The NEJM (June 28,2007) has two commentaries regarding the fall out and continuing analysis of the effects of the changes in house officer hours and rules governing how much time the trainees can work at the hospital.One of the two is available full text for free and can be found here. There is also an audio file interviewing Dr. Ethan Fried, a residency program director.
There is a tension between the hoped-for reduction in errors by having better rested residents and the fear of increased errors and dropped balls by having frequent hand-offs between teams of residents. Dr. Fried believes there may be more risk of the latter in the first day of admission to a hospital but also believes that the supervision and backup by more senior residents can mitigate that tendency.
In addition to the issue of is-the -new- system -less- error prone, there is the fact that since house officers are working less someone else has to. Accordingly, there is a trend to having non-teaching services maned by hospitalists and NPs and PAs at a cost some institutions are hard pressed to bear.
But, in my view even more important is what the new system might do to the evolving competency and mind set of the residents. This issue is discussed by Dr.Wes with his usual insightful analysis.
He wonders if an error free residency what we really want? Do we not learn in part by making errors in an environment where we are buffered and protected by our mentors and more senior colleagues?How will this cohort of residents fare when they are truly out on their own and there will be no team to hand off to when they have been up most of the night taking care of patients and fielding phone calls? Will they call their office and tell them they won't be in until noon because they need their protected ten hours post call ?.
The ACGME kicked off this major change in post graduate medical education in July 2003 and now four years later we seem to be seeing the fall out of a program that may have been initiated and mandated without sufficient planning regarding what now seems obvious collateral effects.The jury is still out regarding if this restricted duty plan actually improves safety or paradoxically has the opposite effect while increasing costs.
When I am old (OK, older) and sick will I want my medical advocate (wife) to insist on a physician who finished his training before July 2003? I have ranted before about the effects of changes in the IM program brought about by ACGME that in my opinion result in a marked loss of the sense of personal responsibility by the doctor for the patient. Teams and systems and protocols and flow charts are no substitute for a physician who believes she is personally responsible for the medical welfare of her patient even if she may be tired. A shift work mentality may be fine for a factory worker but when I grew up medically it was unthinkable for a physician.