Have duty hour restrictions reduce the quailty education during Internship?

[Staryy]

Have duty hour restrictions reduced the quality education during Internship?

I am especially curious to hear the opinions of those that were in Residency before and after the duty-hour restrictions were imposed.


The Effect of Reducing Maximum Shift Lengths to 16 Hours on Internal Medicine Interns' Educational Opportunities.
Theobald CN, Stover DG, Choma NN, Hathaway J, Green JK, Peterson NB, Sponsler KC, Vasilevskis EE, Kripalani S, Sergent J, Brown NJ, Denny JC.

Abstract

PURPOSE:
To evaluate educational experiences of internal medicine interns before and after maximum shift lengths were decreased from 30 hours to 16 hours.

METHOD:
The authors compared educational experiences of internal medicine interns at Vanderbilt University Medical Center before (2010; 47 interns) and after (2011; 50 interns) duty hours restrictions were implemented in July 2011. The authors compared number of inpatient encounters, breadth of concepts in notes, exposure to five common presenting problems, procedural experience, and attendance at teaching conferences.

RESULTS:
Following the duty hours restrictions, interns cared for more unique patients (mean 118 versus 140 patients per intern, P = .005) and wrote more history and physicals (mean 73 versus 88, P = .005). Documentation included more total concepts after the 16-hour maximum shift implementation, with a 14% increase for history and physicals (338 versus 387, P < .001) and a 10% increase for progress notes (316 versus 349, P < .001). There was no difference in the median number of selected procedures performed (6 versus 6, P = 0.94). Attendance was higher at the weekly chief resident conference (60% versus 68% of expected attendees, P < .001) but unchanged at morning report conferences (79% versus 78%, P = .49).

CONCLUSIONS:
Intern clinical exposure did not decrease after implementation of the 16-hour shift length restriction. In fact, interns saw more patients, produced more detailed notes, and attended more conferences following duty hours restrictions.

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[Noegrus]

You REALLY like research, don't you? What are you doing for residency?

 

[Staryy]

Internal Medicine

 

[DocEspana]

could you explain to me how anyone could answer this since duty hour restrictions apply only to interns (AFAIK). So either you had them or you didnt. No one saw it both ways.

I do like the posted study though.

 

[Staryy]

In response to your question...

Senior Residents, Fellows and Attendings can comment on the quality of Interns' work and board passing rates before and after the work hour restrictions.

Senior Residents can compare their performance (as Interns before work hour restrictions) to incoming Intern's .

 

[Buzz Me]

Wouldn't a better measure be interns' in-service exam scores or evaluations?

 

[Staryy]

Looking at in at Intern's in-service exam scores is a great idea Buzz Me.....I tried to find studies that assess in service exam scores before and after duty hour regulations and had no luck.

Are you aware of any studies that look at assess in service exam scores before and after duty hour regulations Buzz Me?

 

[Perrotfish]

Interesting study.

 

[Winged Scapula]

Looking at in at Intern's in-service exam scores is a great idea Buzz Me.....I tried to find studies that assess in service exam scores before and after duty hour regulations and had no luck.

Are you aware of any studies that look at assess in service exam scores before and after duty hour regulations Buzz Me?

I do recall some assessment of surgical residents in training exam scores before and after the change and there was no difference. It was postulated that residents did not use the extra hours to study but rather to wash their clothes sleep and spend time with family.

 

[VA Hopeful Dr]

could you explain to me how anyone could answer this since duty hour restrictions apply only to interns (AFAIK). So either you had them or you didnt. No one saw it both ways.

I do like the posted study though.

The first half of my intern year was 30 hour calls, during the 2nd half we went to the new rules to work out the big before required implementation.

 

[FutureInternist]

http://healthland.time.com/2013/03/26/fewer-hours-for-doctors-in-training-leading-to-more-mistakes/

 

[Perrotfish]

Nvm.

 

[Bostonredsox]

I think we should take 36 hour calls and work 120 hour weeks and cut the residency to 2 years. All this reduction in hours worked is weak sauce. There was a cme here where the geniuses at harvard were talking about going to 60 hour weeks. and the ABIMs answer is well extend all IM residencies to 5 years. f that. There is no hour restriction as an attending. Get used to long hours. In addition, the longer residency shifts and hours help one develop a true appreciation for their time off as an attending. You don't know what its like to have to make a medical decision or perform a procedure on no sleep, which you will have to do as an attending, unless you do it repetitively as a resident.

 

[FutureInternist]

IM is 3 years as is Peds, but if you do Med-Peds then its only 4 years which begs the question, if doing TWO specialties only needs 2/specialty, why is it that when you do nothing but IM, you need 3 years !!

 

[Buzz Me]

I think we should take 36 hour calls and work 120 hour weeks

That's what I'm doing right now.

Oh wait, you were being sarcastic.

 

[Staradmiral]

No way. Who wants to work more than 16hours straight? Must not have a life outside of the hospital....
Being a doctor means having a life too you know. You can't just measure your life with board scores. As supported by the study, more time to sleep and more time to spend with your family makes you a better doctor in the hospital.
Secondly another study showed that being awake for 24h is equivalent to having a blood alcohol level of 0.08 ( the legal limit). I would never let any doctor who has been working for 16h touch me.

 

[Dejavu]

No way. Who wants to work more than 16hours straight? Must not have a life outside of the hospital....
Being a doctor means having a life too you know. You can't just measure your life with board scores. As supported by the study, more time to sleep and more time to spend with your family makes you a better doctor in the hospital.
Secondly another study showed that being awake for 24h is equivalent to having a blood alcohol level of 0.08 ( the legal limit). I would never let any doctor who has been working for 16h touch me.

