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Comments from the Source
Ripples from Resident Work Hour Changes
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Bertrand M. Bell, M.D. Albert Eindtein College of Medicine, none
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bbell{at}aecom.yu.edu Bertrand M. Bell, et al.
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After the tragic death of Libby Zion in 1984, the District Attorney of New York County called the Forth Grand Jury into session to investigate the possibility of returning a murder indictment in the death of Libby Zion. Instead of murder, the Grand Jury indicted Graduate Medical Education. They ruled that "There was insufficent evidence to return an indictment...{nevertheless they were} concerned that the underlying causes of the medical deficent care and treatment in this case might be prevalent in other Level One (University) Hospitals... The most serious deficiencies can be traced to the practice of permiting physicians to staff emergency rooms and allowing interns and junior residents to practice medicine without supervison etc... In addition, we recognize that the number of hours interns and residents are required to work is counterproductive to providing quality medical care.This practice may be cost effective for hospital budgets, but its corresponding cost is a diminished quality of health care.To care properly for patients and to continue the learning process, physicians must be in full command of their mental faculties. It is for this reason that the grand jury proposes "regulations be promulgated to limit consecutive hours of interns and residents..." The recent studies and all the commentaries do not seem to realize that as it was obvioius to the Grand Jury and to the Bell Commision that inadequate supervision of residents(this issue is still unadressed) and the prevention of sleep deprivation and chronic fatigue are deleterious to the care of patients. It is time to end the palaver! |
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Eric H. Stern, MD Mount Sinai School of Medicine; New York, NY 10029
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eric.stern{at}mssm.edu Eric H. Stern
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The Systematic Review on resident work hours and patient safety (1) comes only a few weeks after the publication of a prospective study of medical interns in the critical care setting. Those two articles (2,3) and an accompanying editorial (4) provide some hard data that was not available for the Systematic Review. As a program director (cardiology), I find the prospective study results compelling but I believe they raise fiscal, educational and 'systems' considerations. Assuming a constant patient load, reducing intern work hours means increasing the number of interns or finding alternate methods to care for these patients. For teaching hospitals, federal funding formulae should change to accommodate this new reality. As intern work experience decreases, medical educators must reassess whether there is sufficient training in the time presently allotted. This might entail changing some training methods and/or increasing the duration of training. Alternative methods may not be able to adequately compensate for the reduced number of patients and procedures. Longer training would have profound effects on the cost of post-graduate medical education and, potentially, its attractiveness to future physicians (for financial and social reasons). The decrease in ‘judgment’ errors was heartening but the rather small decrement in other errors was disturbing, bespeaking a ‘systems’ problem. Nurses, pharmacists and other healthcare personnel must serve in intelligent roles (perhaps with electronic support), not merely as conduits for physician orders. The new study is the start of data acquisition the authors of the Systematic Review found sorely lacking. We need to plan our approach carefully as we accrue more information. References (1) Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF, Saint S. Systematic review: Effects of resident work hours on patient safety. Ann Intern Med. 2004;141:851-7 (2) Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351:1829-37. (3) Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838-48. (4) Drazen JM. Awake and informed. N Engl J Med. 2004;351:1884. Conflict of Interest:None declared |
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