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