List Archives

Fri Mar 13 12:44:00 GMT 2009

Paula Chen is a surgical oncologist and transplant surgeon who writes  
regularly for the NYTimes. I think the discussion of "unintended  
consequences" is important.

March 3, 2009
DOCTOR AND PATIENT
On Young Doctors and Long Workdays

By PAULINE W. CHEN, M.D.
Two weeks ago, the Accreditation Council for Graduate Medical  
Education, the organization responsible for accrediting American  
medical residency programs, issued an open letter that outlined its  
plans to review, revise and enforce residency duty hours. The letter  
is part of continuing efforts to improve the way that medical  
residents, the recent medical graduates who care for patients, are  
trained in this country.

Five years ago, the organization established an 80-hour cap on  
resident workweeks, a move spurred in part by the 1984 death of Libby  
Zion, a young woman who was under the care of residents on call, and  
by years of legal wrangling. Despite the reforms, the organization  
came under criticism by a national panel of medical experts that said  
it had failed to address work hour violations that were “substantial  
and underreported.”

I spoke with Dr. Thomas J. Nasca, the chief executive of the council,  
and asked him about resident duty hours, patient safety in teaching  
hospitals and the implications of further duty hour changes to the  
doctor-patient relationship.

Q. What have been some of the effects of decreasing duty hours on  
patient safety?

A. We know there have been a lot of unintended consequences, some of  
which have not been good for patients. One of these unintended  
consequences, for example, has been an increased number of handoffs  
between doctors leaving their shift and new doctors coming on. The  
handoff period is the most vulnerable period for a patient, not  
because the people handing off data are not doing their best or  
because institutions don’t have systems in place. It’s a vulnerable  
period simply because one cannot predict what will happen when a  
patient is ill, and the doctors left caring for those patients don’t  
know them.

Handoffs are when most errors occur, and most of the potential  
reductions of error based on fatigue have been replaced by an  
escalation of errors related to handoffs.

Another unintended consequence has been placing residents in certain  
ethical quandaries. One resident told me about caring for a child who  
was dying. She had taken care of this child for 10 or 12 days and was  
on call when it became clear that the child was going to die in the  
next few hours. But this resident was supposed to go home; her hours  
limit was up.

What is better for the patient and that family — to have a new doctor  
who didn’t know them preside over those very difficult circumstances,  
or someone they knew and trusted? This resident stayed, but there was  
an unintended consequence. She could tell the truth about breaking the  
hours rule, and thus jeopardize herself and the residency program. Or  
she could lie.

What could be worse than a training system that encourages doctors to  
lie because they want to be with their patient? This is the last thing  
we should be doing, but we’ve done it.

Q. If residents are tired, how safe are teaching hospitals?

A. There is no data substantiating the idea that teaching hospitals  
are full of very tired people making a huge number of errors. In terms  
of errors and patient safety, studies have repeatedly shown that  
overall care in teaching hospitals is better than in non-teaching  
hospitals. There is a redundant system in place in teaching hospitals.  
There are multiple layers of doctors — many sets of eyes on every  
order — that decrease the likelihood that an error will reach the  
patient.

Residents and interns also add tremendously to quality. They  
constantly question what is going on and ask if it can be done  
differently.

Q. Some have likened residency duty hours to hazing. Is that a  
necessary part of becoming a doctor?

A. It’s not hazing or abuse; it is a recognition of the reality that  
exists when young doctors are done training. They have to be ready,  
and we cannot fail.

The American public expects to be able to trust their physicians. And  
that trust is predicated on the idea that physicians will place the  
needs of their patients above themselves. If a parent has a sick  
child, that parent needs to be able to trust that the doctor will do  
anything to help the child. Doctors must efface self-interest —  
economical, emotional or physical. Not everyone can do it; it needs to  
be taught.

And just as you can’t become a master violinist or a marathon runner  
without paying a price, you cannot train a young doctor up to the  
level that the public demands without time and clinical experience.

We have to prepare young doctors for the reality of practicing in the  
American system, in what are often less-than-ideal circumstances. On  
July 1, after residents finish their training, they become independent  
doctors and no longer have their teacher, their residency program  
director or their chairman standing over their shoulder. A  
neurosurgeon in Missouri, for example, will have to cover four  
counties and must go to the E.R. and operate regardless of how tired  
he or she is. Otherwise there is no one for that patient.

This is the reality of practice in many areas of the country, and our  
responsibility is to address that reality.

Q. What if we just train more doctors?

A. We need to train more doctors, no matter what. But it’s not just  
more, it’s also the quality of the physician. Educational environments  
with the breadth of talent, resources, clinical experiences and  
research required are very expensive and not easily replicated. This  
is a real challenge now for some of the new medical schools that are  
starting up in areas where there are no teaching hospitals.

Q. What can young doctors expect over the next few years? What can  
patients expect?

A. What I hope residents can expect is that we will not place them in  
the same ethical quandaries they have been forced to face in the past.  
We expect that there will continue to be a limitation of duty hours  
and we will not want them working in a way that impairs their function.

I think that patients can be assured that the quality of care they  
receive in teaching hospitals will continue to be outstanding. They  
will hopefully also continue to see more rested physicians than they  
saw 10 years ago. I hope, too, that they will be assured that the  
doctors we are training today will be there for them when they need  
them, providing superior care worthy of their trust.

Join the discussion on the Well blog

List Archives

For your convenience, find the Trauma List Archive Below

F/U to L. Zion article