Sunday, December 07, 2008

Duty Hours/Regulation/The IOM/The Cost/The Logic/AHHHHHHHH?

So it appears that the IOM has released its recommendations to congress regarding duty hour restrictions for medical residents at programs receiving federal funding (AKA every program). I'd like to take a minute to go over some of these recommendations, discuss the potential impact, and then explain why this is a bad idea. I do not have a comprehensive list. All of my information is second hand, as the report itself is rather expensive to access. If I write anything inaccurate, or anyone else finds something in the report worth mentioning, please let me know.

1. Maintain 80-hour workweek. There is no recommendation in the report as some program directors feared limiting resident work hours to 56 hours a week. The cap is however limited to 80 hours a week, which would eliminate averaging. I guess the big change here is that a congressional mandate would be accompanied by stiffer penalties than the RRC can possibly impose. It would also make some efforts to balance rotations a bit more complex, as the strict 80 hour max is currently not the norm at many surgical programs that have residents cover >80 hours some weeks and make up for it during others.

2. Maintain 30 hour shift max. There is no change here, except for the fact that they now want to require a 5-hour mandatory sleep break within the shift if it supercedes 16-hours. This would be the first required nap at any adult job in the history of working in the United States. It also makes it virtually impossible to cover a night call with only one resident.

3. 1-full Day off per week with NO AVERAGING. For those that suddenly found that weekends could exist again as part of the 80 hour work-week, no more. There are no more golden weekends under this report without extra days off (Something hard to give in a system in which there are multiple residents required for each call and residents can't alternate going above and below 80 hours each week. Whereas now some programs have residents alternate weekend call, this system will soon be a thing of the past if the recommendations are implemented.

4. Call no more often than q3. There will be no more q2 call even for a small stretch. This means that you cannot alternate q2 call to cover vacations. You also cannot do a Friday-Sunday call to give another resident a weekend off.

5. No more than 4 night shifts in a row. Of all the recommendations, this really makes the least sense. The obvious adaptation to all of the above call requirements is to establish a night float. This would only be possible under the recommendations by having people switch onto and off of the night float every few days, making establishing a circadian rhythm impossible.

6. Interns can't be the only MD in-house. This is really ridiculous, as many hospitals currently have no physician in house. In other words, it is legal to have the intern go home, leaving no one in-house, but it would be illegal for him to stay alone. It also makes the call schedule even harder, as junior call interns couldn't cover a potential nap break for the senior residents in a junior-senior joint call system to adapt to the required nap under the new recommendations.

There are some more, but they're escaping me at the moment. Feel free to post them.

Why are we here?

For those of us in the trenches, this really makes no sense on so many levels. I am going to be the resident who should theoretically be receiving the benefit of these work-hour restrictions. By continuing to have 80 hours weeks with a bunch of crazy rules implemented on top of them, compliance costs will go through the roof, AND it will do nothing to solve resident fatigue. There is no evidence base for any of these changes. Why would we even consider implementing these changes as a requirement for every program with no reason to believe that they will work? Again, this smells an awful lot like what happens when we start to dismantle the free market.

Medical licensing is a hot-button issue to bring up in some groups, so I will not go all the way back to that point in terms of market intervention. If we assume that the government should require some minimal level of proficiency in order to practice medicine, then we have to question how that level should be obtained. In other professions with similar requirements, the usual course of action is to have a some degree of professional schooling as a primary requirement. This is the case in every profession from law to architecture. After these different types of schooling, there is usually a state sponsored exam. The bar exam might be an example of this. There is some variability between states and professions, but the concept is the same. This is also true in medicine with the USMLEs, which every state has now simply adopted as its state licensing exam.

After this, certain professions require different things. Most people agree that hanging a shingle immediately after school is complex. In law, this is legal but relatively rare. Most people will go work for a firm, where they will get real world experience. The firm can be a solo attorney or a Devil's Advocate styled enterprise. Nevertheless, it is not formalized. The formal background is found in the schooling itself, and everything thereafter is variable, creating a vibrant heterogenous market. Pay ranges are wide, with some new associates demanding >$100k/year and some receiving $25k. People migrate towards positions that meet their needs for work, pay, hours, training, environment, location, etc... Everyone is a potential employer and a potential trainer.

In medicine of course, we have a formalized residency requirement. Without belaboring the entire history of residency training, some of the following things are true:
1. Every physician who wants a license has to complete somewhere between 1-3 years of formal residency depending on the state.
2. Every physician who wants to specialize must for the most part fit his interests into a series of predefined specialties that require anywhere from 3-10 years of formal training depending on the specialty
3. The government funds almost all of these positions through Medicare
4. Residents receive a surprisingly similar percentage of this money at most programs, with almost all salaries falling between $40k and $60k depending on location, specialty, and post-graduate year.

