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With the recent publication of the results of the FIRST (Flexibility in Duty Hour Requirements for Surgical Trainees) trial, residency duty hours are again in the news.
Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Ryan Gamlin, a former health care management consultant and current medical student at the University of Cincinnati. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.
Ryan GamlinWith the recent publication of the results of the FIRST (Flexibility in Duty Hour Requirements for Surgical Trainees) trial, residency duty hours are again in the news.
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FIRST’s outcomes have been well covered elsewhere, but here’s the takeaway: it doesn’t seem to matter how a program chooses to manage the current 80-hour-per-week cap on hours worked. From the New England Journal of Medicine abstract:
“…flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied.”
Yes, the FIRST trial was important (ditto iCOMPARE). Yes, it strongly suggests that programs should have the freedom to design a training program that meets their goals and those of their trainees. But I’m surprised by what FIRST didn’t do: prompt a broader conversation about other big issues facing the residency-training environment in the United States.
The Accreditation Council for Graduate Medical Education (ACGME) first restricted resident service in 2003, with further revision in 2011, creating an average limit of 80 hours per week. Interns are capped at 16 continuous duty hours, and senior residents at 24 continuous duty hours (each with an additional 6-hour allowance for continuity of care and or education).
The net effect of these changes was to decrease average hours worked by trainees, if only modestly. Largely a response to public opinion and the incipient realization that sleep-deprivation was a contributor to medical error and associated increases in? patient morbidity and mortality, the ACGME’s changes failed to incorporate recommendations from the Institute of Medicine that built on the best science of sleep, cognition, and error-prevention.
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I personally know many doctors who trained under years of q2 long call, a system that meant shifts of 36 or more hours, totaling more than one hundred hours per week in the hospital, for months at a time.
These kinds of arrangements were the modern embodiment of the phrase “house staff” – literally those who lived in the hospital. Some of these same doctors believe that the longer hours trained them by fostering ownership of their patients, and that the opportunity to provide continuity was a learning experience unto itself. The same physicians and surgeons who endured these schedules often add, however, that they trained during “simpler times.”
While their overnight call was certainly brutal at times, many have told me that they see a dramatic increase in the acuity and volume of work expected of a resident during a long call, meaning that the total hours worked may now be fewer, but the work per hour has likely increased.
Next: Is 80 hours per week the right limit in the first place?
At the same time, we must be wary of the unintended consequences associated with changes to residents’ schedules, even when they are made shorter. With each change of shift comes a “handoff” – the transfer of patient care from one team or provider to the next. Handoffs are well studied and known to be dangerous.
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These competing interests – resident wellbeing, associated implications for patient safety, and the need for adequate resident physician training – must be balanced against each other, but like too many things in medicine, the illusion of certainty may serve to stand in the way of progress.
In the wake of the FIRST trial, I’d like to pose three questions to prompt further debate:
All experimentation in the current training state is iterative-it accepts the premise that 80 hours is the correct duty limit. To date, no systematic experiment has been performed comparing an 80-hour duty limit with one substantially shorter on measures of patient safety, resident education, or resident health and wellbeing.
In contrast, training in a country with comparable healthcare delivery standards – the United Kingdom – looks far different than in the United States. The European Working Time Directive imposes a statutory limit of 48 work hours per week for medical residents, though specialty training is of a much longer total duration in the United Kingdom than in the United States.
Next: Should residency-training programs even be of a fixed duration?
Ironically, however, new residents themselves may not want a decrease in duty hours and its accompanying increase in total training duration.
With average medical student debt now at roughly $200,000 (and for students at private schools, often much more), plus any debt from undergraduate or other graduate programs, students now have a perverse incentive to desire shorter, more intense, residency training so that they can complete training and begin paying their debt down.
Competency-based residency training is an idea gaining traction among some in graduate medical education. In a competency-based program, training would last until the resident demonstrated the knowledge, skills, and attributes of a graduating trainee, rather than for a proscribed number of years.
Indeed, in some specialties, the current number of training years may already be insufficient. For a variety of reasons, attendings are increasingly reluctant to grant full autonomy to residents. Residents are, as a result, graduating less prepared for independent practice beyond their training.
This tradeoff is most clearly demonstrated by the advent of surgical “transition to practice” fellowships – an extra year of postgraduate training designed to impart the skills and judgment in fellowship that residents previously got during residency.
Noble and logical, this model has obvious challenges in its implementation. Notably:
1) Hospitals would have to accept variable staffing level throughout the year, as residents all begin in July, but would leave during various months.
2) Training programs would be incentivized (in some ways) to retain trainees beyond the current duration of training, as they provide a net economic benefit.
Next: Who benefits from the current training model?
Residents provide a net economic benefit to the hospitals that employ them. Like any fixed cost, incentives exist for hospitals to wring as much productivity as possible from each resident (balanced, of course against the risk of medical harm that over-work may promote).
While few in any profession would choose to forgo sleep and to put their lives on hold for years as they complete their training, medicine remains unique in its ability to attract the brightest and most driven candidates to the field, and most importantly in the commitment that its practitioners make to the public at large.
For both to remain true, we must continue to explore issues at the intersection of safety, quality, trainee health and well being, and workforce needs of the care delivery system itself, to create the best-performing medical training system in the world.