Path to an uncharted destination

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

I hate to keep harping on the resident work-hour regulations, but the results of two huge studies, which document no significant improvement in patient mortality rates, brings them back into sharp focus. Let's spend a moment reviewing the history of these regulations and then discuss their future in light of this new information.

The process to limit residents' work hours began in 1986 with 18-year-old Libby Zion's death at New York Hospital under circumstances that are still the subject of much controversy. The report from a criminal grand jury seated in the case and a commission of the New York State Health Department, chaired by D r. Burton Bell, resulted in New York's 1989 decision to implement an 80-hour work-week restriction for residents. I was amazed, because had these regulations been in place at the time of Ms. Zion's death, they would have had absolutely no impact on her care. There has never been one shred of evidence that any of the involved physicians were overtired or overstressed. The revised New York regulations included specific requirements for trainee supervision, and this made a lot of sense. At the time, I predicted that the fever to limit residents' work hours would dissipate but the supervisory requirements would incite national fervor. Boy, was I wrong!

The Accreditation Council for Graduate Medical Education, citing specific needs to lessen the frequency of clinical errors and improve patient survival rates, adopted New York's 80-hour work-week regulations in 2003 for trainees in all residency programs. After some debate, which proved futile, and following a brief implementation period, the regulations went into effect and today are being vigorously enforced.

Journal of the American Medical Association

Since 2003, a number of studies have attempted to assess whether the regulations have succeeded in improving health care, their avowed objective. So far, results have been mixed, with some reports noting improvement and many more describing no change. The two recent articles in the carry major weight owing to the huge size of their respective study populations: 8,529,595 Medicare patients admitted to 3,321 acute care general hospitals in the first¹ and 316,636 patients admitted to 131 acute care Veterans Administration hospitals in the companion study.² Both investigations compared data from before and after 2003, as well as more-intensive versus less-intensive teaching hospitals. Mortality rates were adjusted based on hospital location, patient co-morbidities, and common time trends in care. The lack of substantive improvement in mortality rates for patients with myocardial infarction, congestive heart failure, stroke, gastrointestinal bleeding, and those undergoing a host of general, vascular, and orthopedic surgical procedures is both concerning and noteworthy. It certainly suggests that limiting trainee work hours has not been a panacea for hospital ills.

Clearly, the work-hour regulations have had a positive effect on residents' lifestyles. This is long overdue and vital to our success in recruiting the best and brightest into surgery. On the other hand, the regulations have markedly increased the cost of health care by demanding an extraordinary amount of expensive and useless documentation and requiring facilities to recruit and hire additional high-earning physician extenders. Other negative results include a major disruption in the continuity of patient care and the development of an inappropriate shift-work mentality among residents. Medical professionalism has undoubtedly suffered.

Despite some positive outcomes, on balance, I consider the regulation of work hours to have been an expensive, failed experiment. In science, a failed experiment generally prompts the development of new and more thoughtful hypotheses. Rarely are the new hypotheses retrogressive, which I fear may be the future for work-hour regulations. If you think the work-hour regulations constitute a problem now, just wait: the worst is yet to come!

JAMA

One possibility being entertained is further shortening work-hour limits per week. This has been the trend in many European countries, with painful consequences for trainees and training programs. A widely cited article by Barger and colleagues suggests that the current conditions still facilitate medical errors and put patients at risk.³ As scientists who study sleep, the authors urge shortening residents' shifts further and reducing the hours they work each week even more. An editorial accompanying the two recent articles that I mentioned stops short of recommending further reductions in trainee work hours per week, but it does advocate conducting randomized trials with "varying limits of duty hours" to determine the best clinical and educational environment.⁴ I predict that if studies based on 60- and 70-hour work weeks fail to eliminate clinical errors or markedly decrease patient mortality rates (a likely result), the next recommended studies will involve decreasing the work week to 50 and then 40 hours. Someday, we may reach the apex of care, reducing clinical errors and patient mortality rates to zero by restricting trainees from providing any medical care and instead giving them complete freedom to learn from books and the Internet, at home, on their own timetables.

Another approach, which one British group has proposed, is limiting the work hours of attendings as well.⁵ Even though the authors acknowledge the disadvantages of disrupting the continuity of patient care and inhibiting the intimacy of the doctor/patient relationship, they propose imposing work-hour limitations according to the principles used to restrict truck drivers and airline pilots. The number of permitted hours would be established based on the results of objective studies that feature quantitative performance measures, such as "global rating scales, dexterity analysis systems, and virtual reality simulators." While it would be hard to argue against good data, if they can be generated, I maintain that patients are neither trucks nor airplanes, and surgeons are neither truck drivers nor airline pilots.

path to an uncharted destination

I am afraid we have started down a that eliminates individual and situational flexibility, treats patients as statistics, and skimps on the training of future generations of surgeons. At least Hansel and Gretel left bread crumbs to facilitate finding their way back home. We are not even doing that. Despite modern computers, sophisticated statistical analyses, and multiple time trials, we run the risk of obliterating any trail back to the days of exquisite training and continuity of patient care.

REFERENCES

1. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298(9):984-992.
2. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298(9):975-983.
3. Barger LK, Ayas NT, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med. 2006;3(12):e487.
4. Meltzer DO, Arora VM. Evaluating resident duty hour reforms: more work to do. JAMA. 2007;298(9):1055-1057.
5. Leff D, Aziz O, Darzi A. Trucks, planes, and scalpels: is there an evidence-based approach to surgeons' working hours? Arch Surg. 2007;142(9):817-820.