Duty hours of residents don’t seem to make a systematic difference!!

It’s hard not reach this conclusion after reading the 2011 review concerning Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules [J Gen Intern Med 26(8):907–19]. The authors warn us about comparing apples with oranges but the lack of any overall pattern regarding the impact on patients and residents is striking. For example, medical and surgical complications were interesting, with some improving and others worsening. The authors try to explain such differences as a product of less exhausted residents or worse continuity of care etc...As noted by the authors, the greatest limitation of the review is that conclusions rest upon studies demonstrating association, not causality. The authors collate a considerable amount of information, but the review (as acknowledged by the authors) doesn’t succeed in communicating the context. 

GPs decision making

A BMJ Open paper [BMJ Open 2013;3:e002982. doi:10.1136/bmjopen-2013-002982] evaluated compliance on treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients. This was a vignette study with 451 Dutch GPs (but statistical power was weakened by low number of doctors that followed the recommendations). Maybe the most interesting results were; the fact that none of the 451 GPs took the four optimal decisions presented and that none of the relevant doctor characteristics was related to doctor compliance with clinical practice guidelines recommendations on all four treatment decisions. Obviously something else is at work here, but what?

What is the purpose of medical education?

There is an engaging article in the recent issue of medical education [MEDICAL EDUCATION 2013; 47: 942–949]. It’s actually an email dialogue between  Dr David Hirsh and Professor Paul Worley. They attempt to address three important questions; Who are medical schools for? What is medical education for? What is the telos (the ultimate aim) of medical education? There is a lot of rich material in the exchange and I can’t do it proper justice here, but I will select out the elements that I liked best:

1.    The goals and purpose of medical education should be community engaged. Thus, communities should be co-creators of the curriculum and its delivery.

2.    There is a need to move beyond student-centeredness in medical education.

3.    The article highlights Cuba and the Barrio Adentro programme in Venezuela as exemplars of community engagement, and suggests that such models could fuel discovery and innovation.

4.    The final line of the paper is quotable; “The systemic result is that the goal of transforming medical education to repair society may actually transform us!”

These are just four parts that I liked; the paper is definitely worth a read. It’s rare that we see a paper exploring the values needed in medical education

Contradictions between resident education and patient safety?

A recent JAMA paper [JAMA INTERN MED/VOL 173 (NO. 8), APR 22, 2013] reports on a randomised experiment that compares between the 2003 and 2011 duty hour restrictions for US residents. The 2011 rules mandate rest periods between duty periods, increased supervision for junior trainees, and a 16-hour limit on continuous duty hours for postgraduate year 1 (PGY-1) trainees (interns). In a nutshell, the new regulations equal more work compression. Compared with a 2003- compliant model, two 2011 duty hour regulation– compliant models were associated with increased sleep duration during the on-call period, but with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.

Viewing the paper from an organisational psychology perspective, there is a very bizarre narrative going on. There is an overwhelming sense in the paper that we can’t really shorten the hours of residents, and it almost reads like a ‘I told you so!!’ (my interpretation not the authors). Indeed, the authors cite many studies in their conclusion section that found similar results. Additionally, the new system increased handoff related mistakes.  Speaking as a non-physician, the important issue that was screaming out was; WHY ARE HOSPITALS/HEALTHCARE ORGANISED IN THIS WAY? This is a complicated question, but rather than getting everybody focused on more sleep for residents (which is desirable), I want to know the vision and values of everybody at these hospitals. I can imagine that the healthcare professionals are increasingly prompted towards self-preservation rather than a meaningful balance between patient safety and healthcare well being. Finally, there is a really interesting contradiction between less educational opportunities and time. So rather than having meaningful discussions about the way that residents spend their time (in educational terms), we are forced to accept that the system is that way it is. Physicians reading my opinions may be thinking the same way (i.e., we can’t really change the system), but surely the paper suggests that there is no other alternative but to reimagine the system. Let’s get serious about analysing the systems