COMMENTARY

Resident Work Limits Disrupt Continuity of Care

Murray Epstein, MD

Disclosures

January 26, 2016

I recently read an interesting article in the Washington Post titled, "We Know Long Doctor Shifts Are Dangerous. Why Won't Hospitals Adapt?" by Jeffrey Clark and David Harari, two psychiatry residents at the University of Washington in Seattle.[1] The authors focused on two persisting challenges: resident doctors' long work shifts and workweeks, and the hand-offs to physicians who arrive to replace the weary residents at the end of the extended on-call period.

Clark and Harari recounted the infamous Libby Zion case,[2] which dramatically cast a spotlight on the critical issue of residents' long work hours and on whether newly minted interns and young residents working extended shifts are in any condition to evaluate a medical case and render a judgment call. The authors cited a New York Times column written by Sidney Zion, Libby's father, who famously wrote, "You don't need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call—forget about life-and-death."

More background about the Libby Zion case was provided in an earlier Washington Post article written by Barron H. Lerner, a physician and faculty member at Columbia University's Mailman School of Public Health.[3] He recounted in terrifying detail how the 18-year-old college freshman came to the emergency department of New York Hospital one night in 1984 with a fever and agitation. Within hours, her temperature had spiked to 107°F, and she suffered a cardiac arrest and could not be resuscitated. The aftershocks of her tragic death shook the medical establishment.

The Libby Zion Law

As fate would have it, Sidney Zion was not a self-effacing parent who would quietly disappear and just accept his daughter's death. He was both a lawyer and a high-profile New York columnist, a friend of many journalists and part of a fraternity of power brokers in New York City. Sidney Zion had access to the ultimate bully pulpit.

Zion rejected the assertion that his daughter died as a result of an inexplicable bad outcome from a mysterious ailment. Rather, he was convinced that his daughter's death was the result of an inadequate and overtired hospital staff that led to insufficient care and poor decisions. Over time, Zion grew ever more determined to ensure that others not fall victim to the same staffing inadequacies in the teaching hospital system that he blamed for his daughter's death. He vented his outrage about the state of medical education widely and loudly, even appearing on the TV show 60 Minutes.

After multiple investigations and accusations of negligence, the health commissioner for New York State convened an expert panel to examine these charges. In 1989, New York State adopted the Bell Commission's recommendations that residents could not work more than 80 hours a week or more than 24 consecutive hours, and that senior physicians needed to be physically present in the hospital at all times. The changes were to be implemented in all hospitals throughout New York State by July 1, 1989. Officially known as "405 Regulations," after the state health code section number, they became unofficially known as the "Libby Zion Law." In 2003, the Accreditation Council for Graduate Medical Education (ACGME) made reduced work hours mandatory for the accreditation of residency training programs across the country.

A Work in Progress

In addition to the obvious increase in hospital costs, the 405 Regulations challenged many doctors' sense of professionalism and independence. In an oft-cited 1988 article in the New England Journal of Medicine,[2] the authors lamented the new rules. The new "shift work...subjects patients to a succession of physicians, exposes residents to patients in fragmented blocks of time, and subordinates the Samaritan aspects of physicianship to shift-loyalty and the organizational needs of the system."

Identifying the problems inherent in "hand-offs"—shifting care of and knowledge about patients from one set of doctors going off duty to another set coming on—the authors noted, "Doctors form relationships with their patients and have a sense of responsibility to them that does not start and stop at scheduled times. At some point, however, the benefit of having a patient's own physician available is offset by that physician's fatigue."[2]

As I read the most recent Washington Post article positing that long doctor shifts are dangerous, I concluded that 31 years after Libby Zion's tragic death, these changes remain a work in progress. Granted, because of the ACGME edict, there is a limit to the duration of on-call shifts of medical residents. But that is not all that is needed.

In addressing the flaws in postgraduate medical education that still must be resolved, we should pause for a moment and focus not only on the system, but on how the system alters the medical resident in a complex and adverse manner.[3,4,5,6]

An excellent article by the eminent sociologist Terry Mizrahi graphically describes the harrowing nature of medical residents' working lives.[5] Mizrahi's description of the strategies residents use to avoid a "hit" (their term for a patient admission) or to ease their workload is quite interesting. But her description of how the system serves to degrade the impressionable, insecure, and at times bewildered medical trainee really hits the mark. Mizrahi writes:

In this period of their lives, they become responsible for cleaning up the carnage as they see it—much of it gratuitous and self-inflicted—wreaked upon the poor. Additionally, they, themselves, believe that they have been degraded: they lose control over their personal lives, which become dominated by work. They become easily exploitable labor, working extremely long hours for a modest salary. After being seniors in medical school, which is at the apex of the medical school pyramid, they are plummeted to the bottom of the physician hierarchy, where they have low status, albeit temporarily. Even though there is the promise of future rewards—wealth, status and/or autonomy—such degradation breeds resentment.

Loss of Continuity and Ownership of Care

Realizing that we are dealing with vulnerable subjects whose self-image has been affected, let us now turn our attention to the structure of postgraduate medical education. My contention is that the "lesion that we must extirpate" is not solely the extended duration of being on call.[3,6] Rather, I believe that the major defect is the glaring absence of continuity of care and the lack of ownership that once was the norm in postgraduate medical education.

I would not argue the point about fatigue and long hours being detrimental to cognition, good clinical judgment, and performance. Unfortunately, much of the link to continuity includes long hours. I am convinced that the curtailing of hours and the proliferation of "shifts" has hurt continuity of care and, in all probability, collegiality. Where once we had overtired zombies, we now have robotic assembly-line medicine, where the entity responsible for a patient's care is the system and rarely a single doctor.

Many medical errors are made because no single physician is really responsible for the overall care of the patient. As consultants often complain at our medical center (and, I am sure, at other medical centers and teaching hospitals), "I often cannot even find the 'primary' physician in charge so that I can communicate recommendations." Colleagues have confided that rather than searching endlessly to contact the physician of record, "I correct medication errors myself."

The sense of patient "ownership" is gone. Something better is needed to repair the fragmentation of care that now occurs in our hospitals. No one seems to have overall responsibility, and this is truly worrisome.

A Parting Challenge

I wish to unfurl a red flag, a challenge to the legions of bureaucrats who hover under the umbrella of the Centers for Medicare & Medicaid Services and other agencies governed by the Department of Health and Human Services. Rather than focusing on electronic medical records, and expending hundreds of hours honing and refining penalties and dictums for physicians who have transgressed for slight "errors," I recommend that you expend time and energy developing a viable algorithm that is readily comprehended for ensuring continuity of clinical care.

When a patient is asked to name his or her physician in charge, and the response is a blank stare, a deafening silence, or a long list of names, we must recognize that the patient care model currently espoused is broken, and no ACGME dictate will resolve this problem. I suggest that we reach out to the Institute of Medicine, which I regard with great esteem, to become involved and prioritize this problem as one of the key issues to solve in an accelerated timeline.

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