Do resident work hours limits create better physicians?

On a few previous occasions (e.g., Student Debt, Resident Hours, and Primary Care Redux, Jan 2, 2009) I have written about the issue of medical residents’ work hours and the implications that it had, good or bad, for patient care. A recent article in the British Medical Journal (BMJ) by Moonesinghe et al, “Impact of reduction in working hours for doctors in training on postgraduate medical education and patient outcomes: systematic review”, provides the most thorough review to date of studies evaluating the impact of work hours reductions for medical residents in the US and the United Kingdom, where they are even more stringent. They looked at studies examining both “training” (how are the residents learning?) and patient quality and safety.

This was not an easy task; true “meta-analysis” (grouping all the studies together as if they were one and re-analyzing the data) was not possible because they were so different in methodology, issues studied, and quality. In fact, the quality of most of the studies was not terribly high, and they often looked at several different outcomes making it hard to understand whether the changes all went one way, or there were some things that were better and some worse and whether the net result could be stronger (or weaker) if we could focus on only one at a time.

The good news for those who have implemented, supported, and argued for the work hours restrictions is that they seem to have improved the private life of residents, and to have not significantly harmed either the quality of training or patient care, at least insofar as these somewhat contradictory studies seem to indicate. Most of the studies were done in the US, and most were of surgical (28 of 41) or “hospital-based” (e.g., anesthesiology, critical care) trainees, rather than primary care.

Here are some of the results:

Training outcomes:

·    2 papers (both of “low methodological quality”, one of medical residents in the UK and one of surgical residents in the US, which “did not report statistical analyses of the results”) reported an improvement in training outcomes.

·   12 studies found a detrimental association; half from the US (all surgical) and half from the UK.

·    27 studies found no change (20 US and 7 UK)

·    There were also mixed results regarding the quality of “training opportunities” (exam scores, caseload)

Patient outcomes:

·    31 of 34 papers were US

·    4 studies showed improved patient outcomes, including the only randomized controlled trial in the group (note: this was in critical care and coronary care units, where shift work may arguably be more effective)

·    2 studies (in trauma and orthopedics) found increased complications

·    28 studies showed no significant difference

Surgeon and NY Times writer Pauline Chen commented on this article in “Is a well-rested doctor a better doctor?”, April 7, 2011. She describes talking with a surgical resident she knows who is very pleased at how much better her life is than she had feared. “’Training has changed a lot…My life is different than yours was — I have a lot of time outside the hospital.’ She described how she loved her work but was able to sleep at home most nights, go out regularly with friends, stay involved with her church and take an improv class.”  Cool. It is good to know that surgical residents are not acting as slaves, and can have some kind of life outside the hospital.

However, her resident friend was less sure about learning and patient care: “’To be honest, I don’t really know if this is better or worse,’ she said, recounting how she felt she was signing over responsibility for her patients more often than she ever imagined she would, missing key events in their hospital course and even getting dismissed during the middle of a patient’s operation in order to stay within the limits on work hours. ‘Sometimes it seems so counterintuitive to just sign out as if we were shift workers, but this is all any of us know right now…We have nothing to compare it to.’”

So, probably, as Dr. Chen observes, the discussion will go on. Those who believe that working longer hours results in tired physicians and therefore bad patient outcomes will continue to push those ideas; those who (largely, it seems, surgeons) believe that artificial limits on work hours compromise resident learning, thus not only having a negative impact on their current care of patients but, more importantly, their care of patients in the future care because they haven’t had sufficient experience in their residencies. One “side” says “Do you want to be operated on by a surgeon who has been up all night?”, while the other says “Do you want to be operated by a surgeon who is not as skilled because they were coddled in their training and didn’t get sufficient experience?”

“The most important test of success of postgraduate training,” say Moonesinghe and colleagues, “is the professional performance of those who reach the end of it.” They go on to make several suggestions, including, most importantly I believe, that “a consensus should be reached by the medical profession on appropriate measures to assess the quality of postgraduate medical training.” They agree with the assertion (from Temple, et al, “Time for training. A review of the impact of the European Working Time Directive on training 2010”) that “training is patient safety for the next 30 years”. Wise regulation must understand the balance, the risk-benefit of any change, and try to reach the greatest benefit with the least risk.