This set-up is why we are currently dealing with the IOM report. The government funds these positions, which gives them excessive amounts of power in regulating them. Work hour restrictions get tricky on a constitutional level when the government isn't funding things. When they are, it's very simple. They can simply take the money away.

It is also very clear that different people want different things from their post-graduate training. Some people like to work hard and often. Others have different priorities. Different people have different tolerances for stress, labor, sleep-deprivation, etc... Yet every program is regulated to be similar.

As an attorney looking for a niche, let's say tax law, there are a million different ways to fall into the niche. You could get a masters in tax law, you could go work for a big tax firm. You could work for the tax division of a big firm. You could enter a small firm looking to expand into tax law and become the specialist by doing the job. You could hang a shingle. It's all possible. In many ways, the only difference between one of the big firm jobs and a medical residency is that the big firm usually pays better up front with less remote guarantee. However, all of these entities are possible. They are regulated by their ability to get people willing to work in the way that they require, and they are limited by the ability to provide for their clients. A few botched cases, and a big firm doesn't remain as big.

In residency, the only way to change things is to lobby congress. You can't quit easily. You can't find a different training model for your specialty. You can't just go out and work with someone who performs your specialty until you start to feel proficient. One might say that this isn't so bad. I mean, at least we'll set a floor on quality. Close reflection (and the recent IOM report) show what the problem is.

There is no natural adaptation. Residencies functioned until the original RRC changes in nearly the same manner in which they worked 50 years before, with the only major changes being the progressive addition of more years in order to be qualified to do the same thing. The 80-hour work week was the first real new step in 50 years. Normal markets, including those in training programs adapt slowly over time. These changes were abrupt, and rather than being based on mutual preferences, they were imposed from the outside. There was an extremely hetergenous response. Many couldn't or wouldn't adapt at first. Many residents loved it. Many hated it. Many ignored the rules. Many programs made them ignore the rules. Some of the biggest programs in the country went on probation.

Eventually, people mostly adapted to the new rules, but there is no evidence that they've done anything to improve outcomes. Many residents are happy with the changes, but some are certainly not. One must question the decision to force people to work less who want to be more productive. The new restrictions are not based on anything. There is no logic, no evidence, and no real objective standard behind them. However, we are a federally regulated and funded enterprise. Arbitrary rules and compliance are the lot in life of such an entity.

Medicine has evolved over so many years within the system of federal funding and control, that it is hard to see how it would work without it. This doesn't however, mean that it couldn't, Residency would probably have to continue to exist in some form. No one is ready to be a surgeon at the end of medical school, but the rules would have to be different. That may not be so bad. We might eliminate some the conflicts that we have now, where a PA straight out of school can bill as a first-assist on an operation where a chief resident with over 1000 cases cannot. We might change the system in which it costs more money to hire a secretary to do scut work than an intern. Many programs are dedicated to training, but the natural evolution of a training system would slowly lead to a proper balance between training, service, and the reimbursement that is proper to achieve those balances. Service could be exchanged for teaching, and resident reimbursement could be based on what they actually produce. Some could forego residency, though hospital credentialing for all but the most simple practice would require some demonstrated competency, setting a natural floor on the system.

That was probably a long incoherent ramble. Whatever the case, I am scared. As a new trainee, I know that the system is flawed, but it does produce competent physicians in large part. If implemented, these new rules will hit hard. Because we've let ourselves become beggars at the foot of congress, we are essentially powerless to stop them.

17 Comments:

Anonymous Anonymous said...

you have little to no idea what you're talking about. until you go through the grind yourself you'll not understand how ridiculous some of these work hours have been and still are.

and having gone through some clerkships gives you merely a glimmer the fatigue involved..

6:36 AM  
Blogger Yitz said...

I can't see how you think there is no logic in an 80 hour work week or limiting shifts to 30 hours with the 5 hours to sleep. I could understand if you said there might be better ways to do this, but it is a fact that exhausted people make more mistakes, so having more rest will therefore eliminate some mistakes. Sounds logical to me.

7:44 PM  
Blogger MiamiMed said...

There are clear pros and cons to long on-duty hours. These things are not well worked out. There are clearly problems with limiting things too much. This also makes some smaller training programs nearly impossible, where the trade off is sleep deprivation vs. not enough manpower to run a residency at all. A random institute handing down a non-evidence based decree clearly doesn't solve this.

