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- Anthony N. DeMaria, MD, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
- ↵⁎Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
We walked down the hall at a brisk pace, challenged with the task of seeing all the patients before our time for rounds expired. Upon reaching the sought-after room, I inquired “who knows this patient”? One of the residents volunteered that he had admitted the patient, but then he went off duty. Another resident indicated that she had picked the patient up yesterday, but the float resident was on duty during the evening. So together we began to review the patient's hospitalization, each contributing some information or perspective. Such situations are no longer rare in this era of restricted house officer duty hours.
I have just finished another stint as the attending physician on the Cardiology Coronary Care and Inpatient Service at UCSD. The enjoyment of taking care of patients and working with the house staff has been tempered by frustration with the issues wrought by the newly implemented duty-hour restrictions for residents. As everyone involved in a teaching program knows, the Accreditation Council for Graduate Medical Education (ACGME) implemented new duty-hour standards mandating that shifts for first-year post-graduate residents be limited to a maximum of 16 h. Complying with this mandate has required a schedule that has numerous residents coming and going, each covering the service for relatively limited and interrupted time periods. The result has, in my opinion, resulted in some loss in continuity of care, and compromise of a coherent and organized curriculum of cardiology topics as the educational experience of the rotation.
Typical of my generation and that of all physicians until recently, residency involved substantial time in the hospital including evenings and weekends. Often this consisted of working every other day and weekend, and frequent continuous on-call periods of 30 h or more. This was generally considered a “rite of passage,” and a preparation for the grueling demands of clinical practice. However, it was always sensed, if not acknowledged, that the fatigue and exhaustion that could result might impair judgment and performance. Attention was focused on this issue by the famous case of Libby Zion, a young lady who died under the care of residents who had been on duty for over 20 h. Her case initiated progressive reductions in the allowable on-duty time for house staff that, despite the opposition of most medical organizations and the majority of residency program directors, ultimately resulted in the recent ACGME restrictions.
From the onset, the duty-time restrictions for residents were felt to be a bit of a double-edged sword. The shorter work times should minimize fatigue-induced limitations in clinical performance, enhance quality of life, and provide more time for reading and individual learning. On the other hand, shorter work periods threatened continuity of care and might compromise the educational experience involved in patient care and performance of procedures. In the past, I would always start each attending session with core topics that needed to be covered during that period as appropriate patients were encountered. Now, only a subgroup of house staff is present on any given day, and I can only cover most topics with those residents who are on duty at the time. Not surprisingly, considerable research was performed addressing the net result of the restrictions. A meta-analysis of these studies published in 2011 concluded that there was no clear evidence that restricted hours were deleterious to either patient care or resident education (1). Neither, however, did the studies yield conclusive evidence of a benefit in the outcomes of resident care or education.
Why should it not be easy to demonstrate that better-rested residents have superior performance and obtain better outcomes? It seems clear that fatigue compromises cognitive function in all humans, and should limit the performance of residents as well. I believe the benefit of a fully rested house staff may be offset, at least partially, by the lack of continuity of care. In my experience, when one resident signs out to another the reports given are a poor substitute for knowing the patient. During my attending stint, I was sometimes the individual who was most up to date regarding the patient. If, as has been the long-time tradition of academic medicine, first-year residents with appropriate supervision are to be the front-line care providers to hospitalized patients, we need to have a better system to deliver continuity. At the very least, the system of signing out to a covering resident needs to be markedly improved. Finally, scurrying about to bring ourselves up to date further compromises the educational experience as well.
I recognize that I am in a more “chronologically gifted” generation, and that much of the benefit of every other night/weekend on-call duty became clear only in retrospect. Nevertheless, in my view the pendulum has over swung with the stringent new ACGME residency work-hour restrictions. I do not believe that the challenges to continuity of care are of benefit to either patients or trainees. I can personally attest that they are not a benefit to attending physicians. We all recognize that one of the relatively unique aspects of medicine is that patients often develop conditions that require prompt attention “outside the usual working hours.” So trainees need to prepare themselves for these emergencies in practice, and may as well get started as soon as possible. While I would concede that long periods of continuous on-call can produce fatigue sufficient to result in diminution of performance, in this case the cure seems to be as bad as the disease. While I do not know the best answer to resident fatigue, I am fairly confident that the current solution is not optimal. We owe it to both our patients and our trainees to find a better approach. I look forward to the day when I can ask “who knows this patient,” and always have a resident step forward with a complete and confident answer.
- American College of Cardiology Foundation