Wednesday, January 19, 2011

Medical Grand Rounds-new duty hour rules for internal medicine residents

Grand rounds today discussed the new institute of medicine recommendations for resident work hours. In 2003 the IOM placed limits on how much resident physicians can work, 80 hours a week, and only 30 hours in a row without a break. From what I've seen this has made residents' lives a little better, but they still do the same amount of work, the just do the paperwork (electronic) from home now instead of at the hospital so the hours don't count. They even showed a study that showed that almost all residents reported checking labs, ordering tests, and writing notes from home during their off time, even when post call.

Since 2003 there have been a lot of studies to see how this changed practice, none of which were controlled trials. Most of these studies show that: first, resident training suffers. Duh. Less hours means physicians who are not as well trained as they were in the past. Most studies indicate better safety, at least in the near term. Nothing looks at how the detriment to training effects mortality. Most studies indicate less burnout. Thats good at least. Now the Institute of Medicine wants more limitations. The problem is, the work of medicine isn't decreasing, so who will take care of the patients. There are three solutions I heard offered today. First, consulting (attending) physicians will pick up some of the workload. Sure...after working 70 hours a week they'll want to pick up patients for residents. And of course, they'd do it for free, right? Second, physician extenders. Nurse Practitioners and Physician Assistants, nurses or college grads who get 2 years of advanced nursing training, could pick up some of the more routine procedures and clerical work for residents. Problem is, they already do this, they work banker hours, and they aren't any more eager than consulting physicians to take on more work for free.  More worrisome, there are numerous reports of physician extenders working relatively unsupervised or stepping outside their scope of practice, a disaster in the waiting for patient safety. Lastly (and most interestingly) is to have college students work as medical assistants. Most of these are premedical students eager to get any clinical exposure they can, like being a scribe or a nurse assistant. Best of all, they work for peanuts. Sounds like we've found a winner!

So back to the residents. What is the solution? How do we keep the experience the same, a balance between work and education, without increasing the length of medicine residencies? Being that our medical education system is NOT publicly funded, its not likely that the debt ridden and underpaid residents are likely to agree to an additional year of indentured servitude. I've yet to see how the Institute of Medicine proposes to decrease hours, keep the amount of work done the same, and maintain the quality of the medical residency experience.

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