From an old guy who did an old-fashioned internship, the first part of this is heresy, Heresy I Say!

 

[ThoracicGuy]

So as an intern you only work 16 hours, but then as a PGY-2 you are responsible for almost 30 hours worth of work (24 hours + 6 hours post call). So what makes interns so special that they can't do it, but from June 30th to July 1st they suddenly can do it all!

I agree with the 80 hour rule. I had a year pre-80 hour and then the transition to 80 hours. It was much better afterwards. I don't agree with the 16 hour intern rule.

 

[ar2388]

i like the work hour restrictions. the time comes and i bounce home and no one can say anything about it. so basically im all for it! beign a doctor is not the only part of me.

 

[Staradmiral]

i like the work hour restrictions. the time comes and i bounce home and no one can say anything about it. so basically im all for it! beign a doctor is not the only part of me.

I'm with you dude!

 

[ophthope]

There is no hour restriction as an attending. Get used to long hours. In addition, the longer residency shifts and hours help one develop a true appreciation for their time off as an attending. You don't know what its like to have to make a medical decision or perform a procedure on no sleep, which you will have to do as an attending, unless you do it repetitively as a resident.

Spoken like a future academic internal medicine attending. I don't know if it was sarcastic or not, but people going into IM should take note of this attitude and prepare for it to be a common one that you encounter. There are of course plenty of IM docs who want a work-life balance but I have encountered them mostly outside of academic medicine. So glad I matched Ophtho!

 

[Buzz Me]

I remember the days when I logged 80 hours a week and only worked 100. I miss those days...

 

[ar2388]

i refuse to log in false hours. and i hope my program doesnt force me too. obviously, part of it is on me and how efficient i am in my work.

 

[sheldor1234]

i refuse to log in false hours. and i hope my program doesnt force me too. obviously, part of it is on me and how efficient i am in my work.

Would you refuse to log in less hours than you are scheduled to work?
This would occur in a scenario where is extremely efficient.

 

[ar2388]

Would you refuse to log in less hours than you are scheduled to work?
This would occur in a scenario where is extremely efficient.

i would log in the hours that i worked.

 

[dozitgetchahi]

I think we should take 36 hour calls and work 120 hour weeks and cut the residency to 2 years. All this reduction in hours worked is weak sauce. There was a cme here where the geniuses at harvard were talking about going to 60 hour weeks. and the ABIMs answer is well extend all IM residencies to 5 years. f that. There is no hour restriction as an attending. Get used to long hours. In addition, the longer residency shifts and hours help one develop a true appreciation for their time off as an attending. You don't know what its like to have to make a medical decision or perform a procedure on no sleep, which you will have to do as an attending, unless you do it repetitively as a resident.

So a hospitalist working 7 on/7 off is frequently making decisions and doing procedures on 'no sleep'?

 

[Bostonredsox]

So a hospitalist working 7 on/7 off is frequently making decisions and doing procedures on 'no sleep'?

Not frequently but yes it happens. My attending worked 7a-7p as ICU attending, he's also the hospitalist program director, the night guy called in, some emergency with his wife, no one else willing to pick up the night shift so my attending worked it and then was ICU attending the next morning 7a-7p again as scheduled. It happens. Shifts have to be covered.

 

[Perrotfish]

Not frequently but yes it happens. My attending worked 7a-7p as ICU attending, he's also the hospitalist program director, the night guy called in, some emergency with his wife, no one else willing to pick up the night shift so my attending worked it and then was ICU attending the next morning 7a-7p again as scheduled. It happens. Shifts have to be covered.

1) That group should have a backup call system.

2) That being said, no one cares about taking call once a year when someone is struck by lightning. Its the every third/fourth day nonsense that grinds people down.

I think we should take 36 hour calls and work 120 hour weeks and cut the residency to 2 years. All this reduction in hours worked is weak sauce

Do you really think residencies are the length they are because of some impartial scientific determination of exactly how much training we need? Have you ever seen anyone even seriously consider decreasing the length of any residency training in any field? No matter how many parts of our practice splinter off into their own subspecialties the length of training never decreases, it only goes up. They will use you for free labor for however many years and hours they are allowed to. They will keep gradually increasing the length of residency no matter how many (or few) hours you work as long as you work for free. If you get rid of the work hour rules, which were only created due to public outrage over a needless death, then they will just work you 120 hours a week for three years. Until they make it 4 years.

You want a 2 year residency? Cut Medicare funding for everyone but Interns.

 

[Substance]

Its fucking bonkers to have physicians working more than 16 hours max at a time. Working too long does not show dedication. It shows hubris and stupidity.

Of course, the stupid physicians of yesteryear, rather than try to improve the system, barrelled through it thinking that it built character or some such nonsense. Patients deserve better than that.

If residency has to be lengthened, then it should be. Whatever. If residents could bill a % of their services on a fee-for-service basis like the attendings, then I bet residents would LOVE to take more cases.

******ed.

 

[cartoondoc]

We switched from 30 hours to 16 during my internship.

I didn't like the switch personally. Even though I hated the overnights, by December or so, you could actually get a lot of sleep on call and yet be off most of the next day. When we switched, you didn't get to be post-call, so you'd work this really long day, then the next day would also kind of be a long day and there was just no break.

And with patient hand-offs, you were always trying to catch up on what you missed when you were gone.