Work Hour Restrictions – A Painful Gift to Medicine

When I completed my overnight shift and left the Medical ICU the morning of July 1, I raised my arms victoriously. I uttered, “Finally, internship is done!” I may have been one of the last to speak such words.

As of July 1, 2011, intern year forever changed. In the world of medicine the first year of residency, or intern year, is when doctors earn their stripes. Traditionally it is the most demanding year in a decade-long quest to become a practicing physician. But this year, the Accreditation Council of Graduate Medical Education (ACGME) mandated that interns can no longer work more than 16 hours straight, and must have 10 hours off between shifts. Second- and third-year residents can still work 28-hour shifts, but no more 30-hour shifts for interns.

To the outsider, this may seem like a common sense change that would only improve patient safety.  Within the medical field, however, this change is arguably the most controversial in the history of medical education.

Advocates believe these duty-hour modifications will decrease medical errors and improve unacceptable working conditions for residents. ACGME officials still believe that residents should be able to handle the vigorous hours and workload, but believe launching the least experienced physicians — new interns — into those demanding conditions just days after medical school is inappropriate and unsafe. As well, the general public generally favors the new changes.

Physician opinions are split, with many prominent quality and safety advocates such as Harvard’s Dr. Lucian Leape stating that the rules don’t go far enough.  Most physicians I’ve spoken with, however, express concern over the changes.

At the heart of the argument from a patient safety perspective is this fundamental question: Will the number of errors created by handoff of patient care be greater than the number of errors caused by fatigue? I generally don’t guarantee outcomes the way NFL legend Joe Namath does, but I can virtually guarantee that in the long run we will see fewer errors caused by handoffs compared with those currently caused by fatigue.

Quite simply, the answer rests in potential for improvement. Physicians working 24-hour shifts make 36% more serious medical errors and five times as many serious diagnostic errors than those limited to 16-hour shifts. No matter how much technology improves or how smart we become, we have few tools capable of decreasing the number of medical errors from fatigue. More caffeine? Not the greatest solution. In the absence of providing more rest, the fatigue error rate is fixed. In fact, I would argue that the older we get, the more difficult it is to put our bodies through what we did in the past – I doubt I could work the 60 hours straight in the computer lab as I did once as a software developer a decade ago. There is, however, enormous potential to decrease errors from physician handoff.

Our present handoff procedures are primitive. ‘Signout’ is when a physician transfers patient care to another physician in the hospital. Sometimes signout is detailed, but at times a doctor’s signout resembles “46 y/o female with pancreatitis, resolved now. Nothing to do (NTD).” Yes, probably NTD, but if there was truly NTD the patient wouldn’t be in the hospital. We can make basic changes such as emphasizing sign out as a critical cultural practice (some organizations don’t even have a written sign out), eliminating third-party sign out (which ends up like the telephone game), minimizing interruptions, and signing out in order of acuity.

At a more advanced level, we can learn from the field of Knowledge Management & Sharing, which is dedicated to improving information sharing processes. Organizations at the cutting edge of this field are light years ahead of how we exchange information in medicine. With the explosion of mobile computing devices and increased speed of networked technology, sharing will become even more sophisticated and faster. In the future, I foresee patient handoffs incorporating multimedia and video, and specific data will be spontaneously populated to sign out systems based on work completed through the day. Imagine listening to a patient’s lungs and having a significant expiratory wheeze automatically captured so the sound is retrievable in a split second from the signout if needed.

I envision medicine embracing the field of operations to tackle the problem. Sophisticated signout algorithms designed to decrease handoff error rates will be developed, analogous to how ‘queuing theory’ determines the optimal number of lines and workers, for example, to decrease wait times in virtually any service organization. One day, we’ll see handoff of patient care not as a source for error, but instead as another bright mind capable of improving the patient’s outcome.

I admit that implementing the new ACGME rules is a logistical nightmare in the short term. Imagine if a quarter of your employees had their work day cut in half? This is analogous to what it feels like in the medical field now. Also, critics raise legitimate concerns about resident training and costs. For instance, rules such as 10 hours off between shifts make it challenging to absorb all the critical learning taking place during the first 24 hours of a patient’s admission. I believe our system would benefit from having that minimum time between shifts decreased to perhaps 7 hours – on occasion. Most of us in medicine have had to work and study hard to get here, so having less sleep one night every few days (I’m not advocating for 30 hours straight) wouldn’t be a hardship.

Truth is, our field invited these restrictions by not realizing change was inevitable. I knew change was in order 10 years ago when my brother narrowly missed a fatal outcome after briefly falling asleep driving on the FDR Highway in New York City after a long shift as a surgical resident. Even Abraham Flexner, who shaped medical education with the Flexner Report in 1910, said we must adapt to changing scientific, social, and economic circumstances in order to flourish from generation to the next. We have failed to do this, as our training has remained static. While things may get worse before they get better, the new ACGME rules have forced us to change and step out of an archaic cultural practice. The details of medical education and costs are complex (suitable for another discussion), but speaking as a former computer programmer there are thousands of permutations and algorithms that could be developed to create a robust system that will satisfy resident training, patient safety, and cost.

The rules seem painful now, but this is a gift. Physician fatigue error is just a slice in a system with many processes needing improvement. The new rules have forced hundreds of hospitals and residency programs to think creatively, which as a by-product will provide the impetus to improve patient safety processes unrelated to work hours.  I urge my physician colleagues frustrated with the changes to understand that all change navigates a rocky road initially and that resisting will just extend time on that road. Be open and embrace it. A fertile ground has been laid, and with time the seeds will sprout innovative solutions. With all the intelligent minds we have in medicine, we will create an ideal system. I guarantee it.

Vipan Nikore, MD, MBA, is an Internal Medicine Resident Physician at the Cleveland Clinic. He received an MBA from the Yale School of Management, an MD degree from the University of Illinois-Chicago, and a BS in computer science and software engineering from the University of Western Ontario. He has led projects at IBM, Sun Microsystems, Citibank, UNICEF in India, the WHO in Geneva, UCLA, and the Ontario Ministry of Health. He is the President and Founder of the youth leadership non-profit Urban Future Leaders of the World (uFLOW). His posts are personal views and do not necessarily reflect the opinions or positions of the Cleveland Clinic.

2 replies »

  1. As an IT Director at a medical clinic, I find it funny and sad that the medical field still can’t figure out simple metrics when google can already track the progress of flu over the whole Us.

  2. Unfortunately a significant ‘gap’ still exists between training hour limitations and what occurs for the remainder of the physician’s career in real-life practice (ie no work hour limitations). The appropriate evaluation metric (that has not been investigated) is whether limiting work hours during residency translates to altered outcomes and safety after training is completed.

    Practicing in a large community-based hospital, there simply is not enough manpower (compensation) to support full-time rotating teams for hand-offs. While it is true that newer paradigms (surgical hospitalists/shift work) indirectly address this, they are still in their infancy.

    I certainly support appropriate work-hour limitations, and am a proponent of these measures to improve safety, but to those of you in-training preparing to transition to a private-practice, be ready for a harsh slap-in-the-face.