4:54 PM  
Anonymous Anonymous said...

Hey Miami,

First off, let me say: I think this is a brilliant blog. In many more ways than not, I find myself agreeing with you. That's my main criteria for deeming something brilliant. And, quite often, you express the same things I want to say a fair bit more eloquently than I could.

I'm on the fence about your comments regarding duty hours, however. At first, I was VERY supportive of limitations, and incensed by the fact that many programs (hello surgery!) tacitly require their residents to lie when reporting duty hours.

And I must say, having been through intern year, there's no question in my mind that the kind of hours we're asked to put in lead INEVITABLY to poor decision-making. Sometimes this is the result of poor judgement when you are exhausted. Sometimes it's simply out of a desire to get patients to quiet down while you get an hour of sleep in the middle of a 36 hour marathon. I know interns who freely dispense versed and morphine in the wee hours simply to temporize until morning rounds. I think that's unconscionable -- but I understand it, having been there myself. The point is -- after working for 18 hours straight (in the context of doing this several times a week), you WILL make bad decisions.

In addition, it's clear that this kind of exhaustion has ill effects on residents themselves. I've fallen asleep at traffic lights multiple times post-call. What if my foot slipped off the brake? One of my colleagues hit a parked car on the way home when he was struck by the sudden need for a nap. You can't tell me that's healthy.

So, the kind of hours we work are bad, in these respects. There are some ways in which they're 'good' -- i'll get into those later. If I remember.

Why is it that duty hours have become such a big deal? How was it that decades passed with physicians who went through residency without any duty hour limits and seemed to do fine? There are a couple of possibilities I can think of, off the top of my head:

1) We (the current generation) are babies. This is the favorite response of older attendings etc, who tend to sneer at the idea of duty hour limits (an attitude I think is just as unhelpful as being violently pro-limits). I guess this is a possibility. I think there are surveys out there that study changing work-life attitudes across generations. But I don't think anything out there answers this definitively.

As a partial answer, there is a possibility that residents feel underpaid, and this is manifesting as discontent over hours. In the past decade or so, we've seen unprecendented wealth and growth (CLEARLY this situation has recently changed). Many residents saw their classmates go into finance or law etc and make some serious cash. Everyone knows people in those professions also put in ridiculous hours. But somehow, the prospect of working your ass off is more appealing when you're getting paid more than $9 an hour. Maybe this attitude will change now that the economy is in disarray, and people start valuing the relative security of medicine more. I doubt it will change dramatically, though, unless the downturn is prolonged.

2) Maybe the cocnern over hours stems from the fact that residents may be older in general than they have been in previous generations, and more likely to have families, etc. I have no data to nack this up. It just seems to me that medstuds and residents seem to be getting older in general. Certainly I took some serious time off before starting medschool.

3) Maybe there is simply more scrutiny of medical errors, and residents have been identified as a likely, easily targeted source. That scrutiny could be the result of an increasingly litiginous environment, or of a (likely related) search for source of the explosion in health care costs.

4) My 'favorite' possible explanation is that the this concern with hours stems from increasing resident fatigue, as compared to previous generations. Why? There are many possible explanations. Clearly, there is vastly increased volume of cases. In my specialty, we can regularly have days where 30 new post-op pts are admitted to the service. In surgical fields, this could be the result of improved surgical techniques/anesthesia, OR turnover, etc -- all of which permit higher case volume. This higher case volume has to be met by someone. I doubt the increase in residency program size has been commensurate with increase in volume.

Also, related to this is the fact that information is so much more widely and quickly available than previously. A CBC, which may have taken x hours to get done and be reported, now probably takes far less time and is quickly available online for your convenient perusal. This has implications. One is that 'dead time' is seriously reduced. Two is that, with more results being more quickly available, you have to act on them more often. I'm sure there are others.

My point is -- residents are probably far more productive now than they were in the past. My hypothesis is that this causes greater fatigue. Maybe this is a stretch. But I think it's fairly elegant.

5) (am i on 5?) Damn paperwork. There's no question the sheer amount of crap paper work we have to do as residents has improved relative to the past. This is mind-numbing stuff. It's exhausting. It should be farmed out to other staff.

I'd lvoe to keep going -- but I have to go for now. I look forward to your response. I'll be back with more.

11:23 AM  
Anonymous Anonymous said...

Excuse me, re (5) -- I mean the amount of paper work has 'increased'. Not 'improved'. Certainly NOT improved.

11:27 AM  
Anonymous Anonymous said...

your response?

2:12 PM  
Anonymous Anonymous said...

Still no response miami?

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