Great Debates Series

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Bernard Tawfik
 
Bernard Tawfik
 

Year in Medical School: 4th

Place of Birth:
New York City, New York

Where you grew up:
Louisville, Kentucky

College Attended:
University of Louisville

Major in College:
Biology

Goals (Medical School and Beyond): To reach my God-given potential and have the wisdom to know when I am there.

Personal Philosophy on Life and/or Medicine: "Only a live lived for others is a life worthwhile." - Albert Einstein

Favorite Quote: "I do not know the secret to success, but the key to failure is trying to please everyone." - Bill Cosby

 
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The Great Debates Series is an exciting addition to the Oasis repertoire. Each Great Debates Series installment poses an ethical, legal, political, and/or economic dilemma in health care and invites WFUSM students and faculty to write opinionated, persuasive, and even partisan essays on the topics. The responses are then published on this website. The opinions expressed herein are solely those of the contributing authors and do not represent the views of Oasis or Wake Forest University School of Medicine.

The topic for this Great Debates Series is:

Will the new ACGME guidelines have a negative impact on doctors’ education? (Why or why not?) If so, HOW would you restructure the guidelines, if you could? What effect do you think the changes will have on patient care, if implemented?

I Can’t Wait for July

Bernard Tawfik, MSIV

In July of 2011 my class will enter into the brave new world where we are called “Doctor,” where people place their hopes, dreams and the health of loved ones in our hands while we wade through a new healthcare system that is still being implemented.  In addition, July 2011 will mark the beginning of the ACGME’s new standards and, as with most new regulations, these will be met with trepidation and skepticism as our medical society digests and judges their effects on residency training and our education.     

The Accredited Council of Graduate Medical Education’s (ACGME) new standards are the result of a sixteen person panel, most of them senior clinical educators, who spent more than a year interviewing and listening to hundreds of physicians, patients and organizations representing both groups while extensively reviewing the literature and current academic recommendations on the topic.  Their focus was on residency training standards, patient care and sleep issues.  What emerged from this compilation of information were new standards, and the most widely publicized change was a reduction in interns’ consecutive work hours.  These will be reduced from 24 hours + 6 (for patient care transition and education) to 16 hours + 4 while upper level residents will be changed to 24 hours + 4. The new guidelines still allow for the 80 hr work week, although most see this as difficult to maintain with the above limitations.

This change will result in a loss of approximately 250 hours of clinical time for each intern per year if followed correctly.  How can these “lost” clinical hours and educational opportunities be compensated for in this new plan?  Some programs have discussed dropping services, such as leukemia, from the residency workload and placing them entirely into the hands of mid-level practitioners.  This reorganization would reduce the burden on the residency program but deny interns and residents the intimate ward service with those excluded patient populations.  Other programs will undoubtedly expand their residency program, allowing an increased number of residents to care for essentially the same number of patients which will theoretically reduce patient educational opportunities.  Still others discuss having upper level residents incur more ward service months their final year, which may detract from their board preparation and electives.  And there is always the looming possibility of extending training for some residencies to compensate.  However, it is uncertain how many hours and educational opportunities will be lost as residency programs across the country scramble to devise new scheduling scenarios to deal with this change and maintain the 80 hour work week.

But have decreased work hours been shown to decrease education, to increase patient safety or to provide a better resident work life?  Several large studies have revealed neutral or slightly positive effects on patient mortality and other select clinical parameters since implementation of the last ACGME work-hour limits in July 2003 which reduced hours worked to 80 hours a week.Interns in different specialties have indicated improved quality of life, but perceptions are varied about whether reduced hours enhance or detract from patient care and resident education, with no consensus.  With reduced hours, interns and residents are reportedly able to read deeper and focus more on their patients while caring for them, but they may lack adequate exposure to patients and disease processes. However, faculty consistently view duty hour limits as a detractor from residents' educational experiences, a disruption to the continuity of care, and an increased burden on their own clinical workload.  Unfortunately, objective verification of these outcomes to compare with resident and faculty perceptions is significantly lacking.1

Literature has shown that lack of sleep in inexperienced intern physicians with minimal supervision can result in poor patient outcomes.  The 10% spike in death rates at teaching hospitals when new interns arrive in July is not a myth but a researched fact.  Sleep deprivation is the #2 cause of motor vehicle accidents in this country, with 17-21 hours of sleep deprivation equivalent to a 0.8 blood alcohol level, yet our medical society condones physicians making medical decisions at sleep deprivation up to 24hrs.   Long, vigilance-dependent tasks involving newly learned skills are most vulnerable with acute sleep loss, with accuracy maintained at the expense of efficiency.2  These types of tasks are easily comparable to patient care in the ICU or an analagous medical setting.  A study that examined the effects of a modified 16 hr schedule against a traditional 24 hr extended shift schedule on intern errors in the ICU setting found interns worked almost 20 hours less and received 6 more hours of sleep per week.3 Interns on the traditional schedule made 36% more serious medical errors, including 21% more serious medication errors, and were 5.6 times more likely to render serious diagnostic errors compared with the intervention schedule. However, procedural error rates were similar between the two groups.  It is important to note that the number of medications ordered and the number of tests interpreted did not differ.  Surprisingly, there were no differences in adverse event rates between the groups.  This is possibly because colleagues, nurses and ancillary staff gave adequate support to prevent adverse patient outcomes during longer physician shifts.  Overall, those working extended hours faced chronic sleep deprivation and were more likely to report serious conflicts with attending physicians, other residents, and nurses, in addition to increased alcohol use and instances of unethical behavior.  And the majority of residents described profound adverse effects of sleep loss as well as decreased job performance, more stressful personal life, decreased learning ability, and decreased motivation.4

Could these new hourly restrictions hamper our medical education as many of our attendings believe?  This is an undeniable possibility that must be prevented as programs across the nation monitor this upcoming year carefully.  These changes are supported by some evidence that suggests improvement of  intern life regarding job performance, ability to learn and mental well being—all  benefits that cannot be ignored even with scant research.  When this topic was brought up by my attending in a group of residents, the conversation was rich with possible solutions and animosity over the situation.  But what I remember most from the conversation was the look of disdain the residents gave me when they realized that not only would I probably be working less then they had their intern year but that they might have to compensate for that by working more themselves.  So along with the new responsibilities of a long white coat, the faith of patients, the implementation of an untested healthcare system and the new work hour restrictions, we will also face the judgement of our superiors for being the first class to work these reduced hours.

I can’t wait for July. 

1 Olson EJ, Drage LA, Auger RR (2009).  Sleep Deprivation, Physician Performance and Patient Safety.  CHEST:vol. 136 no. 5 1389-1396

2 Owens JA. (2001) Sleep loss and fatigue in medical training. Curr Opin Pulm Med 7:411–418.

3 Lockley SW, Cronin JW, Evans EE, et al. [1](2004) Effect of reducing interns' work hours on sleep and attentional failures. N Engl J Med 351:1829–1837

4 Papp KK, Stoller EP, Sage P, et al.  (2004) The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study. Acad Med 79:394–406

Editor’s Note:  Do you agree with Bernard’s opinions and predictions?  Or do you have a strong counter-argument?  Submit to this ongoing debate for the next issue!

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Last Updated: 10-27-2010
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