I would like to comment a bit upon the issues as they relate, in particular, to primary care training. Most of the studies that have been done have been on surgical specialties, which can measure surgical complications, deaths or morbidity, or in anesthesiology or critical care, because these are hospital based and more amenable to shift work. While a very few of the studies were in pediatrics, they also examined hospital work; none were looking at the training of primary care or family doctors. One of the other reasons that the surgical specialties have been so studied is that they have long been those with the longest work hours; thus, they are both the greatest target of reformers and the greatest resistance by current surgeons and teachers who fear that work hours restrictions will jeopardize the skill of their future colleagues.

The irony is that, as in so many areas, when laws or rules are being violated by one group, they are tightened on everyone, and those who were not violators of the old rules find their greater restrictions to comply with while, often, those who were violating it before continue to. In the 1970s when I was in training at Cook County Hospital, we had a resident union (yes!) and were limited to every-4^th-day overnight call. But the surgeons were on more often. If family medicine or internal medicine or pediatrics violated the rule, they were penalized, but the surgery residents were afraid to complain. And so, today, the violations of hours rules in some specialties increases the restrictions for all.

The problem with applying these rigid rules to primary care is that it is not shift-based. While residents spend time on inpatient services, the core of family medicine training is the continuity clinic where those doctors-in-training follow their own patients. It is important to be able to do this, to show up for your office hours to see your patients who are expecting to see you, even if you were up much of the night delivering the baby of one of your patients. If that happened every day, it would be a big problem, but it doesn’t. Yet there is a “zero tolerance” for work hour violations by the Accreditation Council for Graduate Medical Education (ACGME), so the program would be cited. Rigid cut-offs, indiscriminately applied, are a bad idea.

Residents should have work hour restrictions; they shouldn’t be on call every third night and up all night. They should get days off, should get time to spend with friends and family or sleeping. But the restrictions need to regulate hours in a more global fashion: hours in a week, days off in a week, average or typical number of hours off between shifts. They should not be counting minutes (and they currently do!), not create automatic violations for each instance in which, say, a resident returns to clinic after only 9 ½  instead of 10 hours off. They also should be specialty-specific, examining the character of the specialty’s practice, not to allow exploitation but to make them appropriate to how the specialty is practiced.

Some fields, like ER and critical care, work well with shifts. Some, like most hospital work that characterizes internal medicine and pediatrics training, generally work pretty well with “night floats” and days off, as long as there is careful attention paid to information transfer at the shift changes (“hand-offs”). Surgery may require longer shifts with more days off. And family medicine needs to allow residents to occasionally deliver their babies at night without canceling all the patients on their schedule the next day, as long as it is not the everyday norm.

We can do this rationally. We can have training that both provides time for the non-work lives of residents and good training for their careers; that ensures quality care of their patients now and in the future.

Primary Care’s Image: A Problem?

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Pauline Chen, a transplant surgeon and respected author of “Final Exam: A surgeon’s reflections on mortality” (Vintage Books) also write a “Doctor and Patient” column for the New York Times. On November 12, 2009, the topic was “Primary Care’s Image Problem”, in which she talks about the decreasing interest in primary care among medical students, and the perception among many, increased by many faculty members, that primary care was a backup to more “prestigious subspecialties…like dermatology, orthopedics, plastic surgery or radiology.” In particular, she talks of Kerry, one of her classmates, who wanted to (and did) enter primary care “despite” being at the top of her class, and how this amazed her friends. Dr. Chen addresses the attractions of the “ROAD” (radiology, ophthalmology, anesthesiology, and dermatology) to financial success as well as greater prestige, and the challenges it presents for having an adequate supply of primary care physicians.

While scarcely optimistic (“But even with current legislative efforts to address educational debt, payment discrepancies and lifestyle differences, many medical educators worry that the results will not be enough….Why? It is due to an issue deeper than money and paperwork. While the frisson of continually advancing treatments and approaches to patient care seem to envelope most other specialties, the image of primary care remains one of a vaguely anachronistic practice — a group of doctors who do not stand on the forefront of creative change and who are continually left holding the biggest bag of administrative expectations and clinical care coordination and demands.”), she also notes that “That image, however, may be changing”.

Dr. Chen attended a meeting of the Association of Deans and Directors for Primary Care, held in conjunction with the annual meeting of the Association of American Medical Colleges (AAMC) in Boston on November 9, 2009, where the discussion focused largely on changes in the type of practice, particularly in the creation of a “medical home” and a team approach to care. She quotes organization chair Bruce Gould, MD, of the University of Connecticut: “In a patient-centered medical home, I would not be the sole proprietor. Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader….With a team approach each of us is freed up to practice at the top of our scope of training. And that leads to better patient outcomes and more job satisfaction.”

