Gastroenterology
Volume 136, Issue 4 , Pages 1145-1147, April 2009

Response to the Institute of Medicine's Recommendations on Resident Duty Hours: The Medical Residency Program and GI Fellowship Viewpoints

  • Mark W. Babyatsky, MD, FACP

      Affiliations

    • Drs. Richard and Mortimer Bader, Professor of Medicine, Vice Chairman of Education, Program Director, Internal Medicine Residency, Mount Sinai Medical Center, Department of Medicine, New York, New York
    • ,
  • Hasan Bazari, MD

      Affiliations

    • Assistant Chief of Medicine, Director of Residency Training, Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
    • ,
  • John Del Valle, MD

      Affiliations

    • Professor and Interim Chair, Director of Residency Program of the Department of Internal Medicine, University of Michigan Health System, Department of Internal Medicine, Ann Arbor, Michigan

published online 23 February 2009.

Article Outline

In December 2008, the Institute of Medicine released a report (www.iom.edu/residenthours) on the Accreditation Council for Graduate Medical Education's current duty hour regulations for medical residents. The following two articles address the report's recommendations from the perspectives of the medical residency program and GI fellowship.

 

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The Medical Residency Program Viewpoint 

The training of physicians has evolved from a historical residence of trainees in hospitals principally focused upon inpatient care as a form of apprenticeship and has succeeded in providing round-the-clock care. More recently, ambulatory care training was added and has struggled to compete effectively with inpatient medicine in the minds of trainees. Impetus for further changes in graduate medical education (GME) dates back to the well-known case of Libby Zion, whose unfortunate death was attributed to medical errors associated with long trainee work hours and lack of supervision. Public sentiment has since embraced the notion that prolonged duty hours for residents lead to errors and must be modified. The Institute of Medicine (IOM) released recently an extensive report calling for a major restructuring of resident duty hours in GME1 that extends beyond changes implemented in New York in 1989 or nationally by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. Finding underreporting and noncompliance with ACGME work duty guidelines to be common,2, 3 the IOM council's major recommendations, citing available sleep literature, emphasize limiting continuous work duty hours to 16 hours either through shifts, or instituting a mandatory 5-hour uninterrupted sleep break after 16 hours in a 30-hour shift. In addition, the IOM calls for optimizing “handovers” between caregivers, recognizes potential impediments to resident education, estimates the potential financial and manpower costs for implementation, and advocates for federal oversight of work duty hours. This commentary outlines distinct opportunities, views, and challenges raised by the IOM proposal.

Debate exists as to whether evidence supports the current IOM proposal. There are data for long shifts leading to errors4 and reduced resident well-being,5, 6 although data directly related to effects of work duty hours on patient safety7 or physician well-being remain controversial.8 The fact that such physiologic impacts on trainee performance and patient safety are defended with tenacity may reflect the blind spot that educators may have in being products of a training system that mostly resembles what currently exists; the premise that the “traditional” training system cannot be improved may reflect a perceptional bias. The current debate centers on designing an educational model that provides patients with safe, thoughtful care by developing highly professional physicians who can empathetically solve problems using available evidence while maintaining a sense of commitment to the patient during shorter tours of duty; these challenges span both the financial realm and our pedagogical responsibilities as educators.

The IOM report offers an opportunity to reconsider GME, but unfortunately, at a time of severe economic challenge. Implementing the IOM recommendations in this context will involve painful sacrifices; the report itself notes that without necessary resource allocation, attempts to implement the recommendations “will fail to have the desired benefits and even reduce patient safety.” The authors provide a cost analysis estimating the $1.7 billion for implementation of some of the IOM proposals to be only 0.4% of total Medicare costs,9 but it is a large percentage of the $8.5 billion in 2007 GME costs from Medicare, which would be difficult to achieve in the current fiscal environment. The IOM approximation may underestimate expenses, by mostly addressing the costs of additional health care workers, but not considering necessary increased administrative assistance. Furthermore, comparable costs in fellowship training as in gastroenterology are not addressed (see accompanying GI fellowship viewpoint by Proctor and Katza). Funding for needed multi-institutional outcomes research to determine the effects of these changes on patient safety and physician training will be costly also. The IOM report suggests potential funding sources, but, realistically, GME would require a major shift to include novel sources such as private insurance companies and the National Institutes of Health. Other costly health care priorities will compete vigorously, particularly during an economic downturn with the potential for the currently uninsured and underinsured to grow.

