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Resident Hours in the Pursuit of Better Health Care—Reply

Resident Hours in the Pursuit of Better Health Care—Reply In reply We appreciate the interest in our article and the discussion that it has sparked. We agree with Litchenberg that bedside rounding is crucial for education1 but do not believe that it “would be an instant cure for burnout.” Nor do we believe that restricting resident work hours will solve this entire problem as evidenced by 55% of residents still meeting criteria for burnout after implementing the work-hour restrictions. It is 1 step that may positively impact resident burnout. The quote from Dr Finn about Dr Stead brings up several points.2 First, we agree that there is no better way to learn about the diagnosis and treatment of disease than from direct contact with patients. However, the true measure of contact might not be the number of patients seen but the quality of learning in each patient encounter. The overtired resident may not be able to retain the learning points nor have the energy to supplement learning by reading the current literature. The notion that yesteryear's residents were “overworked but never overtired” may represent recall bias or lack of recognition of burnout in years past. Also, the practice of medicine has changed dramatically, with more acutely ill patients with shorter hospital stays and more advanced diagnostic tests and therapeutic options, with the pressure to contain cost and shift care to the outpatient setting.3 The long-term impact on clinical skills is unknown. The quote ends with the idea that no mistakes were made. The recent study by Landrigan et al4 highlights the problem of medical errors by directly observing interns in the intensive care unit during traditional 24-hour call and a night-float system. They found a 36% decrease (136.0 vs 100.1 per 1000 patient-days; P<.001) in serious medical error when the interns were less sleep deprived. There may be some advantages to a traditional call schedule, but there are definitely many disadvantages. These letters illustrate one of the major problems with graduate medical education. When attending in the hospital and the clinics, we stress to our residents to practice evidence-based medicine. However, when we discuss education, we rely mostly on opinion and anecdotal information. Restricting work hours for residents is the most dramatic change in graduate medical education since the inception of internships and residencies. We must study the effects to this change to improve graduate medical education instead of relying on opinion. Correspondence: Dr Gopal, Department of Internal Medicine, Denver Veterans Affairs Medical Center, 1055 Clermont St, Box 11B, Denver, CO 80220 (ravi.gopal@med.va.gov). References 1. Glasheen JJZwillich C Back to the bedside [letter]. Hospitalist 2005;9 ((1)) 41Google Scholar 2. Bloomfield RLDeBakey MFinn A et al. And the Pursuit of Healthcare: Considering Challenges With Dr Stead. Winston-Salem, NC Harbinger Medical Press2003;200- 201 3. Steiner JFFeinberg LEKramer AMByyny RL Changing patterns of disease in an in-patient medical service 1961-2 to 1981-2. Am J Med 1987;83331- 335PubMedGoogle ScholarCrossref 4. Landrigan CPRothschild JMCronin JW et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;3511838- 1848PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Resident Hours in the Pursuit of Better Health Care—Reply

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References (5)

Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.166.13.1423-b
Publisher site
See Article on Publisher Site

Abstract

In reply We appreciate the interest in our article and the discussion that it has sparked. We agree with Litchenberg that bedside rounding is crucial for education1 but do not believe that it “would be an instant cure for burnout.” Nor do we believe that restricting resident work hours will solve this entire problem as evidenced by 55% of residents still meeting criteria for burnout after implementing the work-hour restrictions. It is 1 step that may positively impact resident burnout. The quote from Dr Finn about Dr Stead brings up several points.2 First, we agree that there is no better way to learn about the diagnosis and treatment of disease than from direct contact with patients. However, the true measure of contact might not be the number of patients seen but the quality of learning in each patient encounter. The overtired resident may not be able to retain the learning points nor have the energy to supplement learning by reading the current literature. The notion that yesteryear's residents were “overworked but never overtired” may represent recall bias or lack of recognition of burnout in years past. Also, the practice of medicine has changed dramatically, with more acutely ill patients with shorter hospital stays and more advanced diagnostic tests and therapeutic options, with the pressure to contain cost and shift care to the outpatient setting.3 The long-term impact on clinical skills is unknown. The quote ends with the idea that no mistakes were made. The recent study by Landrigan et al4 highlights the problem of medical errors by directly observing interns in the intensive care unit during traditional 24-hour call and a night-float system. They found a 36% decrease (136.0 vs 100.1 per 1000 patient-days; P<.001) in serious medical error when the interns were less sleep deprived. There may be some advantages to a traditional call schedule, but there are definitely many disadvantages. These letters illustrate one of the major problems with graduate medical education. When attending in the hospital and the clinics, we stress to our residents to practice evidence-based medicine. However, when we discuss education, we rely mostly on opinion and anecdotal information. Restricting work hours for residents is the most dramatic change in graduate medical education since the inception of internships and residencies. We must study the effects to this change to improve graduate medical education instead of relying on opinion. Correspondence: Dr Gopal, Department of Internal Medicine, Denver Veterans Affairs Medical Center, 1055 Clermont St, Box 11B, Denver, CO 80220 (ravi.gopal@med.va.gov). References 1. Glasheen JJZwillich C Back to the bedside [letter]. Hospitalist 2005;9 ((1)) 41Google Scholar 2. Bloomfield RLDeBakey MFinn A et al. And the Pursuit of Healthcare: Considering Challenges With Dr Stead. Winston-Salem, NC Harbinger Medical Press2003;200- 201 3. Steiner JFFeinberg LEKramer AMByyny RL Changing patterns of disease in an in-patient medical service 1961-2 to 1981-2. Am J Med 1987;83331- 335PubMedGoogle ScholarCrossref 4. Landrigan CPRothschild JMCronin JW et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;3511838- 1848PubMedGoogle ScholarCrossref

Journal

Archives of Internal Medicine – American Medical Association

Published: Jul 10, 2006

Keywords: internship and residency,stress,burnout,intern,work schedules,medical errors,sleep,outpatients,hospitals, veterans,intensive care unit,education, medical, graduate,internal medicine,evidence-based medicine,recall bias,participation in ward rounds

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