I admit that I found it somewhat frustrating, having been in the room, that the 3 physicians Dr. Chen quotes are all general internists, despite the fact that at least half the participants in the meeting and 2 of the 5 speakers were family doctors. I agree with the general theme expressed by many that it is important for primary care doctors to work together and not fight, but there are important differences in these specialties. In addition to the fact that family doctors care for adults and children and often pregnant women, the breadth of their practice makes them more suitable for rural practice, where there may be only a few doctors. While most family doctors do not practice in rural areas, about 20% do, which is comparable to the percent of the overall population; indeed, family medicine is the only specialty that “distributes” according to where people live.

More important for this discussion is that virtually all family physicians practice primary care, thus it is the primary care “bellwether”, going up more when student interest in primary care is up, and down more when it is down. Internal medicine, on the other hand, offers those who complete its 3-year residency the option of entering primary care / general internal medicine practice (or hospitalist practice, which is not primary care) or continuing into a subspecialty fellowship (cardiology, gastroenterology, pulmonary medicine, etc.); it is thus less sensitive to these ups and downs. As I have discussed previously (most recently in “Rankings of medical schools: do they tell us anything?” on September 25, 2009), the trend for general internal medicine is definitely down. General pediatrics, the third primary care specialty, has not seen a decrease, although the distribution and career trajectories are an issue, as I have discussed in “Primary care, pediatrics, and physician distribution” on May 21, 2009. Indeed, facing a shortage of pediatric subspecialists, many pediatrics groups are trying to encourage subspecialization.

Dr. Chen’s article ended with some guarded optimism, and an invitation to join the discussion on Tara Parker-Pope’s “Well blog”, “Giving primary care more respect”. With 180 responses (by November 16), it is clear that there are a lot of opinions out there, from physicians, medical students, other health professionals, and the general public. I admit to adding my comments, and “plugging” my October 8, 2009 blog piece “`Uncomplicated’ Primary Care?”, where I argue that primary care is anything but uncomplicated.

I thought that some comments on this from medical students on this issue might be welcome. The following comments are from students who spent 6 weeks with rural family physicians in Kansas between their first and second years of medical school, from quotes they gave to a reporter from the Kansas Family Physician, publication of the Kansas Academy of Family Physicians:

“This summer, I learned that people don’t choose family medicine because they want an easy profession. They choose it because they want to be life-long learners and truly want to help the community. Their knowledge base and diagnostic ability is no less than any specialist. The only difference they think ‘big picture’, and don’t focus on any one organ system.”

“A young man in his mid-30s came into the clinic. He was a partial quadriplegic of 15 years from a car accident. He was not there complaining of any acute symptoms or any problems; he was just there because he wanted to find a new doctor…Out of curiosity, I asked him what he was looking for in a physician. His only reply was: ‘I want someone who cares about me, not for me.’”

“I could not help but be impressed with the enormity of information family physicians are expected to ideally know. We are talking about working with every organ system of the body and also understanding the procedures and diagnostic tests that go along with these systems.”

“I learned family medicine is not simply caring for patients with chronic health issues or diagnosing and treating the common cold. While family physicians do both of those things almost every day, they also provide a variety of other care. They can deliver babies, provide women’s health, perform EGDs and colonoscopies, manage chronic pain, and diagnose extraordinarily well in the acute setting, just to list a small amount of what they do weekly.”

“Nothing compared to the feeling I got watching a family physician take care of the mother during delivery, perform an emergency C-section, and then treat the infant all within the same day. The ability of a family doctor to care for both mother and child simultaneously made me truly appreciate the rich complexity of family medicine.”

“A family physician should be held in the highest regard among physicians, for he or she must have the patience of a geriatrician, the gentleness of a pediatrician, the courage of an ER physician, the steady hand of a surgeon, and a knowledge base of every medical specialty.”

There are more, and many of them – which maybe I’ll post later – specifically talk to the role of the rural family doctor. Remember, these are not a random sample of students; they elected to do this experience. Many of them are from rural backgrounds and many are also planning careers in family medicine. All of them, having just finished their first year of medical school, have a long way to go before deciding on their specialty, and undoubtedly some will take some variant of the “ROAD”. We know from recent research that empathy takes a nose dive in the third year of medical school (“Are we training physicians to be empathic? Apparently not”, Sept 12, 2009).

However, it is great to hear these attitudes and know that at least among some students family medicine and primary care do not have an “image problem.” We can only hope that it persists in them, and in their peers. Hope, and do everything we can to foster it.
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