The tradeoffs between fatigue from prolonged shifts, errors introduced by multiple “handovers,” and educational mission are the central issues stemming from the IOM report. Although data are limited on the impact of each of these on patient safety, fatigue alone may not be the major causative factor in medical errors attributable to residents. Poor communications during “handovers” between trainees are a particularly frequent identifiable factor.10, 11, 12, 13 Furthermore, an increase in “handovers” between residents has resulted clearly from duty hour restrictions already14, 15 and will accelerate if the IOM report is implemented. Improved, standardized “handover” procedures require enhanced information technology and faculty supervision that should be developed concurrently with further duty hour restrictions. Although the IOM suggests supervised bedside rounds to aid in “handovers” and cross-coverage of patients less familiar to nonadmitting caregivers, adequate nighttime coverage has not been detailed. Specific responsibilities for each member of the inpatient workforce should be clearly delineated and the optimal number of patients cross-covered during nights and weekends should be clarified.

The world in which physicians practice has evolved over the past 3 decades. The virtual disappearance of solo private practice, an increase in technologically focused subspecialties, the creation of multidisciplinary patient care teams in the care of the patient, growth of the hospitalist movement, and the office-based focus and shortage of primary care physicians all impact graduate training. In addition, the shift of workload to attendings and fellows already observed following reductions in work duty hours is likely to further strain the pipeline of clinician-educators needed for both outpatient and inpatient supervision; the availability of an ample workforce to carry out these proposals would require reprioritization of physician payment structures.

By attempting to define the limits of work hours, the IOM implies that design of the schedule will be the major driver of the types of physicians we train. It would be defeatist to surrender to such logic. The goals of training are to train competent physicians who assume full responsibility for their patients, develop into leaders, managers, educators, and researchers as well as contributors to the myriad roles physicians play in society. Educators must instill the knowledge, skills, and attitudes to instill a lifelong approach to learning. To meet these goals within fewer hours, time-based versus competency-based training must be revisited and may lead to calls for lengthening the years of training, posing new economic and other challenges for both for physicians and society.

Despite the comprehensive nature of the IOM report as developed, there are key challenges of proposal which include:


1.The choice of long shift of 30 hours with a 5-hour sleep period versus 16-hour shifts. Both models will add “handovers”; the nap concept may not lead to actual rest in an emotionally intense setting.

2.The increased need for days off combined with shorter shift lengths can lead to more coverage systems involving individuals less familiar with patients they are covering.

3.The tension between inpatient and outpatient training is not addressed and remains an educational challenge and a significant source of handovers.

4.Explicit faculty development to train attending physicians to supervise trainees more closely but facilitate graduated patient care responsibility is needed.

5.Team ownership models for patient care when the primary team is not present must complement individual responsibility.

6.“Handovers” will need to be structured, taught, and observed for feedback and may involve rounding on patients at times of transition of care between shifts.

7.Paradigms for educating an increased number of trainees during night and weekend shifts must be developed.

Finally, the true impact on the patient experience must be explored. Patients are already bewildered by the amount of providers they encounter during a hospitalization. Communication between knowledgeable providers and patients will be at risk as will the trust of patients in the health care system. If the patient experience is not the central focus in restructuring, we will have met all the restrictions and end up failing in the most important mission of all.

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Acknowledgements 

All authors contributed equally to the manuscript.

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References 

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  2. Arora V, Wayne DB, Anderson A, et al. Participation in and perceptions of unprofessional behaviors among incoming internal medicine interns. JAMA. 2008;300:1132–1124
  3. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Academic Press; 2008;
  4. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns; work hour on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–1848
  5. Ayas NT, Barger BE, Cade DM, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006;296:1055–1062
  6. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 205;352:125–134.
  7. Howard DL, Silber JH, Jobes DR. Do regulations limiting residents' work hours affect patient mortality?. J Gen Med. 2004;19:1–7
  8. Fletcher KE, Underwood W, Davis SQ, et al. Effects of work duty hours on residents' lives: a systematic review. JAMA. 2005;294:1088–1100
  9. http://www.cbo.gov/budget/factsheets/2008b/medicare.pdf
  10. Jagsi R, Weinstein DF, Shapiro J, et al. Residents report on adverse events and their causes. Arch Intern Med. 2005;165:2607–2261
  11. VA National Center for Patient SafetyJoint Commission International Center for Patient Safety. 2006;
  12. Gandhi TK. Fumbled handoffs; one dropped ball after another. Ann Intern Med. 2005;142:352–358
  13. Singh H, Thomas EJ, Peterson LA, et al. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167:2030–2036
  14. Horwitz LI, Kosiborod M, Lin Z, et al. Changes in outcomes for internal medicine inpatients after work-hour regulations. Ann Intern Med. 2007;147:97–103
  15. Arora V, Hohnson J, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement a critical incident analysis. Qual Safety Health Care. 2005;14:401–407

 Conflicts of interest The authors disclose no conflicts.

PII: S0016-5085(09)00196-6

doi:10.1053/j.gastro.2009.02.016

Gastroenterology
Volume 136, Issue 4 , Pages 1145-1147, April 2009