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Editors: Reforming Doctors' Hours Won't Be Simple

Warn that fewer hours will make them 'technicians'

WEDNESDAY, Oct. 16, 2002 (HealthDayNews) -- Two top editors of one of America's most prestigious medical journals warn that focusing too much on the time cards of fledgling physicians might turn doctors into mere "technicians."

Congress is now debating bills that would shorten residents' workweeks to 80 hours. Earlier this summer, the Accreditation Council for Graduate Medical Education, which sets standards for the nation's 1,100-odd residency programs, issued mandatory guidelines that limit residents' work weeks to 80 hours, effective next July.

Making these changes "will probably improve learning conditions and should prevent errors due to poor judgment," write Dr. Jeffrey Drazen, editor-in-chief of The New England Journal of Medicine and Dr. Arnold Epstein, an associate editor of the publication, "but will they leave us with physicians who have the professional ethics that patients want and need?"

The guidelines, which are voluntary until next summer, also limit continuous shifts to 24 hours (plus up to six hours for extras such as education and transfer of patients) and impose a minimum 10-hour rest period between shifts. Programs that fail to comply with the rules could lose their accreditation -- and millions of dollars in Medicare payments.

The American Medical Association, the nation's largest doctors' group, has also issued calls for reform similar to that of the accreditation council but providing for an 84-hour work week.

Tomorrow's issue of the journal devotes much of its space to articles about the looming and inevitable changes to duty hours for residents, apprentice doctors immersed in hospital life for several grueling years after medical school.

Dr. Gregory Curfman, executive editor of the journal, says the publication will be addressing other patient safety issues in future editions. He notes the matter of resident shifts has gained "a lot of national attention" lately and that "the timing makes sense to us" to run something on it now. Curfman adds the piece by Drazen and Epstein don't necessarily reflect the views of the entire editorial staff.

Doctors say the existing system, while flawed, has elements worth defending.

It wasn't uncommon for residents to work 100 hours a week or more. But the intensity bred responsibility and accountability to patients beyond personal comfort. Other residents pitied their peers under the "black cloud"-- the one on duty with 12 cases in the hospital when a major disaster overloads the emergency room. But they recognized that the sink-or-swim experience was invaluable, unteachable and ultimately made them better doctors.

How much, if at all, exhausted residents contribute to the estimated 44,000 to 98,000 deadly hospital errors each year in this country isn't known. The U.S. Agency for Healthcare Research and Quality is now funding $300 million worth of studies to address the issue of medical errors, including the role of residents' restfulness and scheduling.

A recent research review published in the Journal of the American Medical Association found that complication rates were 45 percent higher for surgical residents "on call" the night before. It also included two studies of simulated laparoscopy that found that residents performed worse and needed more time to operate on post-call mornings.

If the impact of loss of sleep on patient care is vague, the effects of little rest on doctors themselves are clearer. Residents face a sharply higher rate of deadly car accidents during their training, especially in the hours when they are no longer on call. That may be because fatigue can impair judgment and reaction times as much as alcohol, experts say.

While the focus has been on sleepy residents, seasoned doctors may also be working themselves too hard, says Dr. David Gaba, a patient safety expert at the VA Palo Alto Health Care System and co-author of an article in the theme issue.

"Most of the attention has been on residents because we know that they're working long hours and they don't have much choice in the matter. But this is a problem even for people in private practice, because they may choose to work very long hours," says Gaba, who is also an anesthesiologist at Stanford University School of Medicine.

So while addressing length of hospital shifts is important, it's far from the only solution necessary, Gaba says. Doctors, like other workers, should be taught proper sleep hygiene and encouraged to come to the job well rested. "We need to change the culture" in medicine that equates long hours with commitment and drive, he says: "Being exhausted is not a sign of dedication, it's a sign of danger."

Makeba Williams, legal affairs director for the American Medical Student Association, applauded the journal for devoting attention to the problem of resident workload. "We do appreciate any attention that they bring to the issue," says Williams, whose group supports the 2003 guidelines.

But Williams dismisses the warning that a narrowed work week might lead to medical robots as a "red herring" and "exaggerated." After all, she says, 30 percent to 40 percent of a resident's time is spent on "technical" tasks such as blood-drawing and transporting patients. "I'd like to think we're getting sleep-deprived technicians" with the current system, she adds.

Williams says today's medical students don't buy into the idea that fatigue is the price to pay for inculcating a sense of obligation to their patients. Indeed, the opposite may be true.

Studies have shown that "after working tremendous amounts of hours residents become less sympathetic and less caring," Williams says. "Empathy and humanity are central" to being a good physician.

One article in the journal calls on doctors to take the lead in reforming their field, not leave the task in the hands of lawmakers and other regulators. Ideally that would happen, Williams says, but so far the medical profession hasn't been a model of self-policing.

The student group "has always supported organized medicine handling this problem, but their track record has said that they've been unwilling to do so" until only recently, she says.

What To Do

For more on medical education in the United States, try the American Medical Student Association. For more on patient safety, try the National Patient Safety Foundation.

SOURCES: David Gaba, M.D., director, patient safety center of inquiry, VA Palo Alto Health Care System, and professor, anesthesiology, Stanford University School of Medicine, Palo Alto, Calif.; Makeba Williams, legal affairs director, American Medical Student Association, Reston, Va.; Gregory Curfman, M.D., executive editor, The New England Journal of Medicine; Oct. 17, 2002, The New England Journal of Medicine
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