“I think that shift work mentality is a definite threat to professionalism,” he concludes. “And that mentality is not good for patient care.”
Studies of Standards’ Effects
Few studies have been published specific to the hospital medicine experience with the reduced duty hours. Lin, et al., conducted four focus groups of internal medicine residents at the Washington University School of Medicine (St. Louis, Mo.), and found concerns about the effects of the duty hour restrictions on patient care and medical education.1 A study published this January in Academic Medicine by Dr. Vidyarthi and colleagues at UCSF asked 164 internal medicine residents to rate the value of their educational activities, frequency of administrative tasks interfering with education, and their educational satisfaction after duty hours were reduced.2 Dr. Vidyarthi and her coauthors did not see an increase in educational satisfaction, which was one of the expected outcomes of the new duty hour restrictions. She believes that for educational satisfaction among residents to increase, additional structural changes also must be put in place.
“If this is really an educational endeavor, then we need to make it such,” she says. “Duty hour decreases are here, so let’s make this amount of time that [the residents] are spending in the hospital as educationally valuable as possible.”
Can Less Be More?
One effect of reduced resident availability is that hospital medicine programs must become more thoughtful about the content of the educational experience for residents. If residents will see fewer patients because of fewer hours on duty, how might the remaining patient contacts be maximized for their educational opportunities?
“I think that there is much room for making their time in the hospital as educationally valuable as possible,” asserts Dr. Vidyarthi, “from pedagogical ways of thinking about medicine, to decreasing the number of tasks that they do that are not educational in value.”
Dr. Dressler agrees. “By reducing the resident work hours, we definitely reduce the amount of patient contact by residents,” he says. “Now, whether or not that will dramatically affect the amount of education the residents receive would be difficult to measure. Potentially, down the road, the American Board of Internal Medicine or some other governing board may decide that residency programs need to be longer. Medical training programs have instituted a comprehensive programmatic change [with the new work hours], will attempt to evaluate all the potential downsides as well as the value of this change, and, ultimately, will have to address problems or unexpected results in the new system in order to optimize patient care as well as physician trainee education.”
At California Pacific Medical Center’s residency program, “there are certain components we have had to re-analyze, and consider. [For example,] what is our core educational mandate that we’re trying to achieve? ” asks Dr. Baudendistel. Examining residents’ rotations, he says, has led to decisions to take residents off certain rotations, such as transplant nephrology, in favor of less esoteric rotations.
Hospitalists to the Rescue?
The question remains whether the reduced duty hours are better from the patient’s point of view. “The number of sign-outs that we’re seeing due to the duty hour decreases is significant. Interns will sign out approximately 300 times in a month, which is more than the number of patients they’ll see in the course of a year and, in fact, more often than they will eat in a month,” says Dr. Vidyarthi. “So, the challenge for the safety of patients [one of the impetuses for the decreased duty hours] is being balanced against having better rested, potentially better educated, happier residents. It’s really a Faustian bargain. Are we making this bargain [for better-rested residents] such that patients will, in fact, not be safer, because of the sign outs?”