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Wed Dec 3 11:35:43 GMT 2008

Here's what I don't get: "...... Each time you hand off a patient there is a
possibility of error." So the solution to this is to increase the number of
hand offs.

Rob Smith

December 3, 2008 from the NYTimes
Expert Panel Seeks Changes in Training of Medical Residents
By TARA PARKER-POPE

A national panel of medical experts proposed significant and costly changes
for training new doctors in the nation's hospitals, recommending mandatory
sleep breaks and more structured shift changes to reduce the risk of
fatigue-related errors.

The experts' report, issued by the Institute of Medicine on Tuesday, focused
on the grueling training of medical residents, the recent medical school
graduates who care for patients under the supervision of a fully licensed
physician. The medical residency, which aims to educate doctors by immersing
them in a particular specialty and all aspects of patient care, is
characterized by heavy workloads, 80-hour workweeks and sleep deprivation.

But while popular television shows like "Grey's Anatomy" glamorize residency
training as a gratifying rite of passage for doctors, the worry is that the
huge workload imposed on residents poses a risk to patient safety. The long
hours of often unsupervised residents were found to have contributed to the
1984 death of 18-year-old Libby Zion in New York City, a finding that
eventually led to a series of changes, including limiting residents to an
80-hour workweek and 30-hour shifts.

But the expert panel said those reforms were not enough. Caps on work hours
are often not enforced, and many residents still do not get enough sleep,
putting doctors and patients at risk for fatigue-related mistakes. While the
new recommendations do not reduce overall working hours for residents, the
report says no resident should work longer than a 16-hour shift, which
should be followed by a mandatory five-hour nap period.

The committee also called for better supervision of the doctors-in-training;
prohibitions against moonlighting, or working extra jobs; mandatory days off
each month; and assigning chores like drawing blood to other hospital
workers so residents have more time for patient care.

"One of the problems has been that we limited the hours but didn't change
the work to make it better educationally and in terms of safety," said a
panel member, Dr. Kenneth M. Ludmerer, professor of medicine and history at
Washington University in St. Louis. "You have to look at what they do during
those hours. Is the total experience a learning experience?"

The panel paid particular attention to the so-called patient handoff, the
point at which a resident briefs the next doctor about a patient's history
and needs as he or she is ending a work shift. The handoff is a risky time
for patients, because rushed and fatigued doctors often inadequately brief
incoming staff members, said Dr. Sandeep Jauhar, director of the heart
failure program at Long Island Jewish Medical Center and a reviewer of the
report.

Dr. Jauhar, who recently wrote about his medical training in the book
"Intern: A Doctor's Initiation," recalls when a fellow doctor-in-training
rushed a patient briefing without giving him basic facts about the patient's
serious condition.

"When the nurse asked, 'What do you want to do, doctor?' I didn't have a
clue," Dr. Jauhar said. "I didn't have his case; I didn't know what tests
had been done. Each time you hand off a patient there is a possibility of
error."

The big question from the Institute of Medicine report is whether medical
schools and hospitals can afford the proposed changes, which may add as much
as $1.7 billion in new costs to cover patient care during mandatory nap
times and shift changes. The panel did not propose a financing source and
said only that medical schools, hospitals, the Veterans Administration and
other "stakeholders" in graduate medical training should meet to discuss the
issue. Ultimately, whether the guidelines are enforced will be decided by
the Accreditation Council for Graduate Medical Education, which is
responsible for the accreditation of graduate medical training programs in
the United States.

"We know there is a cost to this," said Brian W. Lindberg, a panel member
and executive director of the Consumer Coalition for Quality Health Care in
Washington. "If we're enabling residents to have sufficient sleep, someone
has to cover care during those periods. We also believe if you look at the
totality of the recommendations, there is the potential for efficiencies in
the system and savings from reduction in errors and harms. In the long run,
it won't cost as much as one might estimate."

While the need for reforms was generally applauded, some health care groups
expressed frustration that more was not being done to relieve the workload
of doctors-in-training.

"How is it reasonable for truckers in our country to be more restricted in
their work hours than doctors and resident physicians?" asked Mary Carol
Jennings, legislative director for the American Medical Student Association.

Dr. Peter Lurie, deputy director of Public Citizen's Health Research Group,
said that doctor hours should be regulated by the government, and that this
report was unlikely to make a difference in patient care.

"It's unlikely to be enforced," Dr. Lurie said. "It gives the appearance of
taking the problem seriously, but, in fact, will likely maintain the status
quo."

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Expert Panel Seeks Changes in Training of Medical Residents