might be good to look at the science. I recall a talk years ago by Charles Czeisler, the chief of the division of sleep medicine at Brigham and Women's Hospital. He certainly made the point that an extended periods without sleep are dangerous (for patients, the residents themselves, and traffic accident victims as residents drove home). But here's the thing: I may remember this wrong, but I thought part of conclusion was that the pattern of sleep-and-awake mattered a lot--in terms of attentiveness--not so much the total number of hours of sleep that one got during a week. If so, the prohibitions set forth by the ACGME may be mis-designed.
But, there is one thing for sure, as noted by the observer above: Residents will never believe that any set of rules is good for them or their patients. They are tricked by their own cognitive errors and imbued with a deep cultural prejudice into believing that they can "handle" anything that comes before them. In that regard, the medical education system has failed them.
The New England Journal of Medicine reports on a survey of residency program directors. Main conclusions:
Program directors reported that many aspects of training and patient care have been unchanged by the 2011 regulations, including resident supervision (62.0%), patient safety (57.0%), balance of service and education (60.9%), scores on in-service exams (73.6%), and fatigue (54.4%). Perceived quality of life for residents was the sole area identified by a plurality of respondents (49.5%) as having improved. Meanwhile, a negative effect was reported for resident education (64.8%), preparedness for senior roles (73.2%), and “ownership” of patients (78.6%); respondents also noted diminished continuity of care (82.0%) and increased frequency of handoffs (88.0%). Most program directors reported an increase in their own workload (73.8%), as well as increased utilization of physician extenders, such as nurse practitioners and physician assistants (61.4%). Finally, less than half the program directors (42.7%) reported that their residents are “always” compliant with duty-hour regulations.
In a previous survey of residents themselves, notes Kaiser Health News,
The residents themselves also [had] negative views of the changes. A similar survey of 6,201 residents published in NEJM in June found that while 62 percent felt that quality of life had improved for interns, half reported that quality of life had gotten worse for senior residents, who were picking up the slack. Meanwhile, 41 percent reported that the quality of their education had gotten worse, and 48 percent disapproved of the rule changes.
What are we to make of this? One observer on the National Patient Safety Foundation listserv said:
I was dismayed by this when I saw it. Then I remembered that this was an opinion survey. It is interesting, though, that residents and interns have so little regard for (and insight into) their own human limitations due to fatigue. They have already been socialized into the wonderful world of medicine, where everyone thinks she or he is superman, able to leap tall shifts in a single bound. Of course, nurses feel that way too. Most would rather work fewer longer shifts rather than more shorter shifts, even when confronted with evidence that the latter is safer.
Before we reach conclusions, it might be good to look at the science. I recall a talk years ago by Charles Czeisler, the chief of the division of sleep medicine at Brigham and Women's Hospital. He certainly made the point that an extended periods without sleep are dangerous (for patients, the residents themselves, and traffic accident victims as residents drove home). But here's the thing: I may remember this wrong, but I thought part of conclusion was that the pattern of sleep-and-awake mattered a lot--in terms of attentiveness--not so much the total number of hours of sleep that one got during a week. If so, the prohibitions set forth by the ACGME may be mis-designed.
But, there is one thing for sure, as noted by the observer above: Residents will never believe that any set of rules is good for them or their patients. They are tricked by their own cognitive errors and imbued with a deep cultural prejudice into believing that they can "handle" anything that comes before them. In that regard, the medical education system has failed them.