Limiting residents' work hours didn't hurt patient safety, but cut time spent with patients, studies say
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Patient-safety issues raised by the critics of limits on resident duty hours have not materialized. But concerns about doctors-in-training spending less time with patients appear to be valid, according to two new studies in the Journal of General Internal Medicine.
The Accreditation Council for Graduate Medical Education set an 80-hour weekly work limit (averaged over four weeks) in 2003. Further limits, including restricting first-year residents to 16-hour shifts went into effect in 2011. The movement to limit resident work hours was originally driven by Sidney Zion, a journalist, prosecutor and novelist, whose 18-year-old daughter Libby died a few hours after being admitted to New York Hospital on the night of March 4, 1984. His fight led to New York state limiting residents to an 80-hour workweek and 24-hour shifts in 1989.
Critics argue that the work-hour limits erode professionalism and create a “shift-work” mentality among new doctors. They also say that patients are put at risk because the work limits lead to fragmentation of care and make necessary more handoffs of responsibility between residents as they come and go between shifts.
But mortality rates at teaching hospitals stayed relatively the same in the first three years after work-hour limits were set and then improved in the fourth and fifth years, according to a study by researchers at the University of Pennsylvania, VA Boston Healthcare System and other institutions.
The researchers studied mortality rates within 30 days of admission for almost 13.7 million Medicare patients admitted for heart attack; gastrointestinal bleeding; congestive heart failure; and general, orthopedic or vascular surgery between July 2000 and June 2008. Heart attack patients had a 16.7% mortality rate during the 2000-01 academic year, but only a 13.9% rate in 2007-08. Mortality rates for congestive heart failure patients fell from 10% to 9.3%; and mortality rates fell from 12.3% to 10.9% for vascular surgery patients.
The researchers cautioned that these results coincided with other interventions such as the National Surgical Quality Improvement Program and the Premier Hospital Quality Incentive Demonstration.
“The absence of relative changes in mortality in the first three years post-reform suggests that the duty hour regulations did not have any direct effect on mortality,” the researchers wrote. “Improvements in mortality in post-reform years four and five suggest that the reform did not harm patients, although we are hesitant to attribute these delayed effects to the reform since it cannot be determined whether the improvements would have been smaller or greater had no reform been implemented.”
They concluded that: “These concurrent changes make it impossible to determine the incremental impact of any single intervention, but we can clearly say that mortality did not worsen following implementation of the 2003 duty hour rules.”
In the second study, researchers at Johns Hopkins University and the University of Maryland observed 29 first-year internal medicine residents at two “large academic medical centers in Baltimore” for a total of 873 hours in January 2012 and recorded how they spent their time. Their findings were then compared to previous studies on the same subject.
The first-year residents, also known as interns, were observed spending 12% of their time in direct patient care, 64% in indirect patient care, 15% in education activities, and 9% in miscellaneous activities such as walking (which accounted for 5.9% of their total time), eating, socializing and sleeping. In all, computer use accounted for 40% of their time. The researchers cited 1989 and 1993 studies that found interns spent 18% to 22% of their time in direct patient care, 42% to 45% doing documentation, and up to 40% on miscellaneous activities including eating and sleeping.
In the new study, the researchers noted that time spent on patient care didn't differ significantly between the two institutions, day and night shifts, or male and female interns.
They also noted that the goal of residency training is to produce physicians capable of independent practice and that the ACGME's training requirements highlight that residents' “essential learning activity is interaction with patients under the guidance and supervision of faculty members.”
The researchers wrote that the decreasing amount of time residents spend with patients could affect both the quality of care as well as the quality of doctor-patient relationships. But they also note that time spent consulting with colleagues and working on a computer could have positive effects.
“This is not inherently undesirable, as the EMR may contain reliable and organized historical information,” the authors wrote about the time spent examining patients' electronic medical records. “Likewise, a team approach to caring for patients necessitates more communication, which encompassed 20% of intern time outside of rounds in this study. While decreasing direct patient-care time, it is possible that focusing on these activities improves education and care quality.”
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