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The junior doctors should get adequate time off
Submit responseAlthough this is a very important step in improving patient care and in educating the junior doctors and interns, yet there are certain factors that should be kept in mind, in order for it to be useful to the community.
The junior doctors should get adequate time off ... else they wont be performing optimally.
The seniors responsible for this activity should be visionaries with a positive outlook and not someone sent just to find faults. The latter could further be detrimental to the system.
It should be a learning process for both the senior and the junior doctor and not just one way.
Conflict of Interest:
None declared
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In response to Dr. Rifkin:
Submit responseWe very much appreciate Dr. Rifkin’s first-hand reactions to our study. As this was a retrospective, observational study, we could not draw any firm conclusions about causality. Nonetheless, we fully agree with Dr. Rifkin that numerous factors likely played a role in the outcomes we observed, including increased supervision by senior residents, fellows and attendings.
The fact that the program schedule was revamped after the study period is particularly interesting in light of the fact that we were unable to detect any evidence of harm to patients. This illustrates the importance of confirming (or challenging) conventional wisdom with carefully-conducted studies.
In constructing schedules, program directors must balance numerous competing demands, including patient care, education and resident well- being. Our study and conclusions were designed to provide evidence only about the effect of work-hour regulation on patient care. We agree with Dr. Rifkin that further study of all aspects of work-hour regulation – using different approaches to regulation, at several sites, and over long periods – is essential.
Conflict of Interest:
None declared
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Attending Faculty Members are Doing More with Restricted Resident Work Hours
Submit responseLeona Horwitz, et al, noted that after the implementation of work hour regulations quality outcome parameters improved in the teaching services. The authors also indicated that they did not find evidence of adverse, unintended consequences after the institution of work hour regulations.
Since the improvement of patient care is the driving force for restricting resident work hours, this publication gives credence to implementation of work regulations by ACGME (2). However, the study did not provide any evidence that the well rested and rejuvenated house officers’ activity is responsible for these improvements. The nature of the variables studied limits other possibilities, such as the expanded work of the faculty and attending physicians to fill the gaps and provide the continuity provided by the residents. Clearly reduction of medical errors, reduction of rate of intensive care unit utilization and improvement in the rate of discharges to home and rehabilitation facility may be surrogate factors for active involvement of senior faculty with less resident coverage as these are issues not fully appreciated by young inexperienced house staff. The restricted work hours for house staff has therefore entailed increased working hours for attending physicians on weekdays and weekends. A casual observation suggested that the ratio of house staff to attending physicians’ presence in the wards had decreased significantly in the evening and weekends. This may be the unintended consequence of restricted work hours for the house officers, which was not measured because of the retrospective nature of the study.
The impact of possible consequent extended hours by senior faculty members is yet to be studied extensively. As this process evolves, it may be that restricted work hours should be extended to all physicians. Patients will and should benefit from well rested house officers and their supervisors alike.
1. Horwitz LI, Kosiborod M, Lin Z, Krumholz HM. Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations. Annals of Internal Medicine 2007; 147:97-103.
2. Statement of Justification/Impact for the Final Approval of Common Standards Related to Resident Duty Hours, Chicago: Accreditation Council for Graduate Medical Education; September 2002. Accessed at www.ACGME.org/ACwebsite/dutyhours/dhstatement.
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Response to: Horwitz et al. Ann Intern Med 2007; 147: 97-103
Submit responseAs a member of the Yale-New Haven Hospital internal medicine housestaff during the time period of the study by Horwitz et al, I read the report with great interest. I would add some comments and caveats to the conclusions.
First, the transition to the ‘nocturnalist’ system was indeed, as suggested in the authors’ discussion, supported by tremendous increases in involvement and quality monitoring on the part of administration, chief residents, attendings, and senior residents. Without this level of internal dedication I doubt the system would have met the benchmarks it did.
Second, the junior and senior residents in internal medicine during the 2003-4 year had all completed a ‘traditional’ internship involving overnight call. This study thus cannot address how housestaff would perform if no individual on the team had ever experienced overnight call duty. Furthermore, on average more of the daily work that year was shifted to the junior and senior residents than had been the norm previously, so the effects seen may be those of increased experience.
Third, and most importantly, the authors do not make note of the fact that the nocturnalist system was discarded at the end of that academic year, with a return to overnight call for residents. Both faculty and housestaff were dissatisfied with the lack of continuity at night and felt that from an educational standpoint this system was inferior. The work- hours regulations were subsequently met with the addition of day float teams.
I believe that for these reasons the conclusions drawn from this study are premature. More study is needed particularly to assess whether the dual goals of care and education are being met by various approaches to the work-hours regulations.
Dena E. Rifkin, MD Tufts-New England Medical Center
Conflict of Interest:
None declared